Hot Seat Case #138 Denouement: 8 mo F with respiratory distress

Posted on: October 10, 2019, by :

Mary Beth Howard, MD, Children’s National Medical Center

The Case: A 8 mo F presenting with respiratory failure and epistaxis, with difficulty oxygenating, anemia, and persistent coffee-ground emesis

Here’s how you answered the questions:

What are your top 3 differential diagnoses?
Less than 3 years PEM experience (12 responses):
Bronchiolitis
NAT
Thrombocytopenia
bleeding diathesis
NAT
Malignancy
Foreign Body Aspiration
Ingestion
Pneumonia
airway anomaly
pulmonary hemorrhage
NAT
aspiration pneumonia
vascular
Sepsis
Pneumonitis
Foreign body
Pulmonary hemorrhage
Heiner syndrome
right heart failure
More than 3 years PEM experience: (4 responses)
Bronchiolitis
pulmonary edema
pneumonia
Aspiration
Bronchiolitis
Pneumonia
NAT
foreign body
sepsis/myocarditis
Pulmonary hemorrhage (?AVM)
DKA (severe metabolic acidosis)
Myocarditis (failure)

Discussion: This is a great example of a case we all fear encountering. A clearly critically ill child without a clear etiology. In these cases, it is often hard to systematically think through the differential, but instead react to clinical status, vitals, and labs as they arise.

With the benefit of being able to appreciate the bigger picture, the differential diagnoses of both fellows and attendings is similar: NAT was high on many differentials, as was pulmonary etiologies such as bronchiolitis, pneumonia, or pulmonary hemorrhage.

In regards to the work up needed in the ED prior to transfer to the PICU, it is clear that this patient needs the PICU, despite an unclear diagnosis. As Dr. Simpson mentioned, additional testing that would indicate the need for surgical intervention (head/chest/abd CT, LFTs) may be considered if patient were stable enough. In addition, asking for help from colleagues – PICU, CICU, surgery, anesthesia, other ED attendings – is a must in this situation.

Ultimately, most fellows and attendings alike agreed that getting this patient to the ICU despite instability was imperative. Given persistent desaturations, this patient needs determination of why she is not oxygenating, which would best be accomplished with ECMO in the PICU.

Denouement: Patient lost pulses in the ED for ~11 minutes. Following ROSC, he was transferred to the PICU where he went on to have 2 additional code events with ROSC. Pulmonary hemorrhage was thought to be the etiology of his presentation. He underwent an extensive work up by cardiology, pulmonology, gastroenterology, rheumatology, hematology, allergy (for milk protein allergy and Heiner syndrome). No clear etiology for his hemorrhage was found during his month-long admission.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Mary Beth Howard
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