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PED-EM-L  November 2011

PED-EM-L November 2011

Subject:

Re: Thoughts on a case?

From:

Amy Baxter <[log in to unmask]>

Reply-To:

Amy Baxter <[log in to unmask]>

Date:

Tue, 8 Nov 2011 20:24:51 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (117 lines)

Was a guaiac done?  And in the situation of FPIES (food enterocolitis)
mentioned in the previous post, do you usually  see a positive guiaic?

-Amy

Garth Meckler <[log in to unmask]> writes:
>Hi Trey, great case.  I think you did a great job, and in retrospect,
>common things being common, this could have been exactly as you piece it
>together: AGE with vagal mediated relative bradycardia.
>The only other things I would have entertained (as you did) would be
>abdominal catastrophes including malrotation with midgut volvulus,
>intussusception, or blunt abdominal trauma from abuse.
>Our surgical colleagues have mentioned the phenomenon of bradycardia with
>intraperitoneal or retroperitoneal blood (mechanism unclear to me, though
>perhaps also vagally mediated).  I haven't personally seen relatively
>bradycardia in the setting of volvulus, however, even with necrotic
>bowel.  Might have also considered intracranial injury (again, NAT?)
>since she was relatively lethargic, bradycardic, and hypertensive(ish). 
>Not sure I'd have jumped right to CT though.
>
>I suppose I would have entertained an upper GI or air enema as the only
>additional studies (perhaps an US could have ruled out intussusception
>non-invasively).
>
>The important thing is that you resuscitated her and kept her in-house.
>
>I'm curious if others would have ruled out malrotation / intussusception
>/ ICH?
>
>Thanks for the interesting case!
>
>Garth Meckler, MD, MSHS
>Oregon Health & Science University
>
>
>On Nov 8, 2011, at 7:03 AM, Trey Katzenbach wrote:
>
>> I am interested in your thoughts on a case that I recently saw.
>> 
>> Pt is a 7 mo who p/w vomiting about 20 times over the 90 minutes prior
>> to arrival, going from clear to yellow; + watery diarrhea x1 tonight;
>> pt looks pale; pt was in usual good state of health until sxs started
>> tonight; no fever; ate cinammon for first time today; uri sxs last
>> week that resolved; no rash; no sob; pt looks lethargic.
>> PMHx was unremarkable. FHx was unremarkable.
>> Vitals in triage: 108/75, HR=161, RR=28, Pox=98%ra, Temp=96.9 rectal,
>8.8kg
>> 
>> I was called to triage by the nurse because the patient was pale and
>> actively vomiting.  I brought the pt right back to a room and got a
>> dextrose-stick of 132. When placed on the stretcher she was somnolent
>> with occasional vomiting and I was struck by her relative bradycardia
>> of 125 with a normal appearing heart rhythm on the monitor.  She began
>> to fall asleep and her pulse ox dropped to 90%ra.
>> 
>> Relevant P/E showed the patient to be afebrile, lethargic, pale,
>> vomiting yellow emesis, not crying. Atraumatic, Normocephalic. Sclera
>> are normal, Ears and nose normal to inspection, Oropharynx normal,
>> Mucous membranes pink and moist, No stridor. Breath sounds clear and
>> equal bilaterally, No respiratory distress, No accessory muscle use,
>> No retractions. Heart sounds normal, Pulses 2+, equal bilaterally, No
>> murmurs, Rate is bradycardic, Rhythm is normal. Abdomen is soft, No
>> distension, No masses, Bowel sounds normal, Liver and spleen normal,
>> heme negative stool. Neuro exam shows no focal motor deficits but pt
>> is lethargic. Skin is warm and dry. Pt is pale.
>> 
>> I placed an IV, got a chest and belly x-ray, and did an ECG.  The
>> xrays were unremarkable. The ECG was read as normal but the HR was 122
>> and I think bradycardic for this age.  Even during stimulation for her
>> IV and D-stick she did not have an active cry and her HR did not rise.
>> Her pulse ox became normal with stimulation up to 98% with blow-by
>> O2.  I gave her 1.35 mg IV zofran and 250cc NS bolus and the vomiting
>> stopped after about 5 minutes.  She became more alert and active with
>> a HR into the 180's after about 20 minutes.  She looked well enough
>> after about an hour to tolerate a bottle of pedialyte with no issues.
>> 
>> A blood cx was sent and the following labs were obtained.  CBC with
>> wbc count of 26.5 (40%N, 51%L, 4%B), hgb=11.4, plt=529; u/a negative
>> except for trace ketones; LFT's and BMP were all within normal limits;
>> UDS was negative.  Given the elevated wbc count, I treated her with
>> 75mg/kg of IV ceftriaxone to cover for possible bacteremia but I
>> really think the elevation was due to a stress response.
>> 
>> What are you thoughts on the differential here given the most
>> impressive things about her were the lethargy, bradycardia and
>> hypoxia?  We entertained intussusception and other mechanical bowel
>> issues, sepsis, meningitis/encephalitis, drug ingestion, and
>> gastroenteritis among others. Ultimately she was back to her baseline
>> within 30 minutes of interventions.  She was admitted to the hospital
>> and discharged after >24 hours of negative blood culture and normal
>> exam with good PO's.  I think all of her sx's may be related to
>> vasovagal issues related to continuous vomiting and hypoventilation
>> from lethargy.  Have any of you ever seen this in this age group?
>> 
>> - Trey Katzenbach, Pediatric attending
>> 
>> For more information, send mail to [log in to unmask] with the
>message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                 http://listserv.brown.edu/ped-em-l.html
>
>For more information, send mail to [log in to unmask] with the
>message: info PED-EM-L
>The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html



Amy Baxter MD
Pediatric Emergency Medicine Associates
404 371-1190


For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html

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