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
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