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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