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I had a similar case Tucson 5 days ago. 19mo previously healthy male presented with a day of low-grade fever, lethargy and a few hours of coffee-ground emesis. No respi symptoms.  Surg work-up was neg. Other initial work- up results were nonspecific w transaminitis, AKI and metabolic acidosis. Then he started seizing. Head CT was negative but had very high opening pressure on LP (52 cmH2O). Also w signif CSF proteinuria (> 600mg/dl) but neg cells. Viral respi PCR  was (+) for parainfluenza. Then he developed bradycardia responsive to fluids and stimulation. Later, echo showed dilated cardiomyopathy w L ventricular enlargement. Prior Xrays did not show cardiomegaly. He was transferred for ECMO the same day but did not make it. 

Ana Swafford, MD
PEM Physician
Tucson Medical Center

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> On Aug 9, 2018, at 12:59 AM, Lisa Amir <[log in to unmask]> wrote:
> 
> Curious for the list's experience…
> We have had 2 children in the last 10 days with intracranial bleeds who had arrhythmias or myocardial dysfunction
> 
> The first was a 5 year old who presented with SE who developed bradycardia and then asystole.  His POCUS-echo demonstrated good cardiac function after resuscitation.  The combination of the two suggested severe ICP and his head CT demonstrated a large SAH due to a bleeding (previously undiagnosed) AVM.  He died the next day from uncontrollable  ICP and v-fib; he developed severely reduced cardiac function about 12 hours after admission
> 
> The second was a 7 day old who presented with stridor.  An extensive workup was negative and then he developed bradycardia with poor perfusion; POCUS-echo demonstrated irregular heart rate but good contractility.  POCUS of his head demonstrated blood in the ventricles.  He was eventually diagnosed with hemophilia and did better after ventriculostome.  I don't have followup as he was transferred to another hospital which manages hemophilia
> 
> I've had patients with bradycardia due to elevated ICP but the primary diagnosis was always clear (head trauma, VP shunt malfunction). I did a quick literature search and this is reported in adults as a known but uncommon complication.  Didn't find any literature on pediatrics.
> 
> Lisa Amir, MD, MPH
> Deputy Chair
> Department of Emergency Medicine
> Schneider Children's Medical Center of Israel
> 
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