A 3-week-old girl presented to the ED via EMS from clinic with concerns for respiratory distress. She was taken to clinic by her mother for a well child check. There, the pediatrician noted grunting respirations that raised concern, and EMS was called for transport. Her mother had no acute concerns on the day of presentation. She reported the child had been acting “normal.” She reported the patient was feeding well; 2 oz per feed. She was making several wet diapers per day and had normal bowel movements. She denied fever, cough, and increased fussiness. The patient born at 36 weeks gestation, and there was an otherwise uncomplicated birth history.
Initial VS: BP 109/65 mmHg, HR 154, T 37.6 °C (99.6 °F), RR 64, Wt 3.79 kg (8 lb 5.7 oz), SpO2 94% on RA
Physical exam was significant for an ill appearing infant. Respirations appeared labored, and there were subcostal and suprasternal retractions. No crackles or wheezing were appreciated. CV exam revealed tachycardia without audible murmur on auscultation. Pulses were diminished bilaterally in the groin.
The differential was broad for this ill appearing infant and included heart failure, pneumonia, and sepsis.
Initially a CXR was obtained:
There was much debate as to whether or not there was cardiomegaly. Mild interstitial opacities were noted.
EKG was obtained and was non-specific, but the providers noted increased voltage.
Given the uncertainty of the CXR, the providers decided to take a closer look at the heart with bedside ultrasound. Here is the parasternal long axis:
What do you think?
Hopefully it only takes you a few seconds to recognize that there is severely decreased left ventricular systolic function. There is also right ventricular enlargement. From this one view, the providers were convinced that the etiology of this child’s respiratory distress was cardiac in nature.
The other cardiac views (parasternal short, apical, and subcostal) were also obtained:
These again show severely decreased LV systolic function.
A lung window was obtained:
This shows b-lines consistent with pulmonary edema.
The PICU team was notified, and they wished to take the patient to the ICU without further work-up in the ED. A stat formal TTE was obtained in the PICU, which demonstrated a bicuspid aortic valve and critical coarctation of the aorta. The LVEF was estimated at <20%.
Infants with critical coarctation can become ill very quickly when the ductus arteriosus closes. When the heart is pumping against such high resistance in the aorta, heart failure ensues.
The patient was given prostaglandin E1, intubated, and started on milrinone in the PICU. Once stabilized, she was transferred to a tertiary care center for definitive management.
Bottom Line: All critically ill patients being resuscitated should have a bedside cardiac ultrasound (even if the patient is an infant!). The information gained is invaluable.
