PEST Case 1: What lies beneath…
“A 2-week-old child with cough and coryzal symptoms for 2 days is brought into ED looking pale with significantly increased work of breathing.”
Clinical findings
A: Coryzal, congested
B: S/C recession, severe increased WOB, diffuse crackles
C: Tachycardic, hypotensive, pansystolic murmur, femoral pulses not palpable
D: AVPU, GCS 13
E: Temp 36.9°C (mottled & pale)
Observations
SpO2 80%
RR 60
HR 169
BP 59/23 mmHg
CRT 4 sec
Diagnosis
Bronchiolitis with underlying duct-dependent cardiac lesion
Why we simulated
Coming into the winter months we see a plethora of infants with bronchiolitis presenting in respiratory distress. Less commonly but inevitably, a smaller group of infants with duct-dependent cardiac lesions present with similar clinical symptoms which can be challenging for clinicians to distinguish. When all we see is Bronchiolitis in our daily practice, our cognitive bias makes it difficult for us to see anything else. We must remind ourselves to stop and consider congenital heart lesions as a potential diagnosis in young infants presenting with respiratory distress.
Learning points
1) Prostin preparation and side effect profile
Prostin (Prostaglandin E1) is a synthetic prostaglandin used to relax the smooth muscle of the ductus arteriosis delaying its anatomical closure in duct-dependent congenital cardiac lesions presenting in the post-natal period. Prostin is a time-critical infusion that is stored in the fridge.
Prostin’s potential side effects include apnoea’s, fever, cutaneous flushing, bradycardia and hypotension. Healthcare providers must preempt such sequelae and react accordingly.
2) Prioritising infusions with limited access?
With only one single IO access point obtained, the team must prioritise which infusion to give in what order?
Fluid bolus of 10ml/kg NaCl 0.9%?
First dose antibiotics – Cefotaxime?
Prostin infusion?
When there is a high suspicion of a duct-dependant cardiac lesion the greatest threat to this baby’s life is the closure of its ductus arteriosis which is maintaining cardiac output and organ perfusion. Whilst we cannot out-rule sepsis, maintaining the ducts patency is the greatest priority over the administration of antimicrobials. In situations where access is limited, Prostin should be prioritised first dose antibiotics which can be administered once a second IV/OI access point is obtained. As the baby is in circulatory shock, the initial fluid bolus could be given as a push (10ml/kg of 0.9% NaCl) whilst the Prostin is being drawn up.
Staff feedback
“This was a very well run simulation that allowed us to consider the differentials of a 2 week old presenting with low saturations and manage appropriately. It was helpful to discuss the in-depth practicalities”.
“Team dynamics, maintaining the structured approach-ABCDE, calling in for help sooner, putting out crash call early, how to prioritise the drugs if have one IV assess. In the given scenario Prostin was most important”.
