Things that make an ER nurse go hmmm...

Specialties NICU

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

Hi all,

I am just looking to get your oppinions or posible dx of a case I had the other night in the ER.

So the mother calls ambulance to bring her 5 day old baby into the ER after a prolonged episode of apnea. Mother states baby was just released from the hospital after treatment with lights for high bili the day before comming into the ER. During that stay mother states baby had multiple episodes of apnea (not always associated with feeding), she told the nurses, who told the physicians who didn't think they were anything to worry about.

Mom stated that the baby had had multiple episodes at home of apnea which were occuring both during and when the baby was not feeding. She called 911 because seh was feeding the baby and this time the apneic episode was prolonged and the infant became cyanotic.

So anywho so I placed the baby on teh monitor, so far no problems, baby looks wonderful and was crying becasue she was hungry so mom decided to give her a bottle. I happen to come in during the beginning of the feeding, baby starts with a weak cough during the feeding followed by about a 30+ second period of apnea with circumoral cyanosis, mottling of the trunk and extermities, and an unresponsive, limp baby. So this was a bit of a suprise to me, so I take baby away from the mother try and give her some stimulation to get her breathing again which doesnt works alittle, but the baby remained limp with eyes half open ( I think there was a gaze, but it happened so quick I do not remember). I kept stimulating the baby to get her to breath and eventually her RR was back up to 64 and she returned to an awake normal colored flexed baby. leaving me to say hmmmmmmmmm.

I had someone call for the ER physician to come into the room and by the time she got there the baby looked fine again so unfortunatly she did not see it. I do however take a majority of the pedi patients in the ER when I am working so I can usually tell when somehting just isnt right. This was not just a brief period of apnea this was more of an episode. It might be important to know that the mother had two siblings die at about 6 months do to heart anomolies.

OK so help me out NICU nurses, What do you think caused this episode??

Sweetooth

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Specializes in NICU.

Sounds like a Tet spell to me. Tetralogy of Fallot - large VSD, overriding aorta, right ventricular hypertrophy, and pulmonary stenosis. Did she mention if the apneic spells were more common when the infant was crying?

Or... maybe some kind of very small tracheo-esophageal fistula? Just a wee communication between the trachea and esophagous, not the big kind where the esophagous is a blind pouch. Secretions, and especially food (hence more common with feeding) going into the airway?

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Specializes in NICU Level III.

I'm wondering if the baby had an echo before he was sent home due to the siblings' history!

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Specializes in NICU, Infection Control.

Baby's got something wrong w/it. I don't suppose you could retrieve the part on the monitor when she was feeding the baby and the episode started.

IMHO. The baby should have been admitted, monitored overnight and had @ least a Heart ECHO, better yet a consult w/the same cardio's that saw her other babies. And maybe gone home on a monitor.

I'm going w/Liz's differential, plus maybe a neuro issue.

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Specializes in NICU.

I'm going w/Liz's differential, plus maybe a neuro issue.

Neuro occurred to me as well - maybe some kind of seizure thing happening?

Also - was the baby initially only kept in the hospital for phototherapy? Or was there some other factor, like sepsis? And what was the peak bili?

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Specializes in NICU, Infection Control.

So, sweetooth---what DID happen? Docs blew it all off and sent the kid home? I hope not, but wouldn't be surprised.

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.
Baby's got something wrong w/it. I don't suppose you could retrieve the part on the monitor when she was feeding the baby and the episode started.

IMHO. The baby should have been admitted, monitored overnight and had @ least a Heart ECHO, better yet a consult w/the same cardio's that saw her other babies. And maybe gone home on a monitor.

I'm going w/Liz's differential, plus maybe a neuro issue.

Monitor pattern remained the same (sinus tachycardia, within normal limits for a neonate), unfortunatly the oxygen sat prob had come off so I dont know if the sats dropped, I do know the monitor picked up the apnea.

The baby was picked up by a NICU team from a tertiary facility and sent there, after comming into our ER, especially after I witnessed that episode. Unfortinatly its too bad no one listened to the mother while the baby was having theses episodes while in the hospital for the high bili.

sweetooth

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.
Sounds like a Tet spell to me. Tetralogy of Fallot - large VSD, overriding aorta, right ventricular hypertrophy, and pulmonary stenosis. Did she mention if the apneic spells were more common when the infant was crying?

Or... maybe some kind of very small tracheo-esophageal fistula? Just a wee communication between the trachea and esophagous, not the big kind where the esophagous is a blind pouch. Secretions, and especially food (hence more common with feeding) going into the airway?

Nope no episodes while crying.

I was thinking the latter as well to, a small fistula.

Sweetooth

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.
I'm wondering if the baby had an echo before he was sent home due to the siblings' history!

Nope, unfotuantly while this baby was hospitalized for the high bili the mother told the staff that the baby was having episodes of apnea and they brushed it off.

I should mention that the heart defects were in the mothers siblings not in the patients siblings.

Sweeetooth

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.
Neuro occurred to me as well - maybe some kind of seizure thing happening?

Also - was the baby initially only kept in the hospital for phototherapy? Or was there some other factor, like sepsis? And what was the peak bili?

Baby was readmitted for high bili only and just received phototherapy. I am unsure of what the bili was, but I do remember the neonatologist that was with the NICU team that picked the baby up saying it wasn't that high.

Sweetooth

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.
So, sweetooth---what DID happen? Docs blew it all off and sent the kid home? I hope not, but wouldn't be surprised.

Unfortunatly when the baby was rehospitalized for the high bili the mother told the nursing staff that the baby was having multiple episodes of apnea adn unfortunatly it sounds like the doctors were blowing it off as nothing, so yes this kid went home with documented apneic episodes while in the hospital without any further testing. No liability there, eh.

Fortunatly when she brought the baby in we beleived her from the beginning, especially since this was her fifth child, it just happened by chance that I witness one of these episodes.

I have not gotten a chance to do any follow up, unfortunatly this kid went to a large urban hospital for tertiary care, so it may be really hard to find out a dx.

Sweetooth

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Specializes in Hospice, LTC.

Hope this baby turns out okay. I can't help but think of something neurological as well. Sounds awful.

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