Age: 0.35
Sex: M
Vaccine: DTAPHEPBIP, HIBV, PNC
Symptoms: Fontanelle bulging, Hypoxia, Oedema, Respiratory arrest
Clinical narrative: I was called to the emergency room to attend to this infant who had infant respiratory arrest at the babysitter's house. The story was that the baby had eaten his typical bottle and had been laid down for a nap on his side. When the babysitter had checked on him, he had gone ahead and rolled over to his tummy and he was noted to be not breathing at that point in time. The babysitter is an EMT and the baby received CPR at the site. Ambulance was called. The baby was bagged and mask ventilated on the way into the hospital. At that time, the EMT arrived and intubated the baby and the baby was resuscitated with Atropine and Epinephrine. The baby then had return of spontaneous heart rate with good pulses and peripheral profusion. The baby remained unresponsive to all stimuli. At the time of arrival, the baby was noted to have a heart rate in the 130's. His color and perfusion were good. His ventilations were supported with an ET tube in good position with clear breath sounds bilaterally. His abdomen was distended. An NG tube was placed with removal of formula followed by just gas which was present in the stomach. A baby Foley catheter was placed as well and there was return of clear urine. The baby's medical history was obtained briefly from the mother who stated that he has been in good general health. He has had no illness whatsoever. Only medication he had ever received was Tylenol. He recently had received his immunizations the Friday before his 4 month well baby exam. He had no recent sign of illness whatsoever. He had been growing and developing normally. Another hospital had already been contacted and air transfer was being arranged. the baby was evaluated with blood gases and required multiple doses of bicarbonate with gradual improvement in the pH, however, we were unable to get the pH above 7 prior to his transfer. His PCO2 was excellent. He was being ventilated well. This was all metabolic acidosis. His electrolytes were evaluated and the only abnormality was a mildly low sodium. His CBC was remarkable for a white count of 16.6 and a hematocrit of 29. Platelets were 441 and DIFF was unremarkable. We did manage to take him to a CT scan. The CT was read by our radiologist as diffuse cerebral edema versus possibility of diffuse subarachnoid hemorrhage. He did also note a small mass lesion in the frontal area which differential included mass versus abscess versus AV malformation. No other specific findings were noted. Chest x-ray was obtained that showed normal heart size, large thalamus and lung fields were inflated with no evidence of pneumothorax. Supportive therapy was continued throughout the time that he was in our emergency room. Life Flight arrived and at that time, the baby was noted to have seizure activity with mainly repetitive jerking of the left arm. This was treated with 20 per kilo of Phenobarbital with plan to give Ativan in flight if seizures recurred. During the time of evaluation, the baby was also noted to have bulging fontanelle and rapidly increasing blood pressures with was treated with Mannitol and Lasix. He had good urine output after that. Clinically, the fontanelle looked less tense prior to his discharge. He was transferred to the care of Life Flight in critical condition. Time of my attendance was 2 hours direct patient care. Discharge Summary received on 2/17/2005 states cardiorespiratory failure, cerebral edema and seizure.