28. Coarctation of the Aorta: Open Your Heart to Me, Baby

Christopher Jones¹ and Jennifer Mitzman^{2, 3}

(1)

Nationwide Children’s Hospital, Columbus, OH, USA

(2)

Nationwide Children’s Hospital, Columbus, OH, USA

(3)

Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus, OH, USA

Christopher Jones

Jennifer Mitzman (Corresponding author)

Keywords

Coarctation of the aorta Cyanotic heart disease Congenital heart disease

Case

A 9-Day-Old Male Presenting with Difficulty Feeding

Pertinent History

This patient was a 9-day-old, former full-term male who presented to the emergency department for difficulty with feeding. The mother stated that he typically breastfeeds for 15 minutes on each breast every 2 hours. Today kept falling asleep while trying to eat. She stated he started sweating with feeding today as well. Right before arrival, the mother noticed his breathing was faster. The mother denied fevers, weight loss, vomiting, or diarrhea.

Pertinent Physical Exam

Except as noted below, the findings of the complete physical exam are within normal limits.

General: Lethargy with poor tone.
Heart: 2/6 systolic heart murmur heard at the left upper sternal border that radiates to the back.
Abdomen: Liver edge down 3 cm below the costal margin.
Vascular: Absent femoral pulses. Delayed capillary refill of 6 seconds.
Skin: Mottled skin.

Past Medical History

The child was born at 39 weeks to a Gravida 2 Para 2 Mother. Prenatal screening for Group B strep was negative. The patient was born via spontaneous vaginal delivery without complication. The patient passed congenital heart disease pulse oximetry screening in the newborn nursery at 24 hours of age.
No medications or allergies.

ED Management

The patient was examined, and the murmur was detected along with other signs of poor perfusion. Lab tests including a venous blood gas, complete blood count, chemistry, ammonia, glucose, and lactate were obtained given the patient’s overall critically ill appearance. A 12-lead electrocardiogram and chest radiograph were obtained to evaluate heart size and rhythm. Four extremity blood pressures are indicated in patients in whom coarctation is suspected. In this patient’s case, the pressures were obtainable only after fluid resuscitation.

Based on the murmur and decreased overall perfusion with absent femoral pulses, fluid resuscitation was initiated. We elected to use serial aliquots of 10 mL/kg normal saline rather than 20 mL/kg to avoid fluid overload.

Since the first item on the differential diagnosis for a critically ill patient of this age is most commonly sepsis, empiric antibiotic coverage was initiated. This included ampicillin and gentamicin. Due to age less than 14 days, acyclovir to cover for risk of neonatal herpes infection was given as well.

The patient’s overall presentation was very suggestive of ductal dependent congenital heart lesion. As a result, we initiated prostaglandin E1 at 0.1 mcg/kg/min. The main risks associated with prostaglandin are apnea and hypotension. This is most commonly seen at initiation, so we were prepared to intubate if necessary. Our patient did develop apnea and was intubated using a 3.5 endotracheal tube and a medication regimen of atropine, ketamine, and rocuronium. Cardiology was consulted when the diagnosis was suspected. However, initiation of prostaglandin was not delayed given its critical nature.

Updates on ED Course

Lab results
Lab	Result	Units	Normal range
Lactate	6	mmol/L	<2.0 mmol/L
pH venous	7.25	–	7.32–7.42
pvO₂	94	mmHg	Not well-established
pCO₂	55	mmHg	35–45
HCO₃	16	mEq/L	21–34 mEq/L
Glucose	40	mg/dL	65–99 mg/dL