Pediatric emergency medicine trisk 1455 1455

periostitis of several bones, and serologic testing is needed to confirm the
diagnosis.

Cardiac Diseases (See Chapter 86 Cardiac Emergencies )
An infant with underlying congenital heart disease (CHD), including
ventriculoseptal defect, valvular insufficiency, valvular stenosis, hypoplastic left
heart syndrome (HLHS), or coarctation of the aorta, may present with shock or
congestive heart failure and clinical findings similar to those of an infant with
sepsis. Symptoms may include tachycardia, tachypnea, pallor, duskiness, or
mottling of the skin. Cyanosis may not be present based on the direction of
shunting and the patient’s hemoglobin level, which decreases physiologically to a
nadir at about 4 weeks of age. There may be sweating, decreased pulses, and
hypotension caused by poor perfusion. A chronic history of poor growth and poor
feeding may help differentiate heart disease from sepsis. The presence of a
cardiac murmur, a gallop rhythm, cyanosis unresponsive to 100% oxygen
administration, hepatomegaly, neck vein distention, or peripheral edema may lead
one to consider primary cardiac pathology. Intercostal retractions and rales,
rhonchi, or wheezing are nonspecific findings and may be present on chest
examination in either heart failure or pneumonia. HLHS or coarctation of the
aorta may present with shock toward the end of the first or second week of life as
the patent ductus arteriosus (PDA) closes. A difference between upper- and
lower-extremity blood pressures in a young baby suggests coarctation of the
aorta, though pulse differences may not be detected if cardiac output is
inadequate. Normal femoral pulses do not exclude a coarctation because the
widened PDA provides flow to the descending aorta. Check the dorsalis pedis or
tibialis posterior pulses; these are more sensitive for detecting coarctation or low
cardiac output.
A chest radiograph often shows cardiac enlargement and may show pulmonary
vascular engorgement or interstitial pulmonary edema rather than lobar infiltrates
(as in pneumonia). The electrocardiogram (ECG) may reveal abnormalities
including right-axis deviation with right atrial and ventricular enlargement in

HLHS, but can be nonspecific. An echocardiogram is usually required to define
anatomy and confirm specific diagnoses.
Rarely, an infant with anomalous or obstructed coronary arteries will develop
myocardial infarction and appear septic. These infants may have colicky
behavior, dyspnea, cyanosis, vomiting, pallor, and other signs of heart failure.
They usually have cardiomegaly on chest radiograph, and the ECG usually shows
T-wave inversion and deep Q waves in leads I and AVL. Echocardiogram or
cardiac catheterization is needed to confirm the diagnosis.