Thanks to Lilac Garden Station Friend @ Mr. Curious's Surgery Room for sharing the case
Patient: 1 month, child, weight 5 kg.
Main complaint: The main reason was admitted to the hospital for "coughing for more than half a month and atrial fluttering for 3 days".
Current medical history: The child had cough, foam in the mouth half a month ago, less sputum, no fever, no vomiting, visited the local hospital, checked the blood routine (2021-03-21): White blood cell count: 12. 3 * 10^9/L, neutrophil percentage: 15. 9%, lymphocyte percentage: 70. 2%, hemoglobin volume: 114 g/L, platelet count: 680*10^9/L, normal CRP.
Electrolyte + liver function + cardiac enzyme + renal function (2021-03-21): sodium 135 mmol/h, total red pigment: 98.7 μmol/L, direct bilirubin: 11.8 μmol/L, indirect bilirubin: 83. 9 μmol/L, total protein: 55.2 g/L, globububumin: 13.6 g/L, alkaline phosphatase: 342 U/L, Y-glutamyl transpeptidase: 120 U/L, cholinesterase: 8877 U/L, CK-MB: 34 ng/ml, lactate dehydrogenase: 1.74 U/L, a-hydroxybutyrate dehydrogenase: 1.74 U/L, human type III precollage 4 flat dimension is fixed 15, its meeting is obviously abnormal.
ECG: disordered atrial rhythm; frequent atrial premature beats: some of them are bipartite, some are triple, some are paired, and some are not transmitted down; short paroxysmal atrial tachycardia.
Cephalosporin was given anti-infective for 5 days after admission, the specific drug and dose are unknown, and the cough did not improve. Azithromycin was then given for 3 days.
On March 31, 2021, on the first day of the second round of Archie treatment, the child appeared pale, weak limbs, cold limbs, no breathing, and immediate CPR was given, and the child did not improve significantly.
Tracheal intubation, the child was crying, the heart rate was 189 beats per minute, and the ECG was checked (2021-03-31 15:18): atrial flutter; left deviation of the ECG axis; QTc prolongation. Cardiac ultrasound (2021-03-31): decreased ventricular wall movements; left-to-right shunt at the atrial level (patent foramen ovale), mild regurgitation of the tricuspid valve, tachycardia, decreased left ventricular systolic function. "Propadone total 25 mg" was given to shizune, "metoprolol 2. 5 mg" orally, the child did not improve significantly, and the ECG still showed atrial flutter.
On April 1 again oral "metoprolol 2. 5 mg", the effect is not good, amiodarone 0.7 ml, 1 ml / h pump point, the child's heart rhythm fluctuations in 150 to 200 times / min, in the early morning of April 2, again oral mercotol 2.5 mg, check the ECG: atrial flutter; right deviation of the ecglytic axis; ventricular premature beat? Room flutter with messenger; QTc extended.
Past history: 7 days of hospitalization in the newborn, for a total of 10 days of oral propafenone.
Diagnosis and treatment process:
2 April: Amiodarone (7 ug/kg/*h) pumping point 2 hours of heart rate 160 to 190 beats/min, upregulated pump rate, amiodarone pump point of (10 ug/kg *h) pump point for 2 hours, no significant reduction in the child's heart rate added to esmololol (100 ug/kg*h).
3 April: The child's heart rate was 170 to 180 beats/min during activity, propafenone hydrochloride (3 mg/kg Q12) was added, and esmolol was raised to (150 ug/kg*h) in the afternoon.
4 April: Amiodarone is (10 ug/kg*h) and esmolol is raised to (150 ug/kg*h) pump point.
5 May: The child's heart rate fluctuates between 120 and 160 beats per minute, but the heart rhythm is not reversed, and the pump point is stopped with oral medication. Digoxin 0.17 mg (0.003 mg/kg) q12; sotalol hydrochloride 15 ug (3 ug/kg) q12, propafenone hydrochloride 16.6 mg (3 mg/kg) Q12, metoprol tartrate 2.5 mg (0.5 mg/kg) q12.
What should the child consider? How to deal with it?