This is a 7 week old term female infant who 
presented in mid-November with wheezing, coughing, 
and two episodes of non-bilious emesis.  She was seen 
by her pediatrician, who suspected that she had 
bronchiolitis, and she was treated with oral albuterol 
syrup.  An RSV (Respiratory Syncytial Virus) nasal prep 
was done, and this was negative; however, the patient's 
condition worsened, and she was brought to the 
Emergency Department later that evening.
     Exam:  VS T37.2R, P168, R70, BP126/86, oxygen 
saturation 96% on room air.  The infant was fussy, 
though consolable, with moderate respiratory distress.  
She was non-toxic in appearance.  The anterior 
fontanelle was soft and flat.  The pupils were equal and 
reactive and the mucus membranes were moist.  The 
neck was supple.  The lungs had diffuse wheezes and 
crackles bilaterally with intercostal retractions.  Heart 
sounds were difficult to auscultate due to the noisy 
breathing, but no obvious loud pathologic murmur was 
heard.  The abdomen was soft and nontender with 
active bowel sounds.  The liver edge was palpated 3-4 
cm below the right costal margin.  Capillary refill time in 
the extremities was 3 seconds.
     The patient was placed on supplemental oxygen and 
a CXR was obtained.  

View CXR image.

     The CXR showed cardiomegaly and possibly 
increased pulmonary vascular markings consistent with 
congestive heart failure (CHF).  The femoral pulses 
were difficult to palpate.  Measurement of blood 
pressures in the four extremities showed 126/86 (left 
arm), 132/92 (right arm), 69/41 (left leg), and 63/59 
(right leg).  An EKG was done.

View EKG.

     It is not easy to see the tracing of some of the 
precordial leads because they are very large.  R2 (R 
wave of V2) extends into the tracing of V1.  R4 is off the 
scale.  Suffice it to say that all the R and S waves in 
V1-V6 are large.  The axis of QRS is 90 degrees 
(roughly isoelectric in I and positive in AVF).  This is a 
rightward axis.  The large QRS's in V1-V6 meet voltage 
criteria for both LVH and RVH.  This EKG shows 
biventricular hypertrophy.
     The patient was treated with furosemide, 1 mg/kg 
IV, and dobutamine, 5 mcg/kg/min as a continuous 
infusion, with marked improvement in respiratory status.
     The infant was admitted to the Pediatric Intensive 
Care Unit, and a cardiology consultation was obtained.  
An echocardiogram showed severe coarctation of the 
aorta, with a tight posterior shelf distal to the left 
subclavian artery.  The left ventricle was dilated with 
markedly decreased function.  The patient subsequently 
underwent operative repair of the coarctation, with an 
uneventful postoperative course.

Teaching Points:
     1.  Wheezing and respiratory distress are a common 
presentation of CHF in infants.  Tachypnea alone may 
be the earliest sign.  Even in the midst of the busy 
winter bronchiolitis season, the clinician must be careful 
to consider that the infant with wheezing and tachypnea 
may be a presentation of CHF, rather than bronchiolitis.  
Physical exam findings of hepatomegaly or a gallop 
rhythm may aid in making the proper diagnosis.  
Parents may also give a history of poor feeding, slow 
weight gain, and increased sweating.  A CXR showing 
cardiomegaly and increased pulmonary vascular 
markings will help to confirm the diagnosis.
     2.  Coarctation of the aorta may present at an early 
age, as in this case, with progressive CHF.  More than 
80% of infants with preductal COA develop CHF by 3 
months of age.  Coarctation of the aorta may also 
present in the first one or two weeks of life with a 
sudden state of shock with CHF and cardiovascular 
collapse when the ductus arteriosus closes 
(duct-dependent lesion).  This is also the typical 
presentation of the hypoplastic left heart syndrome.  
Other types of congenital heart disease which may 
present early in infancy with CHF include large 
ventricular septal defects, a large patent ductus 
arteriosus, anomalous left coronary artery, and critical 
aortic or pulmonary stenosis.  Acquired causes of CHF 
in young infants include viral myocarditis and 
supraventricular tachycardia.
     3.  COA can range in severity from very slight with 
minimal physiologic consequence to severe aortic 
coarctation or hypoplasia.  More severe COA tends to 
present in infancy while less severe COA may present 
in later childhood or adolescence.  The CXR of the 
young infant presenting with severe COA typically 
demonstrates cardiomegaly and increased pulmonary 
vascular markings (CHF).  This is in contrast to the 
CXR of COA presenting later in childhood, which 
typically shows a normal or only slightly enlarged heart, 
and normal pulmonary vascular markings.  Rib 
notching, although pathognomonic for COA, is rarely 
seen in children younger than 9 years of age.  The 
aorta may develop dilation pre and post coarctation 
resembling a "3" (3 sign) when viewing the right side of 
the aorta on an overpenetrated film.  If a barium 
swallow is performed the pre and post coarctation 
dilation of the aorta impinges upon the esophagus 
to it giving an "E" appearance to this area of the 
esophagus (E sign).  These signs are not generally 
seen on routine views that would be ordered in the E.D.
     4.  Treatment of CHF in infancy requires attention to 
the cardinal ABCs of emergency medicine (Airway, 
Breathing, Circulation).  Administration of supplemental 
oxygen should be considered as a first-line therapy.  If 
the patient is unstable, intubation with positive-pressure 
ventilation may be required.  To improve cardiac 
contractility, inotropes such as digoxin or dobutamine 
may be needed.  Dobutamine also has the advantage 
of decreasing afterload.  Diuretics such as furosemide 
aid by decreasing preload.  In severe cases, other 
vasoactive or inotropic agents such as sodium 
nitroprusside and amrinone may be considered.  These 
agents should be used in the intensive care unit, using 
invasive hemodynamic monitoring.  If a duct-dependent 
lesion is suspected, prostaglandin E1 should be started 
as a continuous infusion at 0.1 mcg/kg/min.

References:
     1.  Li MM, Klassen TP, and Watters LK.  
Cardiovascular Disorders.  In Barkin RM ed. Pediatric 
Emergency Medicine Concepts and Clinical Practice.  
St. Louis, Mosby-Year Book Inc., 1992, pp. 576-586.
     2.  Park MK.  The Pediatric Cardiology Handbook.  
St. Louis, Mosby-Year Book Inc., 1991, pp. 83-86 and 
177-182.
     3.  Rosenthal BW.  Wheezing.  In Fleisher GR, 
Ludwig S, eds.  Textbook of Pediatric Emergency 
Medicine, Third Edition.  Baltimore, Williams and 
Wilkins, 1993, pp. 518-525.