376.A 6-day-old infant is brought to the ED by his mom who describes
the newborn as breathing fast, poor feeding, and appearing blue. He has no
history of fever or vomiting. The patient was born full-term at home to a
G4P3 mother with an uncomplicated antenatal course. The mom had pre-
natal laboratory tests but is unaware of the results. On examination, the
patient is lethargic with central and peripheral cyanosis. The rectal temper-
ature is 95.4°F, HR 180 beats per minute, RR 70 breaths per minute, and
BP unobtainable in the extremities by automatic pressure meter. The oxy-
gen saturation on room air is 65% which does not improve with adminis-
tration of 100% oxygen by face mask. Auscultation reveals a harsh 3/6 systolic
murmur with an active precordium. Lungs reveal diffuse, bilateral rales and
wheezes. Liver edge is palpated 3 to 4 cm below right costal margin. Which
of the following is the most important next step in the management of this
patient?
a. Intubation for administration of 100% oxygen
b. STAT portable chest radiograph and electrocardiogram (ECG)
c. Administration of IV antibiotics and full sepsis workup
d. Administration of prostaglandin bolus followed by continuous drip
e. Immediate surgical intervention and activation of extracorporeal membrane
oxygenation (ECMO) team
377.A 27-day-old boy presents to the ED with a complaint of a 2-day his-
tory of nonbilious vomiting. The child has had no fever and no diarrhea.
The baby has always been a “spitter,” according to mom, but this seems
more excessive and “forceful.” The patient has had no wet diapers over the
course of the previous 12 hours and is fussy in the examination room.
There are no other complaints. The mother has just finished feeding the
child formula as you walk into the room and you see the child have an
episode of projectile vomiting. The examination reveals temperature
99.8°F, HR 180 beats per minute, RR 50 breaths per minute, and pulse
oxymetry of 95% on room air. The remainder of the examination is nonfo-
cal and benign except for slightly prolonged capillary refill. You order the
appropriate radiographic studies and consult the appropriate services. If
you were to check a set of electrolytes in this patient, the most likely result
would be?
a. Na 137, K 3.7, Cl−112, HCO 3 22, glucose 110
b. Na 137, K 3.1, Cl−89, HCO 3 39, glucose 55
c. Na 145, K 6.2, Cl−122, HCO 3 35, glucose 55
d. Na 145, K 3.1, Cl−89, HCO 3 16, glucose 80
e. Na 122, K 6.2, Cl−122, HCO 3 35, glucose 55
404 Emergency Medicine