Introduction
Jason is a newborn admitted to the neonatal intensive care unit (NICU) after a normal vaginal delivery with Apgar scores of 9 and 9. A loud murmur was noted in the delivery room as well as a hyperdynamic chest wall, resulting in a referral for evaluation by the NICU staff. Jason was subsequently admitted to the NICU for continuing evaluation. A pediatric cardiology consult was ordered and was conducted within 20 minutes of NICU admission.
Admission Assessment
Vital signs: T- 98.4 F, HR 158, RR 42, BP 55/16, O2 saturation 100%.
Respiratory: Lungs are clear to auscultation, mild intercostal retractions, but no significant distress
Cardiovascular: Acrocyanosis of the newborn, cool extremities with CFT 3 seconds, loud holosystolic murmur heard best at the right upper sternal border, significantly hyperdynamic chest wall.
Neurologic: active, normal newborn
Initial Management
Jason was assessed by the neonatologist as stable and not requiring oxygen or any central intravenous access. A peripheral IV was placed to provide access should his condition change. An echocardiogram was initiated prior to the arrival of the pediatric cardiologist who joined the technologist at the bedside. Numerous exclamations were made during the study such as "look at that" and "it's huge." Jason's vital signs did not change or worsen during this time. Once the study was complete, the cardiologist reported that Jason had a rare congenital heart defect called a left ventricle (LV) to aortic (Ao) tunnel (see Figure 1). It is essentially a pathway without any valve directly from the left ventricle into the aorta. Blood was passing back and forth through this pathway, as well as through the aortic valve. The tunnel was causing 3+ aortic regurgitation. The cardiologist also reported that Jason had relatively poor ventricular function. The cardiologist ordered and obtained a stat ECG that showed ST wave elevation. Having heard this, which of Jason's vital sign causes you concern and why? What do you expect to happen?
(Enlarge Image)
Figure 1.
Left Ventricle (LV) to Aorta (Ao) tunnel