Progression of congenital heart disease. (Critical Thinking In Critical Care).(Abstract)

Rebecca is a 4-month-old sent by ambulance from her pediatrician's office because she is significantly cyanotic with an oxygen saturation measured by pulse oximetry in the low 70s. Her mother reports a recent cold-like illness and regular episodes of vomiting. She has no signs of respiratory distress, but the emergency department intubates Rebecca for low oxygen saturation and arranges for transport to a pediatric intensive care unit.

Past Significant History

Rebecca was born at 36 weeks by vaginal delivery at which time she was diagnosed with multiple congenital anomalies including tracheoesophageal fistula (TEF), a ventricular septal defect, ectopic kidney, and abnormal vertebra. She meets criteria for VACTERL syndrome. Prior to initial hospital discharge, the TEF was repaired by end-to-end anastomosis, and Rebecca was taking all feedings by mouth.

Assessment Findings

General Appearance: Prior to intubation, Rebecca was alert and moving all extremities.

Vital Signs: HR - 130; RR - bagged; Temp 37.8 [degrees] (right axilla); BP - 87/54, [O.sub.2] sat - 84% on 100% bag.

Skin: Dry with normal skin turgor; warm to touch; capillary refill < 2 seconds with no evidence of cyanosis.

Neuromuscular: Moves extremities; reaches for endotracheal tube upon transfer from stretcher to bed; not extremely agitated as she has been medicated with …