Cardiac Tamponade Presenting as an Apparent Life-Threatening Event

Abstract

The initial emergency department (ED) evaluation of infants with an apparent life-threatening event (ALTE) often fails to identify a definitive cause for the event. Many children that present with an ALTE appear normal by the time they arrive to the ED. These factors can desensitize clinicians into prematurely discounting serious underlying causes of the ALTE or being less prompt in their evaluation of these patients. We present the case of a young infant who presented to an ED with an ALTE resulting from cardiac tamponade. Cardiac tamponade has not been reported as an underlying cause of infants presenting to the ED with an ALTE. Previously reported cases of cardiac tamponade in children have occurred as a complication of malignancies, cardiac surgery, trauma, infections, central venous catheter placement, rheumatologic, and autoimmune diseases. This case should serve as a reminder to clinicians to maintain a broad differential diagnosis and promptly evaluate all infants presenting with an ALTE.

Do All Infants With Apparent Life-Threatening Events Need to Be Admitted?

“…Others suggested that ALTEs may indicate underlying sepsis, pertussis, physical abuse, arrhythmias, metabolic diseases, seizures, or even cardiac tamponade. [6][7][8][9][10][11] The SIDS rate for infants with ALTEs who required cardiopulmonary resuscitation was found to be 10% in one study, and it increased to 28% with multiple ALTEs. 11 On the basis of these studies, it became common practice to view infants presenting with an ALTE as being at high risk, to admit them to the hospital for a diagnostic evaluation, and to consider discharge with home apnea/bradycardia monitoring.…”

Cardiac Tamponade in a Child With Fever of Unknown Origin

“…3 Tachypnea has a sensitivity of 87% to 89% and has frequently been described in the pediatric literature. 10,11 It should particularly raise concern in the setting of clear pulmonary fields on auscultation and imaging. JVD is almost always present in euvolemic adult patients 3 but is much less commonly seen in children 10,11 and has an overall sensitivity of 76%.…”

“…10,11 It should particularly raise concern in the setting of clear pulmonary fields on auscultation and imaging. JVD is almost always present in euvolemic adult patients 3 but is much less commonly seen in children 10,11 and has an overall sensitivity of 76%. 9 Regardless of age, JVD is unreliable if a patient is hypovolemic.…”

“…9 Its use, however, is limited in the agitated child and has not been widely cited within the pediatric literature as a clinical indicator of cardiac tamponade. 10,11 CXR has 89% sensitivity for pericardial effusion if cardiomegaly is seen with clear lung fields. 9 However, the cardiac silhouette may not be appreciably enlarged on CXR until at least 200 mL of fluid accumulates in the pericardium, representing a late finding in tamponade.…”