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Difficulty: EasyPediatric Cardiovascular Disorders

A 55-month-old boy is brought to the pediatric clinic by his parents due to increasing fatigue during bottle feeds. The parents notice that he stops frequently to catch his breath and sweats profusely around his forehead while eating. His weight has dropped from the 40th40^{\text{th}} percentile at birth to the 5th5^{\text{th}} percentile currently. On physical examination, the infant is tachypneic with a respiratory rate of 62/min62/\text{min}. A loud, harsh, grade 4/64/6 holosystolic murmur is audible across the precordium, loudest at the lower left sternal border. Auscultation of the lungs reveals diffuse fine crackles and scattered expiratory wheezes. The liver edge is palpable 4 cm4\text{ cm} below the right costal margin. Which of the following is the most appropriate initial pharmacologic intervention to address this patient's acute symptoms?

  1. FurosemideAnswer
  2. B
    Inhaled albuterol
  3. C
    Oral azithromycin
  4. D
    Inhaled ipratropium and systemic corticosteroids
  5. E
    Routine dietary modifications and reassurance

Answer

The correct answer is Furosemide.
The correct answer is Furosemide. This infant presents with classic signs of a large Ventricular Septal Defect (VSD), indicated by the harsh holosystolic murmur at the left lower sternal border. The left-to-right shunt has resulted in pulmonary overcirculation and congestive heart failure, manifesting as failure to thrive, diaphoresis during feeding, tachypnea, crackles, wheezing ('cardiac asthma'), and hepatomegaly. The most appropriate initial pharmacologic intervention to relieve these symptoms is diuresis with furosemide, which decreases intravascular volume and reduces pulmonary congestion.

Step-by-Step Solution

1
Identify the underlying diagnosis from the physical exam.
The harsh holosystolic murmur at the left lower sternal border, combined with poor feeding and failure to thrive, points to a large Ventricular Septal Defect (VSD).
Recognizing the structural heart defect is necessary to understand the pathophysiology of the patient's current symptoms.
2
Determine the cause of the respiratory distress and appropriate treatment.
The crackles, wheezing, tachypnea, and hepatomegaly indicate congestive heart failure (volume overload) due to left-to-right shunting. Diuretics (Furosemide) are the first-line therapy to clear pulmonary edema.
Symptomatic relief of heart failure relies on reducing preload and fluid overload before definitive surgical repair can be planned.

Key Concept

The classic presentation of a Ventricular Septal Defect complicated by heart failure involves failure to thrive, diaphoresis with feeds, a holosystolic murmur, and signs of pulmonary overcirculation, which are initially managed with diuretics.
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Topics

Pediatric Cardiovascular Disorders

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