Case RoundsLaura Miles

Teams Case RoundsFebruary 10 2012

Case 1Case 1

ObjectivesObjectives Develop a differential diagnosis for chest

pain

Review the common causes of chest pain in children and adolescents

Recognize ‘red flags’ needing further investigation

Go through cardiac causes of chest pain

16 yo old male

Admitted to emerg with crushing chest pain

HistoryHistory Several months of intermittent CP

CP occurs for 5-10 minutes at a time

No relieving factors

No obvious aggravating factors

Occasionally feels lightheaded with chest pain

Several ?syncopal episodes

More HistoryMore History Chest pain is worse in left anterior chest but

does radiate across both sides

Usually 8-10/10 pain

No respiratory symptoms

No association with eating

No history of trauma

Past Medical HistoryPast Medical History No major medical illnesses

Immunizations probably up to date (he thinks)

No known allergies

No regular medications

Social HxSocial Hx Smoker – ½ ppd

Hx of drug use – cocaine, ecstasy, marijuana etc. Denies recent use

Currently living with Aunt – mom unable to care for him

Ddx?Ddx? MSK

Respiratory

GI

Cardiac

Red FlagsRed Flags Syncope

Family Hx Need to ask specifically about sudden deaths Include unexplained drownings, single vehicle

collisions

Exercise induced

MSKMSK Chest wall pain accounts for over 30% of

pediatric chest pain

Can be muscular, bony or involving connective tissue

Can be traumatic or atraumatic

Costochondritis – usually related to traumatic strain

Precordial catch – short duration, unclear etiology

RespiratoryRespiratory Significant proportion of

children/adolescents presenting with chest pain actually have uncontrolled asthma Dyspnea Cough Pneumothorax

Pneumonia

PE

GIGI Hx of chest pain worsening after meals can

be very suspicious for reflux

Peptic ulcer disease

PsychogenicPsychogenic History can be key

CardiacCardiac Arrhythmias

SVT VT

Coronary Arteries Kawasaki disease Anomalous origin of coronary artery

compression between aortic and pulmonary roots

Myocardial Myocarditis Cardiomyopathy

Cardiac continuedCardiac continued Aortic

Dissection associated with connective tissue disease

Pericardial Acute pericarditis

Valvular Severe aortic or subaortic obstruction

Limited cardiac output during exercise Severe mitral regurgitation

Volume overload of the left ventricle and increased myocardial work

Back to our patient…Back to our patient… Any further history you want?

Physical ExamPhysical Exam

Ix?Ix? Normal CBC and extended electrolytes

Troponins normal x 3

Urine tox screen positive only for cannabis

ECGECG

Ok, so for those of you who know the case, that wasn’t his actual ECG…

The conclusions…The conclusions… Despite some abnormal findings on his

actual ECG his chest pain was thought to be psychosomatic

Chest pain in retrospect could be brought on by stress

Chest pain would improve as he was able to calm himself down

Case 2Case 2

ObjectivesObjectives To recognize some of the more common

arrhythmias and their ECG pattern and symptoms

To develop an approach and differential diagnosis to an uncommon arrhythmogenic presentation

16 year old male

Seen in peripheral hospital for palpitations, chest pain and feeling generally unwell

You are called by the emerg doc at the peripheral site who is looking for advice

What do you want to What do you want to know?know?

Had been playing hockey

Initially felt unwell and had to leave the ice and sit down

Developed chest pain, some shortness of breath and noticed his heart was ‘beating funny’

Chest pain was predominantly on the left side

Stabbing pain 8/10

Hx continuedHx continued Feeling lightheaded, worse with standing

HR 200

RR 30

BP 85/40

O2 sats 95% on room air

Looks very pale and overall unwell

Well hydrated

Pulses slightly weak

CRT 3-4 seconds peripherally

Cardiac exam: normal S1,split S2 no murmur

Quiet precordium

Respiratory exam clear

Normal abdominal exam

What should I do??What should I do??

IV access and started fluid bolus

ECG – ‘looks like SVT’

Drawing up medication – but chest pain and increased HR spontaneously stop

What’s going on?What’s going on?

SVTSVT Paroxysmal supraventricular tachycardia

Narrow complex tachycardia originating above the ventricular tissue

Accessory pathway

Sudden onset and usually sudden cessation

Diagnosing SVTDiagnosing SVT ECG during event

Palpitation diary – teach parents or patient how to count a HR and record HR during events

Event Recorder

SVT ECGSVT ECG

SVT ManagementSVT Management Initially – vagal maneuvers

Beta blockers

Ablation

SVT in infants…SVT in infants… Need to be especially careful in this

population

Because infants can’t tell you about a racing heart, they can go into heart failure if not discovered early

Teach parents how to count HR

Repeat ECGRepeat ECG

Wolff Parkinson WhiteWolff Parkinson White ‘Preexcitation’ a portion of the ventricle is

being activated ahead of schedule

Can present with AV Reentry tachycardia

At risk for antegrade conduction Can consider ablation in certain cases

Your patient finally Your patient finally arrives…arrives…

HR 100

RR 20

BP 100/60

Sats 100 % on room air

CRT improved – 2 seconds peripherally

Looks much better than previously advertised

ECGECG

Ventricular Ventricular TachycardiaTachycardia

Incidence of ventricular ectopy 0.5% in infants up to 18-50% in adolescents

Differential diagnosis includes SVT with aberrancy, antidromic reciprocating tachycardia (AV reentry with atrial to ventricular conduction)

Classified as VT once you have at least 3 ventricular ectopic beats in a row

Ventricular Ventricular TachycardiaTachycardia

Most commonly seen after repair or palliation of congenital cardiac lesions

Cardiomyopathy

Channelopathies Long QT Brugada syndrome

Abnormal coronary artery placement

Ventricular Ventricular TachycardiaTachycardia

Idiopathic – often has absent symptoms

Arrhythmogenic right ventricular dysplasia RV dilatation Myocardial thinning Fatty replacement of the myocardium Familial inheritance Increased risk of sudden death

Cardiac tumours

Ventricular Ventricular TachycardiaTachycardia

Catecholamine related polymorphic VT Occurs with emotion or stress Often results in syncope Can degenerate into V fib Tx with beta blockers to prevent recurrent

episodes ICD in refractory cases

Management of VTManagement of VT Unstable: synchronised cardioversion

Antiarrhythmic medication for asymptomatic/stable patients Amiodarone

Torsade de pointes – magnesium

Cardiology referral

Further testing – echo, MRI, stress testing

Thanks!Thanks!

Any questions?