with Desiree Seevaye, Children's National
The Case
Famhx: Adopted
PE:
36.4C, HR 56, RR 16, BP 121/53, 100%RA, wt 84kg
Gen: Alert and oriented
HEENT: WNL
Cardiovascular: RRR, No murmurs, gallop, or rubs
Respiratory: CTAB, normal work of breathing, No chest wall tenderness
Abdomen: Soft, NT, ND, +BS. No organomegaly
Musculoskeletal: No extremity edema or tenderness
Neurological: A&O X3, no focal deficits
You obtain an EKG.
Questions for you
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Come back later for the denouement of this case
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
I'm no expert, but it looks like an inferior MI to me. I would go down the STEMI pathway and get the kid out of my ED in a timely fashion (to a place where he could potentially get a therapeutic cath). I wouldn't consult cardiology because I don't have a question for them. But I would ask them to help coordinate with adult center to expedite process and to tell me if they disagree based on the ECG and clinical scenario.
ReplyDeleteMy practical approach would be: IV, nitro-, morphine, oxygen, CXR. I would think about PE, pericarditis, and mediastinal mass as other potential serious diagnoses. But if the child meets voltage criteria of ST elevation, better to get the kid to a therapeutic center.
I notice ST elevation in the inferior region (II, III, avf) and lateral (V4-6), a diffuse pattern making me think of pericarditis. Since the patient is uncomfortable but otherwise shows no tachycardia and no narrowed pulse pressure and no hypotension, I don't feel urgency about consulting Cardiology, but would put them in the loop while waiting for labs.
ReplyDeleteQuick ddx for pericarditis: viral (large majority), autoimmune illness (SLE, JIA), uremia, MI. He is adopted, so ask about TB status. Ask about exposure to histoplasmosis- as we learned yesterday, ask about barns and caves. Bacterial: he would be much sicker and febrile.
Labs: cbc, esr, crp, cmp, cardiac enzymes, no blood cx, ?viral titers for coxsackie, EBV, influenza, echovirus, HIV (check this with Cards, but probably not necessary).
CXR
Echo from Cardiology colleague, may try myself first.
Disposition: home depending on imaging studies and on his vital signs.
Red flags in the history of this patient that point to a possible cardiac cause of pain include:
ReplyDelete1. Sudden onset
2. Radiation to the neck
3. “pressure”-like (I think ischemia with all of these)
4. SOB
Factors that point to a noncardiac cause include:
1. It started at rest
2. Worse with laying down (typical of pericarditis)
3. No diaphoresis
4. No syncope
The denial of substance abuse does not preclude getting a urine drug screen as cocaine, marijuana and amphetamines are well known to cause coronary vasospasm, angina, and ischemia.
Obtaining an EKG +/- CXR in most pediatric patients with chest pain are “low risk, high yield” in terms of ruling out pathology of the heart and lungs, as well as giving parental and patient reassurance if these are normal.
His VS are stable, with a bradycardia that may be normal due to his age and gender. The lack of reproducible chest wall tenderness raises another red flag for me, however not all cases of muscular pain have chest wall tenderness. The normal cardiovascular exam and lack of hepatomegaly is reassuring but does not rule out cardiac causes of chest pain.
The EKG shows normal sinus rhythm, HR 54, normal left inferior axis, normal PR interval, normal QTc of 0.34, and normal QRS duration of 0.08 seconds. The morphology of the QRS complex shows Q-waves in leads II, III and aVF, as well as ST elevation in these leads as well as aVR, aVF, V2-6. Pathologic Q-waves are > 0.04 seconds in duration and > 25% of the total QRS amplitude, hence the Q-waves seen in III and aVF seem to be pathologic.
The inverted T waves in leads V1 and V2 are normal for age. The other T waves have normal morphology. There is normal R-wave progression from V1 to V6. There is also a deep S wave in V1, Q-wave in III but no T-inversion in III (the S1Q3T3 pattern typical of PE, but seen in only about 20% patients), and no R-axis deviation or diffuse T-wave inversions that are more typical of PEs.
The pattern shown on EKG could indicate an inferior wall MI (Q-waves in III and aVF, ST elevation in II, III and aVF), however the diffusely elevated ST elevation in most leads could indicate an inflammatory process such as pericarditis vs benign repolarization with J-point elevation seen commonly at this age. The lack of tachycardia or any other arrhythmias are reassuring but do not definitively rule out an MI.
Since the EKG points to a possible inferior wall MI, I would rule this out first. I would obtain cardiac enzymes, urine drug screen and inflammatory markers of ESR/CRP while consulting cardiology emergently. A CXR should be done to assess for cardiomegaly which could be due to dilated cardiomyopathy, a pericardial effusion, or pulmonary causes of chest pain such as pneumothorax.
The acute treatment of acute MI includes MONA (morphine, O2, nitroglycerin, aspirin). The patient should be placed on O2 to optimize cardiac muscle oxygenation and pain control with morphine if needed to decrease anxiety and improve cardiac coronary perfusion. I would consider giving nitroglycerin after cardiology consultation as nitrates in inferior wall MIs can precipitate profound hypotension. Although rare, cardiac ischemia in children can occur from undiagnosed coronary abnormalities such as ALCAPA or ALCA from the right coronary sinus, or coronary fistulas. Getting cardiology on board early to perform ECHO and cardiac catheterization is essential to preserving cardiac muscle and function.
If the cardiac enzymes are normal, they should be repeated in 3 hours, and serial EKGs should be obtained. If there is elevation in ESR/CRP, this may point to peri/myocarditis. If all the labs are normal, then the diffuse ST-elevation may just be caused by early repolarization and the patient can be reassured. If he continues to have chest pain and SOB despite proper pain medication with NSAIDS, further workup may be needed e.g. to rule out a PE.