Edison’s contribution to medicine…

EMS calls in with a 14 yo female who fell off her skateboard, not helmeted, and after the fall she felt a “pounding” in her chest. Since the fall, she hasn’t felt right. In the field, EMS finds the patient to be very tachycardic, pale, cool and moist, but maintaining a BP of 110/70. Her HR is reportedly in the low 200s. Per EMS, patient denies headache, neck or back pain, and had no LOC. EMS has tried adenosine (2 rounds), Cardizem (2 rounds) and lidocaine (2 doses) enroute to the ER. Upon arrival at the ER, patient is still tachycardic.

Upon presentation to the ER, mom reports child had a major cardiac surgery at 23 months (repair of transposition of great vessels) and has been event-free since. Child is normally in good health and last saw his cardiologist 8 months ago for routine follow-up.

Patient still c/o “funny-feeling” in her chest, some mild SOB, denies headache, head, neck or back pain. Does complain of R shoulder pain with movement. Otherwise, she has a few abrasions on his R forearm only. Of note, no bruising noted on chest wall or belly. She is tall and lanky, about 125 lbs, pale, dusky appearing, sweaty, and cool to touch. No JVD, but you can appreciate her chest wall is fluttering as his heart is beating.

PMH and PSH
- Transposition of great vessels with surgical repair

Allergies
- None

Vitals
BP 100/70
HR – 230 BPM, regular
RR 18, shallow
O2 sat – 95% on 2lpm
Temp 36.8C

Exam – as noted above; HR too fast to appreciate any murmer/rubs.

Here is the first strip:
First Strip

 

 

 

 

So:

1) Sick or not sick?

2) What is the diagnosis?

3) What is the cause of the diagnosis?

4) What is the treatment?

5) Would you consider further pharmaceutical intervention? If so, what would you use? Why?

6) What cannot be overlooked as a cause of this condition? What is one way to see if this is the cause of this condition?

7) How lucky is this kid?

Here is Strip 2 run at 50mm/sec:

Strip 2

 

 

Here is Strip 3 after conversion:

Strip 3

 

 

 

 

8) What is the final diagnosis? Any further thoughts or comments?

Posted in: Cardiac

About the Author:

5 Comments on "Edison’s contribution to medicine…"

Trackback | Comments RSS Feed

  1. MediMike says:

    1) Sick or not sick?

    Sitting here in a chair evaluating this patient I’d be leaning towards not sick, having seen kids tolerate WCTs pretty well for a long period of time, but this is clearly a rhythm unresponsive to pharmacological treatment (Well they didn’t try amio…) so just due to the fact that kiddos can compensate for so long and then crump I’ll go with sick.

    2) What is the diagnosis?
    Looking at it on my computer while sitting at work it appears to be a wide complex tach, which is going to be V-Tach until proven otherwise. You would of course be looking at SVT w/ Aberrancy or WPW as alternate dx.

    3) What is the cause of the diagnosis?
    Irritable foci in the ventricles…or some other cause related to the kid’s surgical hx which I’m probably missing!

    4) What is the treatment?
    Since the guy is stable(ish) at this time, unresponsive to atrial antiarrythmics and lido, I’d give Amio 150mg/10mins and see what happens. If this didn’t lead to conversion then the next step would be a synchronized cardioversion.

    5) Would you consider further pharmaceutical intervention? If so, what would you use? Why?
    Amiodarone has been proven to resolve both atrial and ventricular arrthymias due to it’s K-channel blocking abilities, lido didn’t work so this would be my next step.

    6) What cannot be overlooked as a cause of this condition? What is one way to see if this is the cause of this condition?
    Myocardial ischemia/infarcted tissue? Check a troponin?

    7) How lucky is this kid?
    Lucky I’m not the one treating him at the clinic haha

  2. Medimike,

    Good commentary so far. Definitely sick, at least if not dealt with shortly, but you are right, you have a little time to deal with it by other means before firing up the defibrillator.

    V-tach is the primary concern vs. WPW or SVT with aberrancy. At this rate though, figure with a fill time og less than 200 milliseconds, he will eventually give out and crash. Hard.

    What is the cause? That is the 64,000 question. Could it be his surgery? Perhaps – but I am going to let that one stew a bit more…

    Amio is a good choice – would you give it to a 12 year old? What else is possible? There is always cardioversion as the definitive treatment too.

    It could theoretically be a secondary cardiac event – not likely. What does his history tell you?

    And it sounds like you hit all the nails on the head. He may do just fine in your clinic…

    Others?

    • PM2PA says:

      Building off of MediMike,

      3) What is the cause of the diagnosis? Any pneumothorax concerns given his lanky build/predisposition coupled with asthma? Perhaps the fall broke a rib and the irritation/small fracture is causing the V tach. Lung sounds?

      4) What is the treatment? Given his BP and general appearance, I’m not sure he would last for ami 150 mg/10 minutes. Sedate and cardiovert before meds (thinking of my old protocols here for unstable v tach).

      5) Would you consider further pharmaceutical intervention? If so, what would you use? Why? Perhaps procainamide with refractory cardioversion? Given his age and weight, I think treating this kid with adult doses is justified.

  3. PM2PA,

    Good thoughts on other causes of the VT. When he fell, he did hit his chest. No pneumo seen and his LS were fine.

    I did amiodarone over 10 minutes and while doing it, he vomited once. Otherwise, he tolerated it well. I went with amiodarone over procainamide but in truth, I could have gone with either one to start. He was adult sized (small adult) so treated him accordingly.

    G

  4. Bike Mike says:

    6) What cannot be overlooked as a cause of this condition? What is one way to see if this is the cause of this condition?
    T-wave look a bit peaked – hyperkalemia? Is the kid on any meds (ACE inhibitors/ARB)? Check electrolytes.

Post a Comment