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
HR – 230 BPM, regular
RR 18, shallow
O2 sat – 95% on 2lpm
Exam – as noted above; HR too fast to appreciate any murmer/rubs.
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:
Here is Strip 3 after conversion:
8) What is the final diagnosis? Any further thoughts or comments?