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Pediatric M&M

Seth Trueger PGY-2 25 November 2009. Pediatric M&M. “Chest Pain” 2:00. 11y boy no PMH 10pm TV acute onset “like my chest caving in” “my heart stopped” SOB near syncope mild URI mostly resolved. brother with similar 4 months ago negative ED & specialist work up

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Pediatric M&M

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  1. Seth Trueger PGY-2 25 November 2009 Pediatric M&M

  2. “Chest Pain” 2:00 11y boy no PMH 10pm TV acute onset “like my chest caving in” “my heart stopped” SOB near syncope mild URI mostly resolved

  3. brother with similar 4 months ago negative ED & specialist work up “patient concerned he has asthma” no personal or family history

  4. Family History no sudden death grandmother cardiac father diabetic

  5. Exam 126/80 82 20 35.9 100% RA cardiopulmonary normal tender chest wall

  6. Initial Plan 2:22 +0:22 likely costochondritis mild viral/URI screening CXR & EKG NSAID IV O2 monitor CE x2

  7. EKG 2:22.01 +0:22.01

  8. Q wave III aVF STE V2 V3 V4 QTC 453 ms

  9. Ischemia? 2:55 +0:55 ibuprofen aspirin CXR normal labs normal

  10. Reevaluation 3:37 +1:37 feeling better awaiting 2nd CE repeat EKG

  11. Recurrence 4:36 +2:36 pain anxiety “afraid it's something bad”

  12. Plan 4:36 +2:36 sublingual NTG 0.2mg x2 systolic 140-145 repeat EKG

  13. Plan Cardiology paged 4:48 +2:48 morphine 2mg 4:59

  14. Pressure Drop 5:16 +3:16 106/43 Cardiology re-paged J point elevation “ischemia in children is usually exertional” F E

  15. Disposition 10:00 +8:00 2nd CE feeling better parental reassurance discharge follow up Cardiology

  16. Return 16:54 +14:54 recurrant pain resolved “mild J point elevation” Cardiology agreed “anxiety” discharged 18:42 +16:42

  17. Causes of ST Elevation

  18. J ST Elevation? relative to the PR or 60-80 ms after J point PR ST Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins.

  19. Differential Diagnosis STE early repolarization Prinzmetal's LVH BBB hyperkalemia The Brugada Syndrome AMI myocarditispericarditis PE LV aneurysm SAH “critical illness” Wang K, Asinger RW, Marriott HJL. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med (2003) 349:2128–35. Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins. Delehanty, JM, & Pinto, DS. (2009). Variant angina. Uptodate. Retrieved from http://utdol.com/online/content/topic.do?topicKey=chd/22906

  20. Prevalence of STE in young men 91-93% Hiss RG, Lamb LE, Allen MF. Electrocardiographic findings in 67,375 asymptomatic subjects. Am J Cardiol 1960;6:200-231. Surawicz B, Parikh SR. Prevalence of male and female patterns of early ventricular repolarization in the normal ECG of males and females from childhood to old age. J Am Coll Cardiol 2002;40:1870-1876

  21. Benign Early Repolarization location character magnitude associated

  22. Location widespread precordial V2-V4 not in limb leads Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins.

  23. Character upwardly concave inflection point notched J point Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins. Tikkanen JT et al. (2009). Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med. Epub: November 16, 2009

  24. Magnitude small <3.5mm <1mm <0.5mm V5-6 <2mm >45yo Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins. Mattu, A. (2009, July 9). Quoted in: Ekg in the chest pain patient. S. Weingart, Ed. Retrieved from http://emcrit.org/065-132/ekgsmi.htm

  25. Associated LVH concordant tall TW not wide young patients African Americans no evolution no ST depression Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins.

  26. BER Review V2-V4 concave up J point small STE tall QRS & TW Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins.

  27. Case

  28. Benign? Tikkanen JT et al. (2009). Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med. Epub: November 16, 2009 Rosso R, Kogan E, Belhassen B, et al. J-point elevation in survivors of primary ventricular fibrillation and matched control subjects: incidence and clinical significance. J Am Coll Cardiol 2008;52:1231-1238.

  29. J point elevation? diagnosis differential BER The Brugada Syndrome hypothermia MI

  30. Differential Diagnosis Pediatric Chest pain

  31. Pediatric Chest Pain Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  32. Pediatric Chest Pain Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  33. Pediatric Chest Pain Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  34. Pediatric Chest Pain Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  35. Cardiac 5% of Peds ED chest pain MI is rare usually classic classic is not specific greatest risk pre-existing (CHD, Kawasaki’s) drug abuse Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595. Mahle W, Campbell R, Favaloro-Sabatier. Myocardial infarction in adolescents. J Pediatr. 2007 Aug;151(2):150-4. 2007 Jun 22

  36. Infarct/Ischemia structural anomalous coronories HCM troponins preload/afterload

  37. Q waves >1 little box >25% height R Smith SW, Zvosec DL, Sharkey SW, & TD Henry. (2002). The ECG in acute MI: an evidence-based manual of reperfusion therapy. Philadelphia: Lippincott Williams & Wilkins.

  38. Common things are common 12-20% pulmonary 30-45% musculoskeletal 12-45% idiopathic Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  39. Pulmonary asthma RAD pneumonia PE pneumothorax Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  40. Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  41. Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  42. Brenner, JI, Ringel, RE, Berman, MA. Cardiologic perspectives of chest pain in childhood: a referral problem? To whom? PediatrClin North Am 1984; 31:1241.

  43. Brenner, JI, Ringel, RE, Berman, MA. Cardiologic perspectives of chest pain in childhood: a referral problem? To whom? PediatrClin North Am 1984; 31:1241.

  44. Recommendations Diagnosis interpret pediatric EKGs with caution especially without exam findings chest pain in children is usually benign Brenner, JI, Ringel, RE, Berman, MA. Cardiologic perspectives of chest pain in childhood: a referral problem? To whom? PediatrClin North Am 1984; 31:1241. Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

  45. Recommendations Management “Cardiac causes of chest pain generally require cardiology consultation” Brenner, JI, Ringel, RE, Berman, MA. Cardiologic perspectives of chest pain in childhood: a referral problem? To whom? PediatrClin North Am 1984; 31:1241. Matsuno Wendy C, "Chapter 8. Chest Pain" (Chapter). Gary R. Strange, William R. Ahrens, Steven Lelyveld, Robert W. Schafermeyer: Pediatric Emergency Medicine, 3e, 2009: http://www.accessemergencymedicine.com/content.aspx?aID=5339595.

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