Case Rounds Laura Miles Teams Case Rounds February

Case 1

Objectives 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

History 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 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 History No major medical illnesses Immunizations probably up to date (he thinks) No known allergies No regular medications

Social 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? MSK Respiratory GI Cardiac

Red Flags Syncope Family Hx Need to ask specifically about sudden deaths Include unexplained drownings, single vehicle collisions Exercise induced

MSK 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

Respiratory Significant proportion of children/adolescents presenting with chest pain actually have uncontrolled asthma Dyspnea Cough Pneumothorax Pneumonia PE

GI Hx of chest pain worsening after meals can be very suspicious for reflux Peptic ulcer disease

Psychogenic History can be key

Cardiac Arrhythmias SVT VT Coronary Arteries Kawasaki disease Anomalous origin of coronary artery  compression between aortic and pulmonary roots Myocardial Myocarditis Cardiomyopathy

Cardiac 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… Any further history you want?

Physical Exam

Ix? Normal CBC and extended electrolytes Troponins normal x 3 Urine tox screen positive only for cannabis

ECG

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

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 2

Objectives 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 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 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??

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?

SVT Paroxysmal supraventricular tachycardia Narrow complex tachycardia originating above the ventricular tissue Accessory pathway Sudden onset and usually sudden cessation

Diagnosing SVT ECG during event Palpitation diary – teach parents or patient how to count a HR and record HR during events Event Recorder

SVT ECG

SVT Management Initially – vagal maneuvers Beta blockers Ablation

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 ECG

Wolff 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 arrives… HR 100 RR 20 BP 100/60 Sats 100 % on room air CRT improved – 2 seconds peripherally Looks much better than previously advertised

ECG

Ventricular Tachycardia 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 Tachycardia Most commonly seen after repair or palliation of congenital cardiac lesions Cardiomyopathy Channelopathies Long QT Brugada syndrome Abnormal coronary artery placement

Ventricular Tachycardia 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 Tachycardia 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 VT Unstable: synchronised cardioversion Antiarrhythmic medication for asymptomatic/stable patients Amiodarone Torsade de pointes – magnesium Cardiology referral Further testing – echo, MRI, stress testing

Thanks! Any questions?