1. Case Rounds Laura Miles Teams Case Rounds February 10 2012

2. Case 1

3. 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

4. 16 yo old male Admitted to emerg with crushing chest pain

5. 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

6. 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

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

8. 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

9. Ddx? MSK Respiratory GI Cardiac

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

11. 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

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

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

14. Psychogenic History can be key

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

16. 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

17. Back to our patient… Any further history you want?

18. Physical Exam

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

20. ECG

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

22. 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

23. Case 2

24. 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

25. 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

26. 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

27. Hx continued Feeling lightheaded, worse with standing

28. HR 200 RR 30 BP 85/40 O2 sats 95% on room air

29. 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

30. What should I do??

31. IV access and started fluid bolus ECG – ‘looks like SVT’ Drawing up medication – but chest pain and increased HR spontaneously stop

32. What’s going on?

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

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

35. SVT ECG

36. SVT Management Initially – vagal maneuvers Beta blockers Ablation

37. 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

38. Repeat ECG

39. 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

40. 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

41. ECG

42. 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

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

44. 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

45. 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

46. 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

47. Thanks! Any questions?