kargiver Posted June 3, 2013 Share Posted June 3, 2013 Hi All, Case no. 3 is posted over at my EM education site - take a look and let me know what you think. This is a great learning case... cards in a youngin. Looking forward to your comments. http://www.empaguru.com/?p=67 E, take a look. You'll love it. G Link to comment Share on other sites More sharing options...
jmj11 Posted June 4, 2013 Share Posted June 4, 2013 I just wanted to comment that you have a great looking web site. Being a headache guy I rarely seek ECGs anymore (except for studying for the recerts). So, without embarrassing myself too much, do I see delta waves? Then I would suggest WPW and an ablation of the extra pathway would hopefully be curative. But I will wait to hear from the real brains here. But again, a great looking website. I would love to do the same for the headache world. Link to comment Share on other sites More sharing options...
Guest JMPA Posted June 4, 2013 Share Posted June 4, 2013 Hi All, Case no. 3 is posted over at my EM education site - take a look and let me know what you think. This is a great learning case... cards in a youngin. Looking forward to your comments. http://www.empaguru.com/?p=67 E, take a look. You'll love it. G V tach until proven otherwise. Link to comment Share on other sites More sharing options...
kargiver Posted June 4, 2013 Author Share Posted June 4, 2013 Gracias about the site comments - most appreciated. Good question - delta waves? Hard to say at a rate of 230 bpm, and with the history of transposition of great vessels, who knows what is in there for scar tissue. But JMPA is right - gotta treat it as V-tach until proven otherwise. I'll reveal more as it develops with responses. G Link to comment Share on other sites More sharing options...
Guest JMPA Posted June 4, 2013 Share Posted June 4, 2013 Gracias about the site comments - most appreciated. Good question - delta waves? Hard to say at a rate of 230 bpm, and with the history of transposition of great vessels, who knows what is in there for scar tissue. But JMPA is right - gotta treat it as V-tach until proven otherwise. I'll reveal more as it develops with responses. G failure of adenosine would point away from svt in a wide comlex tachycardia, no long acting blocker should be used, the next DOC would be amiodarone if stable otherwise defibrillate Link to comment Share on other sites More sharing options...
jmj11 Posted June 4, 2013 Share Posted June 4, 2013 Gracias about the site comments - most appreciated. Good question - delta waves? Hard to say at a rate of 230 bpm, and with the history of transposition of great vessels, who knows what is in there for scar tissue. But JMPA is right - gotta treat it as V-tach until proven otherwise. I'll reveal more as it develops with responses. G Sorry, I thought the V-tach was a given. I thought you were looking for the cause of the V-tach and with his history of congenital deformities and, this is where I'm not that skilled, I thought I saw delta waves in his post-conversion strip, that this could be WPW that precipitated V-tach. Link to comment Share on other sites More sharing options...
kargiver Posted June 4, 2013 Author Share Posted June 4, 2013 Always correct to assume that in the presence of a wide-complex tachycardia that it is V-Tach until proven otherwise. However, and this is where it gets sticky, what if it is WPW (SVT with aberrancy)? That has been a fair amount of literature about this in the EM world lately, and procainamide has definitely made a comeback. I have used it several times myself to terminate SVTs with aberrancy or WPW cases. JMJ, i agree, there is some notching that is concerning but after the fact, it wasn't felt to be WPW (by peds cards at the local tertiary center). They thought is was something else. There is something that everyone is overlooking though - take a look again at the history - what is missing? G Link to comment Share on other sites More sharing options...
jmj11 Posted June 4, 2013 Share Posted June 4, 2013 I love these brain twister-riddles. Now I have to refocus on the work in front of me but I'm looking forward to seeing how this plays out. Link to comment Share on other sites More sharing options...
mdebord Posted June 4, 2013 Share Posted June 4, 2013 There is something that everyone is overlooking though - take a look again at the history - what is missing? G Looks like borderline LVH. If I recall, those pts (esp if it's HCM) are more likely to break into an arrhythmia after blunt trauma, such as falling off a skateboard. With a h/o of transposition, I doubt this particular pt has HCM, but perhaps the hypertrophy applies. Link to comment Share on other sites More sharing options...
CCEMPA Posted June 4, 2013 Share Posted June 4, 2013 Was the surgery completely corrective as a child? If not, I'd venture if his vessels are transposed the vtach could be secondary to hypoxia/cardiac ischemia. For an otherwise healthy kid his sats (though I hate pulse ox) are borderline toilet. The picture you painted seems also seems to rule out a pnuemo, but what are the over all lung sounds? Especially given hx of asthma. If truly cardiac, probably consider an amiodarone drip considering he's stable, and you'd get the both the artia/ventricles. If all else fails, sync cardiovert that sucker up. Monitoring this thread for the answer. Link to comment Share on other sites More sharing options...
Guest JMPA Posted June 4, 2013 Share Posted June 4, 2013 Always correct to assume that in the presence of a wide-complex tachycardia that it is V-Tach until proven otherwise. However, and this is where it gets sticky, what if it is WPW (SVT with aberrancy)? That has been a fair amount of literature about this in the EM world lately, and procainamide has definitely made a comeback. I have used it several times myself to terminate SVTs with aberrancy or WPW cases. JMJ, i agree, there is some notching that is concerning but after the fact, it wasn't felt to be WPW (by peds cards at the local tertiary center). They thought is was something else. There is something that everyone is overlooking though - take a look again at the history - what is missing? G neurogenic cardiac injury seems to fit the history. Link to comment Share on other sites More sharing options...
kargiver Posted June 5, 2013 Author Share Posted June 5, 2013 neurogenic cardiac injury seems to fit the history. Definitely does - his CT scan of his head and neck were negative. That crossed my mind while treating him as well... I'll cut to the chase - I thought there would be more interest in a V-Tach in a 13 yo patient after a fall. This is a not-so-classic presentation of commotio cordis, The patient hasn't died from their arrhythmia yet. Depending on where you hit your chest can precipitate different rhythms (for example, hitting your sternum directly puts you at a higher risk for VF whereas hitting your lower chest wall puts you at risk for VT). Complicating the picture was the prior history of transposition repair - but the last cath done on patient the year before showed no underlying pathology. The peds cardiologists believed ultimately though it was the fall and landing on his chest that caused the initial arrhythmia. Ultimately, the patient was treated with amiodarone and vomited during administration. His BP began to drop, his LOC started decreasing so a single 50J DC cardioversion fixed the problem. Once cardioverted, patient was and remained asymptomatic. He was watched in the PICU for 24 hours and D/C to home from there. About 35% of Commotio Cordis cases are successfully resuscitated, but those stats only are of those reported cases and of those cases, nearly all presented in VF. The take home point I want to make is that it can also present as VT, polymorphic VT, VF, or any SVT. There have even been reported cases of heart block occurring. VT and VF are pretty straight forward to deal with - but add in the age and the sphincter factor tends to climb for all in the room. We walked this patient and the family through everything we did and it helps to make all of the difference. G Link to comment Share on other sites More sharing options...
MediMike Posted June 5, 2013 Share Posted June 5, 2013 Awww! I had commotio cordis on the ddx list but have always heard the presentation as solely Vfib. Good to know, thanks again for your site! Link to comment Share on other sites More sharing options...
cbrsmurf Posted June 5, 2013 Share Posted June 5, 2013 good case! Link to comment Share on other sites More sharing options...
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