Tuesday, May 6, 2014

A 16 year old girl has syncope while playing basketball.....

A 16 yo Female with no previous medical history had a syncopal event while playing basketball.  She arrived to the ED in severe respiratory distress, awake but agitated.  She was tachypneic in the 40s-50s.  She was intubated shortly after arrival, and had an ECG recorded:  

Sinus tachycardia with massive ST elevation in I, aVL, V5 and V6, with extreme ST depression in V3 and V4, and reciprocal ST depression in II, III, aVF.  This is diagnostic of a very acute posterolateral STEMI.


The ECG was briefly inspected by a pediatric emergency physician unaccustomed to diagnosing acute MI.  He did not recognize it and then set to the side.  An emergency medicine ultrasound fellow came to ultrasound the heart and happened to glance at the ECG.   He of course interpreted it as an acute STEMI although for a brief time this interpretation was doubted until the cardiac US showed a large wall motion abnormality.

The cath lab was activated.  Pt was taken to the cath lab, arrested twice during catheterization, and was found to have a coronry occlusion related to an anomalous coronary artery.  Unfortunately, the contributor could not remember the exact details of the cath nor of the specific intervention that was used to open the artery, but the patient did have ROSC, and eventual good neurologic outcome.

Lesson:

Children and young people do have MI.  They may have premature atherosclerosis, Kawasaki disease coronary aneurysms, and anomalous coronary arteries.  There are pediatric reports of MI due to LVH, cocaine, methamphetamine, and tumor embolism, dysplastic aortic valve   They also have myocarditis,  WPW, HOCM, long QT, congenital anatomic abnormalities and more.  In trauma, they can have myocardial contusion.

When children have chest pain, syncope, dyspnea, or other potential cardiac symptom, record an ECG.  It is cheap, noninvasive, and provides critical information.

Moreover, anyone with exertional syncope, at any age, needs a maximal stress test.

References

1. Excellent review article (unfortunately, no free pdf):   Reich JD.  Campbell R.  Myocardial Infarction in Children.  Am J Em Med 16(3):296; May 1998.  http://www.sciencedirect.com/science/article/pii/S0735675798901073

2. Anomalous left coronary artery origin from the main pulmonary artery is the most common significant coronary artery anomaly (Bland-White-Garland syndrome).
Arciniegas E, Farooki ZQ, Hakimi M, Green EW. Management of anomalous left coronary artery from the pulmonary artery.  Circulation. 1980;62(2 pt 2):I180–I189

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