Pediatric Syncope Part Deux…Still Fell Out

Buck Kyle MD...AKA pediatric cardiologist extraordinaire... is back to finish up part two of our in-depth look at pediatric syncope and the thirteen causes of sudden cardiac death.  Never feel threatened by the patient with a chief complaint of DFO (done fell out) again!  For the next hour we will cover the rest of the electrical, structural, and miscellaneous conditions that are responsible for V Tach/DFO, which may can ultimately to sudden cardiac death.

Pediatric Syncope and POC Echo Article

Pediatric ECG Cardiomyopathy 8mm Q-wave lead III

ECG of the Week – 27th April 2015

Some old ECG's from my collection for this week. These ECG's are from an 80 yr old female who presented with pre-syncope. The three ECG's were performed over the course of an hour.



ECG 1
Click to enlarge 
ECG 2
Click to enlarge

ECG 3
Click to enlarge
Things to think about

What are the key features of each ECG ?
What the potential causes for the ECG findings ?

ECG of the Week – 20th April 2015 – Interpretation

This week's ECG is form a 73 yr old male who presented to the Emergency Department complaining of 10+ hours of chest pain, sore throat, cough and dysponea. He has an AICD in situ and known cardiomyopathy (EF 25%). Vital signs were within normal limits. 
Check out the comments on our original post here.



Click to enlarge

Rate:
  • Mean ventricular rate 96 bpm
Rhythm:
  • Sinus complexes each followed by unifocal ventricular ectopics 
    • Bigeminy
Axis:
  • Sinus complexes
    • Normal
  • Ventricular ectopics
    • RAD
Intervals:
  • Sinus complexes
    • PR - Normal (~160ms)
    • QRS - Normal (80ms)
    • QT - 400ms (QTc Bazette 380-400 ms)
  • Ventricular complexes
    • QRS - Prolonged (160-180ms)
Segments:
  • Sinus Complexes
    • ST Elevation lead aVR (2mm)
    • ST Depression leads V2-6
    • Down sloping baseline makes ST segments in the inferior leads difficult to assess
  • Ventricular complexes
    • Appropriate discordant 
Interpretation:
  • Bigeminy
  • Diffuse ST depression with ST elevation in lead aVR
The Bigeminy Challenge - 'Seeing the Wood for the Trees'

Multiple PVC's can prove a distraction particularly when trying to assess ST segment change as the PVC's tend to draw the eye. I've used Paint to remove the PVC's from our ECG above and the ST changes in the native complexes are clearly more apparent. You can do this with hard copy ECG's by using bits of paper to cover the PVC's.

PVC's Removed
Click to enlarge


What happened ?

The patient remained in bigeminy and the ST segment changes were seen on older ECG's. Prior angiogram showed diffuse multi-vessel disease. The patient troponin was significantly elevated and a repeat angiogram was performed during which the the left circumflex was stented.

References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

Severe reactions to “Spice” on rise, some associated with drug MAB-CHMINACA

AB-CHMINACA

AB-CHMINACA

3 out of 5 stars

In vitro and in vivo human metabolism of the synthetic cannabinoid AB-CHMINACA Erratico C et al. Drug Test Analysis 2015 Apr 12 [Epub ahead of print]

Abstract

The New York Times reported today on the recent dramatic increase in emergency department visits related to use of synthetic cannabinoids (call colloquially, but somewhat inaccurately, “Spice”). This phenomenon has been seen in many states, especially Mississippi, Pennsylvania, and New York.

According to reports, patients often present with agitation, delirium, and hallucinations. Medical complications have included rhabdomyolysis and acute kidney injury, including that of a soldier at Fort Hood.

Preliminary media reports indicate that at least some of these cases may be associated with the synthetic cannabinoid MAB-CHMINACA (also known as ABD-CHMINACA.) This chemical seems to be a strong agonist at the CB-1 receptor, with a reported 10 times the affinity of the synthetic cannabinoid JWH-018.

This paper is mainly concerned with identifying metabolites of the structurally similar compound AB-CHIMINACA with an eye on developing screening tests. However, in their introduction the authors discuss the indazole-carboxamide (INACA) class of synthetic cannabinoids. Adverse effects include:

  • seizures
  • coma
  • agitation
  • altered mental status
  • loss of consciousness
  • dyspnea
  • death

Many INACA chemicals are now classified as schedule I substances by the U.S. Drug Enforcement Administration. At this point, MAB-CHMINACA is not.*

To read the 2014 DEA announcement temporarily classifying MAB-CHMINACA and similar drugs as schedule I, click here.

*The original post erroneously stated that MAB-CHMINACA had been classified as a schedule I substance by the DEA. A tweet from @forensictoxguy informed me that although it has been banned in Louisiana, it is not listed as schedule I on the federal level. To read @forensictoxguy’s take on MAB-CHMINACA on his blog “Dose Makes the Poison,” click here.

Tasty Morsels of EM 047 – Arthrocentesis

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Reasons to tap a joint

  • fluid for analysis
    • infection
    • crystals
  • drain tense haemarthroses
    • trauma
    • heamophilia (only after factor replacement)
  • evaluate communication with a wound
  • instillation of analgesics (remember you can inject morphine in a joint) or anti-inflammatory agents

Contraindications (pretty much all relative):

  • cellulitis over the joint
  • coagulopathy (but with small needle, it’s well described)
  • prosthetic joint (you really want ortho involved here)

References:

  • Rosen’s 8th Chapter 116

[featured image: CC License, Knee effusion, James Heliman MD, Wikipedia]

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