PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "cardiology"

PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="59"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old recently moved to the U.S. from Mexico with left sided chest pain for one day, and a fever to 38.2. Lung sounds are clear, the O2 sat is 100% on room air, and the CXR is negative. The ECG shows diffuse 1mm ST elevations and PR depression. The patient is well appearing with normal vital signs and hemodynamics. [yop_poll id="49"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2yo child is brought in after having taken some of Grandma’s “heart medicine.” Because the pills are kept in an unlabeled box and not their original container, the parents don’t know what the medication was. The child has sinus bradycardia with frequent PVC’s on the ECG, a blood glucose of 90; electrolytes on the i-stat are normal except for a slightly elevated potassium level. [yop_poll id="43"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child recently brought from a third world country with PMH of an unrepaired hole in the heart and mild cyanosis is brought in to the ED. The patient fed in the AM, then began to cry and became unconsolable, hyperpneic, and deeply cyanotic. On arrival, the patient has a temp of 37.6, HR 180, RR 60, BP unobtainable, O2 sat 40% on room air. [yop_poll id="24"]
(Click the link to comment and to vote - voting not working through email, sorry!) A previously healthy 5 year old boy with PMH of ADHD presents with 9 days of lethargy, fever, vomiting, diarrhea, and weight loss. He recently was diagnosed with strep pharyngitis and treated with amoxicillin for 3 days. His vital signs are: temp 39 C, HR 140, RR 24, BP 154/99, O2 sat 99% on room air. His exam is significant for agitation and restlessness, and tachycardia with bounding pulses and a hyperdynamic PMI. His mother feels that his anterior neck looks swollen. [yop_poll id="23"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are evaluating the electrocardiogram of a 2 year old boy. The patient presented for fever and the ECG was inadvertently ordered on him instead of another patient. [yop_poll id="21"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6 week old ex-30 4/7 weeks twin A male infant was seen at an outside clinic because his parents felt that his heart was beating faster than his twin sibling’s and was found to have a hemoglobin of 7.9 g/dL. The clinic referred him in to the ED for blood transfusion and hematology consultation. The heart rate is 165 bpm on the monitor, blood pressure is 74/40, cap refill is < 2 seconds, and color is pink. The remainder of his CBC is normal, and the patient is afebrile, feeding and growing well, and asymptomatic except for his heart rate. Reticulocyte count is 4.77%. [yop_poll id="20"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy presents after taking 3-4 of grandma’s pills about an hour prior. It is unknown what Grandma takes, but she has “chronic pain, a heart condition, high blood pressure, and sugar problems”. He is altered, but arousable to stimuli and answers questions. He says he took the pills because he was “curious.” His vital signs are: Temp 36.6, HR 49, RR 12, BP 80/40, O2 sat 98% on room air. Physical exam is significant only for miosis, bradycardia, and somewhat weak pulses. Bedside glucose is 100. [yop_poll id="18"]
A 14yo boy presents with fever and chest pain for 2 days. The chest pain is pleuritic and worse with leaning back. On examination, lung sounds are clear bilaterally, heart is regular with no murmurs, but a friction rub is heard. Which of the following is true of this condition? A. Treatment of choice is NSAID therapy B. All patients must be admitted to the hospital on a cardiac monitor C. CXR is always abnormal D. Electrocardiogram most commonly shows ST elevation isolated to leads II, III, and aVF E. Pain is rarely referred to shoulder or back
A 12yo boy with very high risk ALL, recent chemotherapy 4 days prior, presents to the ED with fever and lethargy. Temperature is 39C, HR 180, RR 24, BP 80/50.  The patient is lethargic, has no nuchal rigidity, lungs are clear to auscultation, heart is tachycardic but regular rate and rhythm, abdominal exam is benign, and there is no rash. Pulses are bounding, there is flash capillary refill, skin is warm and dry. After adequate fluid resuscitation, cultures, and empiric antibiotics, the patient remains hypotensive. The next best treatment is: A. Dopamine IV at 5 mcg/kg/min B. Epinephrine IV at 0.1 mcg/kg/min C. Norepinephrine IV at 0.1 mcg/kg/min D. Dobutamine IV at 5 mcg/kg/min E. Hydrocortisone 1 mg/kg IV
17yo boy with long legs and arms, h/o scoliosis and mild pectus excavatum, hyperextensibility of the thumbs, presents with sudden onset ripping quality chest pain and feeling lightheaded. On exam, patient is anxious appearing, afebrile, HR 105, BP 98/45, RR 14, pulse ox 98% RA, alert, HEENT non-revealing, Lungs BCTA, Cor RRR with mid-systolic click followed by a late systolic murmur at the apex, Abd soft ND NT, Extremities and Skin non-contributory.  Of the following, which diagnostic study is the best choice? A) POC troponin B) Arterial blood gas C) Bedside ultrasound looking for lung sliding D) CT angiogram E) CT abdomen

Tips and Tricks

Improve success of vagal maneuvers for patients in simple SVT by adding the "REVERT" maneuver: the patient performs valsalva maneuver in a semi-recumbent position, then the practitioner immediately puts the patient into a supine position with legs passively raised at a 45 degree angle. This maneuver improved conversion to NSR at 1 minute from 17% to 43%, for a NNT of 3.8. A simple way to have a patient perform a valsalva maneuver is to blow on the tip of a 10cc syringe hard enough to move the plunger. For an excellent discussion of the trial and a video of the maneuver see REVERT for SVT
It's July, so good time to review the basics. For pediatric resuscitations of any type, the mnemonic ABCDEFG is great - Airway, Breathing, Circulation, Don't Ever Forget Glucose. Children have lower reserves and become hypoglycemic more easily than adults when stressed. This mnemonic also came from a fantastic quick review of pediatric congenital heart disease presentations from the awesome folks at
A quick rule of thumb for estimating whether the QTc is normal is to look for it to be half the preceding RR interval (see figure below from ECG Interpretation). However, note that this rule of thumb is not accurate at heart rates < 62 bpm. Also, it is conservative at heart rates > 66 bpm. An excellent thorough explanation can be found at Dr. Smith's ECG blog here. For heart rates < 62 bpm, Dr. Smith suggests using QT < 40% of the preceding RR as rule of thumb. Also, be careful - computer calculated QTc are often incorrect - may need to get those calipers out! (or just count little boxes - each one is 0.04 sec, or 40msec). The most common formula used to correct QT is the Bazett formula QTc = QT / sqrt(RR), although this formula produces false positives at high heart rates. Here is a calculator at MedCalc that will do the math for you! QT half RR

Oops! We detected that you are on mobile and in portrait mode.

Please turn your phone to landscape mode to view this website. If you are not on mobile, extend your browser window.