Morning Report Case Presentation

AUGUST 29, 2018

Case: Initial Presentation
8 y/o previously healthy female
transferred from OSH to PCH ED for
fall, possible CHI and seizure.
CC: Fall, Possible Seizure
HPI:
- Running on sidewalk at school when
she fell
- Unconscious per witnesses, initial
GCS 8 per EMS
- Possible seizure (uncertain timing)
- Seen initially at OSH:
◦ Head CT reportedly normal
◦ Received Zofran for N/V
Case: Differential Diagnosis
- Primary mechanical fall w/ associated injuries
(Concussion, ICH, Skull fracture, post-impact
seizure)
- Primary seizure/neurologic event w/ secondary
fall (?Underlying IC process, Seizure D/O,
intoxication)
- Primary syncopal event
◦ Cardiogenic
◦ Neurologic
◦ Vasovagal
◦ Metabolic
◦ Other
 PE: GCS 15, No head injuries noted, CV normal, RESP normal,

NEURO: CN intact, PERRL, Gait normal, Coordination intact

Case:
ED Work-up & CT Head (overread): Normal head CT
Outcome
ECG: NSR, Normal axes and intervals, QTc 411 msec

Patient discharged home with concussion care information

Case:
Re-presentation
to ED
Approximately 5 weeks later…
Patient presents to
PCH ED in cardiac arrest
following a witnessed
collapse
while running at school.
HPI:
- Running across field when patient fell
forward, unconscious
- Bystander CPR initiated
- Initial GCS 3, irregular respirations
- Intubated by EMS
- CPR/Resus x14 minutes (EMS) with ROSC
(Total down time 24 minutes from collapse)
- Admitted to PICU
 Intubated, mechanically ventilated

Required pressor support for decreased function, evidence of

myocardial ischemic injury on ECG

Concern for underlying arrhythmia

Multiple episodes of short runs of VT, sinus tachycardia, and sinus bradycardia Case:
MRI with diffuse ischemic injury PICU Course
-Acutely decompensated 1 week into PICU course; found to have
uncal/transtentorial/tonsillar herniation

Brain death exam x2 on Hospital Day 8

Syncope:
Benign vs.
Dangerous
Benign vs. Dangerous
Syncope: Benign (Non-life threatening)
15-25% of adolescents have 1+ episode of syncope
Vasovagal Syncope (most common)
◦ UNCOMMON before adolescence
◦ Prodrome of dizziness, nausea, pallor, palpitations, headache
◦ Associated with POSITION CHANGES/STANDING
◦ Paradoxical fall in BP and HR
Postural Orthostatic Tachycardia Syndrome (POTS)
◦ Venous pooling associated with standing
◦ Increased HR; Stable/mildly decreased BP
Syncope: Benign and Other Causes
Exercise-related Syncope
◦ Sudden syncope immediately AFTER strenuous activity
◦ Related to venous pooling with cessation of activity + Dehydration
◦ Should warrant work-up to differentiate from pathologic arrhythmias
Other Causes
◦ Hypovolemia
◦ Dysautonomia (deconditioning, medications [CCB, β-blockers, diuretics],
neuropathies)
◦ Hyperventilation (hypocapnia)/Anxiety
◦ Metabolic derangements (ex. Hypoglycemia)
 Syncope: Dangerous (Cardiac) Causes
ARRHYTHMIAS STRUCTURAL
◦ Long QT Syndrome ◦ Aortic Stenosis
◦ Short QT Syndrome ◦ Pulmonary Stenosis
◦ WPW ◦ HOCM
◦ Brugada Syndrome ◦ Pulmonary Hypertension
◦ Catecholaminergic ◦ Coronary Artery Anomalies (KD, Anomalous
Polymorphic CA)
Ventricular
Tachycardia (CPVT)
◦ AV Block MYOCARDIAL DYSFUNCTION
◦ Arrhythmogenic RV Dysplasia
◦ Cardiomyopathy
◦ Myocarditis
 Syncope Red Flags
- Sitting or recumbent
- Outside typical age or no prior episodes
- DURING exercise
- No prodrome
- Palpitations or racing heart rate prior to syncope
- LOC >1 minute
- Family history of unexplained deaths, arrhythmias, pacemaker/ICD, or unexplained
drownings
- ECG abnormalities
◦ Long/Short QT
◦ Pre-excitation/Delta Waves (WPW)
◦ RBBB + J-point elevation (Brugada)
On INITIAL presentation, what should have prompted further investigation?

- No prior history of syncopal episodes or seizures

- Episode occurred DURING activity
Case in Review - No prodrome
- No evidence of head injury on exam or imaging
(to support seizure secondary to injury)
History, History, History

• * Sensitivity limited for intermittent

ECG arrhythmias (i.e., CPVT, RV dysplasia)

Echocardiogram
• * If exam/history concerning for
structural problem Next Steps
• Cardiology
Consults • Neurology

• Exercise stress test, Ambulatory

Specialty testing monitoring, EP studies
Case Wrap Up
No autopsy performed/No cardiac pathology collected

Suspected underlying arrhythmia

• Most likely CPVT, ARVD, or rare inherited arrhythmia

• Genetic testing sent for inherited arrhythmiasVariant of unknown significance found

Siblings referred to cardiology

• No major ECG abnormalities found

• Will follow periodically for re-evaluation
Resources
Park MK. Park’s Pediatric Cardiology for Practitioners, 6th Ed. Elsevier Saunders. 2014
Cannon B, Wackel P. “Syncope”. Pediatrics in Review. 2016; 37(4): 159-168.
Rizzo C, Monitillo F, Iacoviello M. “12-lead electrocardiogram features of arrhythmic risk: A focus
on early repolarization”. World Journal of Cardiology. 2016; 8(8): 447-455.
Toscano J. “Review of important ECG findings in patients with syncope”. American Journal of
Clinical Medicine. 2012; 9(2): 92-96.
Buxton A, Zimetbaum PJ, Downey BC. “Catecholaminergic polymorphic ventricular tachycardia”.
UpToDate. July 2018.