ALiEM Sim Case Series: Pediatric WPW

Case Writer: Nikita Joshi, MD

Keywords

Pediatrics, Syncope, Wolff Parkinson White (WPW), PALS

Educational Objectives

Medical

  • Discuss a broad differential diagnosis for pediatric syncope
  • Identify critical findings in pediatric EKG
  • Manage WPW tachycardia

Communication

  • Obtain a focused history in a pt with WPW focusing upon family history
  • Communicate as an interdisciplinary team

Case Synopsis

10 yo boy BIBEMS s/p syncope. Pt was playing on the football field, running down field when he suddenly collapsed. Bystanders quickly went to the boy and within 1 minute the pt had regained consciousness without any intervention. When EMS arrived on the scene, the boy was sitting with his mother telling everyone he wanted to go back and play.Upon arrival in the ED, pt is well appearing, however had a heart rate of 180 bpm and BP of 115/80.  EKG shows a wide complex tachycardia rhythm.  If team gives AV nodal blocking agents, the pt will devolve into a VF rhythm, and the pt will become nonresponsive. If team administers procainamide, pt will go into a rate controlled rhythm that reveals WPW and should then be placed on a procainamide drip. If team performs cardioversion, the pt will go into a rate controlled rhythm that reveals WPW. If the team does nothing, the pt will eventually go into a ventricular fibrillation cardiac arrest.

 
Peds WPW Case Flow3

Download PDF of this flowchart

Peds WPW ABEM Milestone PC1
PDF this case-specific ABEM Milestone breakdown of PC1
PDF of more detailed scenario description

Critical Actions

  1. Analyze and interpret pediatric EKG for life threatening causes of syncope
  2. Initiate PALS for tachydysrhythmia
  3. Avoid AV nodal blocking agents in undifferentiated wide complex tachycardias
  4. Cardiovert pt early to avoid further decompensation
  5. Obtain family history of WPW with ablation

Learners

  • Residents (EM, pediatrics)
  • Nurses
  • EMS providers
  • Students (medical, nursing, EMS)

Location

ED resuscitation bay

Patient

10 yo boy

Equipment

  • Advanced airway equipment
  • Airway adjuncts
  • Broselow tape
  • Cardiac monitor
  • Cardioverter / defibrillator
  • IV fluid
  • Pediatric cardiac arrest cart
  • Syringes

Moulage

  • Sports clothing for manikin

Confederates

  • EMS provider – Gives history of well appearing pt on the football field. They did not obtain vitals because pt was so well appearing upon their arrival.
  • Mother – Unconcerned of syncopal episode, not good historian, thinks her son does not require medical care
  • Nurse – Completes and executes all orders provided
  • PICU attending (voice) – Discusses case with team over phone
  • Pediatric cardiology attending (voice) – Discusses case with team over phone

Supporting Files / Media

  • CXR – normal
  • EKG 1 – wide complex tachycardia, irregularly irregular
  • EKG 2 – VF
  • Echocardiography – normal, no effusion, good ejection fraction

Translation

AV = atrioventricular
BIBEMS = brought in by EMS
BP = blood pressure
CXR = chest x-ray
HR = heart rate
IV = intravenous
LOC = loss of consciousness
neg = negative
RR = respiratory rate
pt = patient
s/p = status post
T = temperature
WPW = Wolff Parkinson White
US = ultrasound
VF = ventricular fibrillation
yo = year old


References

  1. Boren SD. Commotio cordis. N Engl J Med. 2010. 362(23):2229-30. PMID: 20568311
  2. Fischer JWJ. Cho CS. Pediatric Syncope: Cases from the Emergency Department. Emergency Medicine Clinics of North America. 2010. 28;3. PMID 20709241
  3. Life in the Fast Lane Blog Post:  http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/
  4. Mottram AR. Svenson JE. Rhythm Disturbances. Emergency Medicine Clinics of North America. 2011. 29;4. PMID 22040704

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