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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

By |2019-02-19T18:02:41-08:00May 17, 2013|Pediatrics, Simulation|
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PV card: Early repolarization vs STEMI on ECG

You are handed an ECG for a 50 year old man with moderate chest pain for 2 hours now and no associated symptoms typical for ACS, PE, aortic dissection, or any other red flags of chest pain. He has no prior ECG’s on file.

  • Is this early repolarization or ST elevation MI?
  • Should I activate the cardiac catheterization lab?

Image courtesy of Dr. Steve Smith at HQMedEd-ecg.blogspot.com

Here are some great literature-based pearls compiled by Dr. Jason West (@JWestEM), an EM resident from Jacobi/Montefiore.

PV Card: ECG – Early Repolarization vs ST Elevation MI


Adapted from [1–7]
Go to ALiEM (PV) Cards for more resources.

Furthermore, there is a formula to differentiate early repolarization vs STEMI, per Dr. Smith’s publication6:

(1.196 x STE60V3) + (0.059 x QTc) – (0.326 x RA V4)

  • STE60V3 = STE elevation height at 60 msec (1.5 small boxes) after the J-point in lead V3 (mm)
  • QTc = The computer-read QTc interval
  • RA V4 = R wave amplitude in lead V4 (mm)

A result of > 23.4 is predictive of a LAD occlusion causing a STEMI, rather than early repolarization.

P.S. The above ECG image shows early repolarization.

References

  1. Brady W, Syverud S, Beagle C, et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med. 2001;8(10):961-967. [PubMed]
  2. Brady W, Perron A, Syverud S, et al. Reciprocal ST segment depression: impact on the electrocardiographic diagnosis of ST segment elevation acute myocardial infarction. Am J Emerg Med. 2002;20(1):35-38. [PubMed]
  3. Smith S. Upwardly concave ST segment morphology is common in acute left anterior descending coronary occlusion. J Emerg Med. 2006;31(1):69-77. [PubMed]
  4. Larson D, Menssen K, Sharkey S, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298(23):2754-2760. [PubMed]
  5. Nfor T, Kostopoulos L, Hashim H, et al. Identifying false-positive ST-elevation myocardial infarction in emergency department patients. J Emerg Med. 2012;43(4):561-567. [PubMed]
  6. Smith S, Khalil A, Henry T, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012;60(1):45-56.e2. [PubMed]
  7. Chung S, Lei M, Chen C, Hsu Y, Yang C. Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED. Am J Emerg Med. 2013;31(5):825-829. [PubMed]
By |2021-10-08T09:16:44-07:00May 16, 2013|ALiEM Cards, Cardiovascular, ECG|
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Three predictors for success in cardiac arrest resuscitations

The goal of resuscitation in cardiac arrest is to respond in a timely, effective manner that leads to good patient outcomes.  Resuscitation is not taking an ACLS and BLS course and going through the motions of a code. There have been several studies looking at the quality of intubation and CPR, and their association with good patient outcomes.

By |2019-09-10T13:38:38-07:00May 14, 2013|Cardiovascular|
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PV card: Ectopic pregnancy

Ectopic pregnancy is the leading cause of maternal death in the first trimester of pregnancy. A recent JAMA systematic review,1 from The Rational Clinical Examination series, looked to risk-stratify women in early pregnancy presenting with abdominal pain or vaginal bleeding for ectopic pregnancy. The authors set out to identify the accuracy and precision of elements in the history, physical examination, beta hCG, and ultrasound in ectopic pregnancy.

The systematic review consisted of 14 studies (n=12,101). The search consisted only of English language studies from 1965 to 2012 in which ectopic pregnancy was the final diagnosis with 100 or more patients per article. The summary prevalence of ectopic pregnancy was 15% (95% CI, 10-22%) in women presenting with abdominal pain or vaginal bleeding.

History and Physical

  • Patients symptoms had limited clinical value. Most symptoms had an unhelpful positive LR of less than 1.5.
  • The absence of cervical motion tenderness, peritoneal signs, adnexal mass, or adnexal tenderness did not significantly decrease likelihood of ectopic pregnancy.
  • In descending order, the most significant physical exam findings were:
    • Cervical motion tenderness (Positive LR = 4.9)
    • Peritoneal findings (Positive LR = 4.2-4.5)
    • Adnexal mass (Positive LR = 2.4)

Ultrasound showing normal IUP as shown by the double decidual rings and presence of a yolk sac in a gestational sac

Ultrasound showing normal IUP as shown by the double decidual rings and presence of a yolk sac in a gestational sac

Ultrasound

  • Findings of an intrauterine pregnancy (IUP) such as gestational sac or fetal pole ruled out ectopic pregnancy, except in rare cases of heterotropic prengnacy.
  • Bedside ultrasound is the single most useful diagnostic test. Positive LR = 111. 

Beta-hCG

  • The “discriminatory zone” continues to be debated – no consensus on the number.
  • A one-time hCG level does not rule out ectopic pregnancy.

PV Card: JAMA Review on Ectopic Pregnancy


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Crochet J, Bastian L, Chireau M. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729. [PubMed]
By |2021-10-08T09:20:50-07:00May 9, 2013|ALiEM Cards, Ob/Gyn|
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Pediatric Appendicitis: CT or Ultrasound?

Appendicitis is the most common pediatric surgical emergency accounting for 5% of urgent pediatric outpatient visits for abdominal pain. Computed tomography (CT) and ultrasonography (US) are two imaging modalities used in the diagnostic evaluation of acute pediatric appendicitis. Both have decreased the incidence of negative appendectomy results. It is well known that CT has greater diagnostic accuracy than US for diagnosing acute appendicitis, but there is concern over long-term cancer risk, with routine use of CT in children.

What modality should be used for pediatric patients who are suspected of appendicitis?

By |2026-06-16T16:01:40-07:00May 8, 2013|Pediatrics, Radiology|
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