ECGs in the ED - PEM Source
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ECGs in the ED Ronn E. Tanel, MD Key Words: ECG, cardiology From the Division of Pediatric Cardiology, Department of Pediatrics, Uni- versity of California, San Francisco, CA 94143 (email: [email protected]). Copyright * 2009 by Lippincott Williams & Wilkins ISSN: 0749-5161 CASE A 9-year-old girl with a history of tetralogy of Fallot presents to the Emergency Department with fever and cough. She has had a fever for the past three days with a maximum temperature of 101.6-F. The cough was first noticed 5 days ago and is described as a dry, staccato cough. Her respiratory effort has not changed, but her mother has noted cyanosis with longer episodes of cough. There has been some clear rhinorrhea and a scratchy throat. She has had an intermittent headache, but no earache. There has been no vomiting, diarrhea, or hemoptysis. She has been taking good fluid intake and has had normal urine output. She denies palpitations, chest pain, shortness of breath, or syncope. The past medical history is significant for tetralogy of Fallot with pulmonary atresia. She has had several prior cardiac catheterization procedures and two surgeries. Her baseline oxygen saturation is 86% and everything was de- scribed as stable at her last outpatient cardiology appointment. Her medications are furosemide and aspirin. She received acetaminophen earlier in the day. She has no known drug allergies. The family history is noncontributory for congenital heart disease. She lives with her parents and three siblings, one of which has a similar illness. In the Emergency Department, the girl is cyanotic but in no respiratory distress. She has an occasional cough, but no tachypnea or retractions. The temperature is 100.8-F. The heart rate is 104 bpm, the respiratory rate is 26 per minute, and the blood pressure is 96/52. Pulse oximetry on room air is 80%. The head and neck exam is significant for moist mucous membranes, clear tympanic membranes, and a mildly erythematous orophar- ynx. The chest has bilateral breath sounds with bibasilar rales. The cardiac exam is significant for a right ventricular heave. There is a normal first heart sound and a single second heart sound. There is no gallop. There is a III/VI systolic ejection murmur at the left upper sternal border and a II/IV long decrescendo diastolic murmur along the left sternal border. The pulses are full and equal. The abdomen is soft with the liver edge palpable 1 cm below the right costal margin. The extremities are warm and well-perfused. A chest radiograph showed an enlarged cardiac silhouette with decreased pulmonary vascular markings. There were bilateral lower lobe interstitial infiltrates. An electrocardiogram was performed (Fig. 1). FIGURE 1. Electrocardiogram performed on presentation to the Emergency Department. ECGS IN THE ED 364 www.pec-online.com Pediatric Emergency Care & Volume 25, Number 5, May 2009 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Transcript of ECGs in the ED - PEM Source
ECGs in the EDRonn E. Tanel, MD
Key Words: ECG, cardiology
From the Division of Pediatric Cardiology, Department of Pediatrics, Uni-versity of California, San Francisco, CA 94143 (email: [email protected]).Copyright * 2009 by Lippincott Williams & WilkinsISSN: 0749-5161
CASEA 9-year-old girl with a history of tetralogy of Fallot
presents to the Emergency Department with fever and cough.She has had a fever for the past three days with a maximumtemperature of 101.6-F. The cough was first noticed 5 days agoand is described as a dry, staccato cough. Her respiratory efforthas not changed, but her mother has noted cyanosis with longerepisodes of cough. There has been some clear rhinorrhea and ascratchy throat. She has had an intermittent headache, but noearache. There has been no vomiting, diarrhea, or hemoptysis.She has been taking good fluid intake and has had normalurine output. She denies palpitations, chest pain, shortness ofbreath, or syncope. The past medical history is significant fortetralogy of Fallot with pulmonary atresia. She has had severalprior cardiac catheterization procedures and two surgeries.Her baseline oxygen saturation is 86% and everything was de-scribed as stable at her last outpatient cardiology appointment.
Her medications are furosemide and aspirin. She receivedacetaminophen earlier in the day. She has no known drugallergies. The family history is noncontributory for congenitalheart disease. She lives with her parents and three siblings, oneof which has a similar illness.
In the Emergency Department, the girl is cyanotic but inno respiratory distress. She has an occasional cough, but notachypnea or retractions. The temperature is 100.8-F. The heartrate is 104 bpm, the respiratory rate is 26 per minute, and the bloodpressure is 96/52. Pulse oximetry on room air is 80%. The headand neck exam is significant for moist mucous membranes,clear tympanic membranes, and a mildly erythematous orophar-ynx. The chest has bilateral breath sounds with bibasilar rales.The cardiac exam is significant for a right ventricular heave. Thereis a normal first heart sound and a single second heart sound.There is no gallop. There is a III/VI systolic ejection murmur atthe left upper sternal border and a II/IV long decrescendo diastolicmurmur along the left sternal border. The pulses are full andequal. The abdomen is soft with the liver edge palpable 1 cmbelow the right costal margin. The extremities are warm andwell-perfused.
A chest radiograph showed an enlarged cardiac silhouettewith decreased pulmonary vascular markings. There werebilateral lower lobe interstitial infiltrates.
An electrocardiogram was performed (Fig. 1).
FIGURE 1. Electrocardiogram performed on presentation to the Emergency Department.
ECGS IN THE ED
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DISCUSSIONThe electrocardiogram has a regular rhythm at a rate
of 100 bpm. The lead II rhythm strip demonstrates a narrowQRS complex at a physiologic rate. There is a P wave beforeeach QRS complex and a QRS complex following each Pwave. The P wave axis is normal at 60-. The QRS complexfrontal plane axis is 120-, consistent with right axis devia-tion. The T wave frontal plane axis is 80-, which is concordant(within 60-) with the QRS complex frontal plane axis. The PRinterval is 230 msec, which is prolonged and consistent withfirst degree atrioventricular block. The QRS duration is normaland measures 70 msec. The corrected QT interval is 430 msec.There is a tall (almost 5 mm in height) P wave in lead II sug-gestive of right atrial enlargement. The lead II P wave is alsoprolonged, and there is a biphasic P wave in lead V1 with a deepnegative terminal component. These later findings are consis-tent with left atrial enlargement. There is a tall, pure R wave (noS wave) in lead V1 and a deep reciprocal S wave in lead V6
that is consistent with right ventricular hypertrophy. In addition,there is a qR pattern in lead V1 that strongly supports right ven-tricular hypertrophy.With respect to the Twaves, they are usuallyinverted in lead V1 at this age, and suggest right ventricu-lar hypertrophy when they are upright. As right ventricularhypertrophy progresses, the T wave in V1 inverts again untilthere is a more obvious repolarization abnormality and Bstrainpattern[. On this study, the inverted T wave, along with theaccompanying right ventricular hypertrophy, is a sign of ad-vanced right ventricular hypertrophy and repolarizationabnormality.
The electrocardiogram demonstrates sinus rhythm withfirst degree atrioventricular block, right axis deviation, biatrialenlargement, and right ventricular hypertrophy with a repolariza-tion abnormality. These findings suggest that there continues tobe residual right heart disease. The right axis deviation and rightventricular hypertrophy are probably due to persistent rightventricle hypertension. Elevated pressures in the right ventriclemay be caused by residual right ventricular outflow tract obstruc-tion or pulmonary stenosis. In tetralogy of Fallot with pulmonaryatresia, patients frequently have diminutive pulmonary arteriesthat result in downstream stenoses and obstruction, even if theright ventricle egress is widely patent. The atrial enlargement isnot surprising in this situation, especially if there is tricuspid valveinsufficiency. The cyanosis indicates that there is a residual right-to-left shunt, which could either be atrial or ventricular in a patientwith this diagnosis. The exam is consistent with this history andelectrocardiogram. The right ventricular heave suggests an en-larged right ventricle. The murmurs are consistent with residualright ventricular outflow tract obstruction as well as pulmonaryinsufficient. The chest radiograph is also consistent with thesefindings. All of these findings occur following repair of tetralogyof Fallot since the right ventricular outflow tract obstruction isrelieved surgically with a patch or conduit and resultant pul-monary insufficiency. The first degree atrioventricular block is animportant finding to note, but does not currently require inter-vention as long as there is no higher grade atrioventricular blocknoted at other times. The patient was admitted with a presumeddiagnosis of mycoplasma pneumonia. She received supplementaloxygen since her pulse oximetry was lower than baseline.
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