An 11 year old male presents with complaint of substernal chest pain, 6/10, unable to describe the sensation but non-radiating, which started while running.
- Patent airway
- Adequate respiratory effort with no signs of distress
- skin is pink, warm and dry, with no signs of hypoperfusion
Pertinent medical Hx:
- Chronic Interstitial Lung Disease
- Secondary Pulmonary Hypertension
No allergies reported
- Acetaminophen PRN
- Furosemide 20mg
Baseline vital signs:
- Heart rate: 112 beats/min
- Respiratory rate: 24 breaths/min
- SpO2: 97% on 2 lpm O2
- Capillary refill: < 2 seconds
The patient is evaluated in the ED and admitted or further evaluation. The following 12 lead ECG is obtained:
- Sinus rhythm
- Biatrial Enlargement or Abnormality
- Right Ventricular Hypertrophy (R > 7mm in V1-2)
- Rightward Frontal Axis (QRS axis approximately 121 degrees)
- Right Precordial ST segment depression
As many prehospital and in-hospital providers are initially taught, ST segment depression and T wave inversion indicates myocardial ischemia. However, there are other conditions which can present with ST segment depression and T wave inversion, and not be ischemia related. These are commonly due to ventricular repolarization abnormalities, electrolyte imbalances such as Hypokalemia (low serum Potassium) and Hypomagnesemia (low serum Magnesium) and in the pediatric setting, Juvenile T waves or Juvenile T wave Inversion.
Reponarization abnormalities, such as the ones seen in ventricular hypertrophy, ventricular beats, Bundle Branch Blocks or ventricular paced rhythms, are knows as Secondary ST-T changes, which again, are not due to ischemia but the altered repolarization conduction. At times, it might be hard to differentiate between the two, however, in this case, the patient is admitted and diagnosed with Cor Pulmonale, treated for Pulmonary HTN and mild Hypokalemia of 3.0 mEq/L following blood work. Cath performed show no structural coronary artery deffects or occlusion.
28 days later, the same patient presents to the Emergency Department complaining of chest pressure and is again admitted. The following 12 lead ECG is obtained:
Biatrial enlargement or abnormality
Rightward Frontal Axis at 112 degrees
Biventricular Hypertrophy voltage criteria
Secondary ST-T changes
An Echocardiogram study is performed which showed mild dilated Right Atrium (RA) and dilated Right Ventricle (RV) with decreased RV systolic function and tricuspid valve regurgitation. Normal Left Ventricular function and size noted.
The patient is admitted and treatment remained with Viagra (sildenafil) 20mg, Ambrisentan 10mg, Lasix 20mg and shceduledÂ Bipap. Hemodynamic monitoring was established with Central Venous Pressures (CVP)Â and Pulmonary Artery Pressures (PAP) assessed and controlled.
16 days later, the following 12 lead ECG is obtained, with no complaint or symptoms:
- Biventricular Hypertrophy voltage criteria
- Rightward Frontal Axis at 98 degrees
- Secondary ST-T changes
This time, Echo showed thickened RV free wall with improved systolic function and tricuspid valve insufficiency. There is a dilated main pulmonary artery with normal branches. The LV remained within normal limits.
Take home value:
In the emergency medicine setting, a large portion of pediatric population will present with pulmonary and cardiac related complications, which mostly arise from congenital etiology. The pulmonary and cardiac systems (Cardiopulmonary) are unavoidably related for normal physiologic function. Although RV forces are typically predominant in the early stages of life and often normalizes as the LV increases in workload and size, pathologic RV changes are one of the most common abnormal findings during pediatric ECG evaluation, which often, not only reflect cardiac abnormalities, but pulmonary system deffects.
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