all i need is a cast… shawn dowling, pgy-4. case 11 yoa m. seen in ed last week after fall during...
TRANSCRIPT
![Page 1: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/1.jpg)
All I need is a cast…
Shawn Dowling, PGY-4
![Page 2: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/2.jpg)
Case
• 11 yoa M. Seen in ED last week after fall during Lacrosse game.– Dx with a Distal Radius Buckle #– Discharged with a removable brace.
• Returns to ED today to get a cast because his “friends” are hitting his broken arm in the splint
![Page 3: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/3.jpg)
Physical Exam
• BP – 116/70, • HR – 42, RR-20,
SpO2-97%• Tender at distal
radius• Wrist/elbow shoulder
normal
![Page 4: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/4.jpg)
Normal Vital Signs
![Page 5: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/5.jpg)
Your options
1. Describe to him the Buckle Fracture study in detail and keep him in the splint
2. Cast him and avoid the hassle
3. 1 or 2 + have a discussion about what “friends” are
4. 3 + ECG
![Page 6: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/6.jpg)
Diagnosis?
![Page 7: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/7.jpg)
![Page 8: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/8.jpg)
P’s map out
QRS’s map out
Where is the escape rhythm coming from?
![Page 9: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/9.jpg)
Complete heart block
• No atrial impulses reach the ventricle through the AV conduction system– AV Dissociation– :. Always more atrial beats than ventricular
• Escape rhythm can occur anywhere below site of block – The more distal, the slower the HR– The higher the block the more likely to respond to
atropine/catecholamines– Proximal to/at bundle of His; narrow QRS, HR>40– Distal to bundle of His; wide QRS, HR<40
![Page 10: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/10.jpg)
![Page 11: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/11.jpg)
Further history
• Patient had presyncope and SOB with exertion in the past
• Saw pediatrician a few years ago– Did iron studies -> normal,
told there is nothing to be concerned about
• Over past few months increasing Sx
• Made appt with FP for two wks from now
• PMHx – ADD • Meds - Concerta, • FHX – no SCD, no
premature deaths, no pacemakers
![Page 12: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/12.jpg)
DDx
• Idiopathic progressive cardiac conduction dz
• Ischemic heart disease• Drugs (many, MC are…)
– Amiodarone– B-blocker– CaCB– Digitalis– Concerta NOT one
• Valvular Heart disease– Calcification extend to AVN
• Hyperkalemia
• Infiltrative dz – lymphomas, tumours
• Familial disease• Congenital Complete
heart block• Infectious/Post-infectious
– Myocarditis– Rheumatic fever– Lyme carditis
![Page 13: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/13.jpg)
Congenital Complete Heart Block
• Incidence – 1 in 15,000 – 22,000
• Diagnosed:– In utero/Neonatal– Later in childhood
• Etiology:NEONATAL– Neonatal Lupus (95%)
LATER IN CHILDHOOD– Myocarditis– AV discordance– Corrected TGA– Polysplenia with AV
defect– Hereditary disorders
![Page 14: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/14.jpg)
Pathophysiology – Neonatal
• With neonatal lupus the problem is maternal lupus AB
• These AB bind to AV nodal tissue leading to autoimmune injury and fibrosis of the AV node and surrounding tissue
![Page 15: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/15.jpg)
Pathophysiology – older children
• With most other causes, the problem is fibrous tissue that either replaces the AV node/surrounding tissue or there is a disconnect between the atrial myocardium and the AV node
![Page 16: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/16.jpg)
In Utero/Neonatal presentation
• Bradycardia is the MC presentation• IN UTERO
– Significant number have IUFD (7-21%)– Other presentations include hydrops fetalis, PCE
• NEONATAL– High neonatal MR (9-27%), – Worse Px when fast atrial rate (>150bpm) and slow
ventricular rate (<50bpm)– Better PX when Dx as neonate (rather than in utero)
![Page 17: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/17.jpg)
Childhood presentation
• Up to 40% may not present until older (mean age 5-6 yoa)
• 5% had unrecognized neonatal lupus• Can be intermittent initially – becomes
persistent with advancing age– Age at presentation likely dependent on VR
• Usu present w/ bradycardia related Sx – Exertional SOB– Presyncope/syncope
![Page 18: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/18.jpg)
Treatment
• In utero/perinatal– Steroids (if associated with neonatal lupus)– Isoproterenol
• Childhood– Pacemaker (type based on MD preference)
• Ventricular (VVI)• Dual Chamber(DDD): MC since more physiologic,
– 90% by age 60
![Page 19: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/19.jpg)
![Page 20: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/20.jpg)
Pacemaker IndicationsClass I conditions• Symptomatic bradycardia (syncope or
presyncope) • Moderate to marked exercise intolerance • Heart failure thought related to the
bradycardia • Left ventricular dysfunction or low cardiac
output • A wide QRS escape rhythm or block below
the His bundle [33] • Complex ventricular arrhythmias [31,37] . • In an infant, <50 to 55 bpm or <70 bpm
w/SHD• Sustained VT• 2 or 3 ºAVB >7 post cardiac Sx• Cardiomegaly• Prolonged QT• Ventricular arrhythmias related to a slow
rate or abolished by a more rapid heart rate.
Class II conditions• 2 or 3 ºAVB within the bundle of His in an
asymptomatic patient. • Prolonged subsidiary pacemaker recovery
time with a pause greater than three seconds
• Transient post Sx 2 or 3 ºAVB that reverts to bifascicular block.
• 2 or 3 ºAVB and a ventricular rate below 50 bpm when awake beyond the first year of life
• Complete AV block with double or triple rest cycle length pauses or minimal heart rate variability.
• Asymptomatic neonate with congenital complete heart block and bradycardia in relation to age [3] .
• Long QT syndrome. • CHD and impaired hemodynamics due to
sinus bradycardia or loss of AV synchrony. • Neuromuscular disease with any degree of
AV block
![Page 21: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/21.jpg)
Prognosis
• Neonatal CHB– 17% die prior to 3 months (usually from fetal
hydrops/premature delivery)
• Childhood CHB– Higher likelihood of poor outcome in patients with HR
<50 and with unstable jxn escape– Study of 102 patients followed up between 7-30 years
• 27 patients had syncopal episode• 8 of these were fatal, 6/8 were first syncopal episodes• 44 of the remaining patients received a pacemaker
![Page 22: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/22.jpg)
– HR decreased with age from 46bpm at age 15 to 39 bpm at 40 yoa
– Everyone with a prolonged QTc had a syncopal attack
• Without PM:– Many develop cardiomegaly (compensatory
for low CO) and CHF– Risk of SCD increases with age
![Page 23: All I need is a cast… Shawn Dowling, PGY-4. Case 11 yoa M. Seen in ED last week after fall during Lacrosse game. –Dx with a Distal Radius Buckle # –Discharged](https://reader033.vdocuments.us/reader033/viewer/2022051216/5697bfdc1a28abf838cb10f1/html5/thumbnails/23.jpg)
Px Post-Pacemaker
• Px is excellent with pacemaker– 5-11% develop CHF– Related to myocardial fibrosis, ventricular
asynchrony– Will require – Most live normal productive life