Case: A 4 day old female born at 36w1d via C-section presents for tachycardia. Father at bedside states that he placed a heart monitor on the patient and it read over 200 bpm. Patient was seen at urgent care and transferred to ED via ambulance. Baby has otherwise acting normally, eating frequently, making 6+ wet diapers per day. No prior medical history. No family history of abnormal heart rhythms. Vitals include BP 85/53, HR 300, Temp 97.5F, RR 50, SpO2 100%. Exam shows a well appearing, interactive neonate with tachycardia on auscultation. 

Differential diagnosis: Arrhythmia, dehydration, anemia, infection, hyperthyroidism

EKG is obtained and shown below:

EKG interpretation: Supraventricular tachycardia at rate of 300

Case continued: Patient is placed on continuous cardiac monitoring. Vagal maneuvers are attempted including rectal temperature without success in terminating SVT. An IV is placed and adenosine is administered. Repeat EKG following adenosine is shown below. Pediatric cardiology is consulted and recommends administration of digoxin and transfer for further evaluation. Patient is then transferred to a pediatric center in stable condition.

Learning points:

• A heart rate > 220 bpm in an infant or > 180 bpm in a child with rate out of proportion to clinical status is likely supraventricular tachycardia.²
• Vagal maneuvers should be attempted initially for patients who are stable.
  • Maneuvers that can be attempted in infants include obtaining a rectal temperature or applying a cold ice pack to the face to activate the mammalian diving reflex.
• If vagal maneuvers fail, rapid push of IV adenosine at a dose of 0.1 mg/kg is recommended.
• If the patient is unstable or adenosine fails to terminate the rhythm, perform synchronized cardioversion at a dose of 0.5-1 J/kg.
  • Subsequent synchronized cardioversion attempts should be dosed at 2 J/kg.

References:

Hauda, II WE. Resuscitation of Children. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. 

Kleinman  ME, Chameides  L, Schexnayder  SM,  et al: Part 14: pediatric advanced life support. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122(18 suppl 3): S876, 2010. [PubMed: 20956230]  

By: Alexander Hilbmann MD

HPI:

52 year old female with pmhx of hypothyroidism who presents to Emergency Department with bilateral leg swelling and SOB with exertion. Reports swelling began one week ago and has progressively worsened. Denies any other symptoms. Patient has not seen a cardiologist/had an echo performed before. Reports she has not taken her prescribed levothyroxine for two years now.  

Physical Exam:

Vitals BP 128/82 HR 80 BPM Temp 92.8F Oral Resp 29 SpO2 99%

Abnormalities on physical Exam:

Periorbital Swelling of bilateral eyes

Rales present in bilateral lower lungs

Distension of abdomen

Bilateral lower extremities with non pitting edema

12 Lead ECG:

Interpretation: Sinus bradycardia, low voltage ECG

Bedside subxiphoid cardiac ultrasound:

Interpretation: Circumferential pericardia effusion, RV collapse consistent with pericardial tamponade physiology

For a FANTASTIC review of ultrasound guided emergency pericardiocentesis, check out the Ultrasound Podcast Youtube video HERE

Case continued:

• Patient found to be hypoglycemic at 50 mg/dL, D10 administered
• Patient found to be hyponatremic at 125, likely in setting of fluid overload
• Cardiology consulted for cardiac tamponade, pericardiocentesis performed with 1.4 L drained. 
• Ascites drained via paracentesis, other diagnoses ruled out with hypothyroidism most likely cause.
• Patient restarted on levothyroxine and began liothyronine (T3)in hospital
• Patient discharged home in stable condition after 10 days in hospital with levothyroxine, has not returned to hospital since

Pearls:

• Consider hypothyroidism if patient has pmhx or classical physical exam findings: bradycardia, hypothermia, hypotension, lethargy, constipation, hair loss/thinning, facial swelling, coarse skin, pretibial myxedema(thickened, nonpitting edema), menstrual changes, decreased reflexes.
• Hypothyroidism increases permeability in the blood vessels of the body and decreases drainage of lymphatic system, causing an accumulation of fluid outside of blood vessels and can present as pretibial myxedema, pericardial effusion, or pleural effusion.
• Precipitating factors of hypothyroidism include medication nonadherence, infection, cold exposure, stroke, autoimmune disorders, thyroid radiation/surgery,  and medications (amiodarone, lithium).
•  Management of hypothyroidism includes supportive, hydrocortisone(prevents adrenal crisis), levothyroxine (T4) and +/- Liothyronine (T3) supplementation.

References:

Chahine J, Ala CK, Gentry JL, et al Pericardial diseases in patients with hypothyroidism Heart 2019;105:1027-1033.

Patil N, Rehman A, Jialal I. Hypothyroidism. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519536/

Kane McKenzie M.D.

Dialysis Fistula Bleeding Aneurysm

HPI

69 year-old female with a past medical history of ESRD on HD, HIV, Pulmonary HTN, HFrEF (EF 25%), anemia, thrombocytopenia presents after dialysis with left upper extremity pain and swelling. The dialysis RN reports there was shiny skin present over the LUE AVF and they cannulated to avoid that area, the patient received one hour of treatment that was stopped due to pain. Patient reports the her arm above the AVF has been slowly enlarging

Vitals

BP: 98/54, HR: 78, RR 20, T: 97.6

Exam:

Alert and oriented, no acute distress, chronically-ill appearing

LUE with no external bleeding, fistula has a palpable thrill. Swelling and tenderness are present above the AVF, over the medial upper arm.

Cap refill >2 seconds

Rest of exam unremarkable

Clinical Course

-CTA upper extremity was obtained to assess for active bleeding – showed AV fistula with aneurysmal dilatation, large hematoma with upper arm approximating a volume of 1000cc. No evidence of active hemorrhage

-Direct pressure was held above and below the AVF.

-Repeat BP 58/24

-Central line placed, resuscitated with 2U PRBC, 1 platelets, 1 FFP. Required norepinephrine and vasopressin drip

-Taken level 0 to OR for Brachiocephalic fistula ligation and hematoma evacuation with 500cc hematoma removed

-The patient was stabilized and recovered after being treated for hemorrhagic shock

Pearls

-AVF aneurysms can develop from repeated ruptures, increased venous pressure, and immunosuppression. They are usually asymptomatic, rarely rupture. Aneurysm formation is present in 5-7% of AVF

-Skin changes, pain, high output heart failure, and thrombosis can result from aneurysms and are an indication for operative management.

-AVF pseudoaneurysms can develop from extravasation of blood from cannulation sites, are more prone to rupture, develop more quickly

-Aneurysms/pseudoaneurysms can be identified by their shiny, thin, atrophic skin. In more severe cases can present with necrosis.

-Apply pressure and/or tourniquet above and below the AVF if life threatening hemorrhage is suspected

-Emergent consultation with vascular surgery warranted for operative repair

References:

Pasklinsky G, Meisner RJ, Labropoulos N, Leon L, Gasparis AP, Landau D, Tassiopoulos AK, Pappas PJ. Management of true aneurysms of hemodialysis access fistulas. J Vasc Surg. 2011 May;53(5):1291-7. doi: 10.1016/j.jvs.2010.11.100. Epub 2011 Jan 26. PMID: 21276676.

Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP; National Kidney Foundation. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020 Apr;75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001. Epub 2020 Mar 12. Erratum in: Am J Kidney Dis. 2021 Apr;77(4):551. PMID: 32778223.

Saeed F, Kousar N, Sinnakirouchenan R, Ramalingam VS, Johnson PB, Holley JL. Blood Loss through AV Fistula: A Case Report and Literature Review. Int J Nephrol. 2011;2011:350870. doi: 10.4061/2011/350870. Epub 2011 May 30. PMID: 21716705; PMCID: PMC3118665.

by: Kaitlyn Dixon M.D.

Author: Jordan Spaude M.D.

Author: Dan Harwood M.D.

HPI:

A 63 y.o. female with PMH of migraines and chiari malformation presents with headache. Patient reports that for the past 10 days, she has had a right-sided migraine that she describes as similar in quality to her prior migraines but longer-lasting. However, at 2 PM yesterday, she experienced an acute worsening of the severity of her headache – additionally, the pain became bilateral and occipital at this time. The patient reports dizziness, nausea, and photophobia, and her husband states that the patient has been slower to respond to questions for the past day. Denies vomiting, visual changes, or fever.

Vitals: BP: 133/90 | Pulse: 71 | Temp: 98.1F | Respiratory Rate: 18 | SpO2: 99%

Neuro exam is non-focal. Patient appears tired, but responds to questions appropriately. 

Clinical Course:

Patient given Tylenol, 10 mg IV Compazine, and 1 L lactated ringers with significant improvement in symptoms. Given change in headache quality from prior migraines and acute worsening of headache, CT Head wo contrast ordered. 

CT revealed a large hemorrhagic neoplasm in the right frontal region with associated mass effect and 1.2 cm leftward midline shift resulting in obstructive hydrocephalus. Patient subsequently noted to be increasingly somnolent compared to initial presentation. Neurosurgery was emergently consulted who recommended decadron, Keppra for seizure prophylaxis, and admission to the Neuro ICU.

Headache Pearls:

The majority of headaches are due to primary headaches such as tension headache, migraine, or cluster headache. However, as 18% of patients with chief complaint of headache may be experiencing a secondary headache disorder. Many of these secondary headaches represent life-threatening emergencies such as intracranial bleeding or CNS infection. The SNOOP mnemonic is a helpful tool for remembering “red flag” headache symptoms to identify headache patients who warrant further imaging/laboratory work-up in the ED. Additionally, improvement in symptoms with medication does not decrease the likelihood of a secondary headache disorder.

Systemic: Systemic signs or conditions such as fever, weight loss, immunocompromise, HIV, cancer

Neuro: Neurologic findings including mental status changes, vision changes, seizure, confusion, or focal neuro findings on exam

Onset: Onset that is acute with progression to worst severity within minutes

Older: Older patient (50 y.o. or older) with new headache or a progressive headache

Previous: No history of previous headaches, or in a patient with history of headaches, a change in severity/symptoms/location from prior headaches

Pregnancy: Headache in pregnant or post-partum patient

References:

Ashenburg Nick, Marcolini Evadne, Hine Jason. Approach to Headache. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/rec8eRzSrPsVUiMuV/Approach-to-Headache#h.pq7xksb5a2qy. Updated October 8, 2022. Accessed December 22, 2023.

Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003;3:87–92.

Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144. doi:10.1212/WNL.0000000000006697