FROM THE BLOGOSPHERE
Editor’s note: Emergency Medicine residents and faculty at the University of Louisville have a private blog called
Room9ER.com. With permission, we share select posts with Louisville Medicine readers.
14 YEAR OLD WITH CHEST PAIN
Thomas Cunningham, MD
14
yo male presents to ER triage as a
level 2 in severe respiratory distress.
The nurse calls for a doc and I stroll
into the trauma bay for what I think is another
run-of-the-mill asthma exacerbation. I walk by the respiratory
therapist and even say. “Hey we’re gonna need a mini-neb in here
can you get that started.” This kid is working hard to breathe, accessory muscle use, speaks in short sentences. He looks like your basic
asthmatic, sitting up leaning forward supporting his body with his
arms on his knees. His mother tells me that he has been complaining
of SOA for the last 2 days and that last night he wasn’t even able
to lie flat because he couldn’t breathe. So I put the kid back to see
what happens: “NO, no, don’t do that it hurts my chest and I can’t
breathe.” The respiratory therapist is now getting ready to put the
breathing treatment on him and the nurse is getting him hooked up
to the monitor. On exam he has some wheezes bilaterally, but not
to the degree that you would expect given his work of breathing;
no complaints of abdominal pain, just can’t lie flat and can’t seem
to get his breath.
I glance up at the monitor as the nurse is getting the first pressure
to cycle. Sat 93% on NRB. Breaths>40. Pressure is.....85/67.?!? Not
what I expected...can we get a Chest X-Ray in here. TEMP? JVD?
At this point I’m thinking, “Did this kid blow a bleb, undiagnosed
cardiac abnormality!?” Mom is now at bedside and starts to give
some more history - she states he hasn’t really been feeling well over
the last week; little cough but no fever, no n/v/d/ or constipation.
No heart trouble and no history of asthma. No family history of
heart abnormalities, arrhythmias; never been in the hospital. She
says she thought he had GERD over the last two days based on his
complaints but now his SOA is worse.
SO I’m thinking lets slap the bedside ultrasound on this kid and
get an ECG ....
ECG:
hmmmm.....diffuse ST elevation, PR depression. Pericarditis! In a
14y/o, what? Well we have our answer for the chest pain, but what
about his SOA. So I slap on the cardiac probe, parasternal long axis.
Bedside ECHO:
Best freezed image of what we saw:
No JVD
TEMP: 97.8F
CXR:
This young man had pericarditis with a 3cm effusion. We contacted
interventional cardiology and he was whisked to the cath lab for a
tap. I followed and watched as they did a formal US which confirmed
the findings at bedside, 2.7cm at its largest point in the apex and
1.3 cm posteriorly. The RV and RA had some dyskinetic motion
suggestive of early tamponade. His vitals remained around 90/60’s
with sats in the low 90%. Anesthesia sedated him with ketamine and
the interventionalist aspirated the fluid under ultrasound guidance.
Take it into your own hands. LM
Note: Dr. Cunningham is a third year Emergency Medicine resident
at the University of Louisville.
OK...no pneumothorax, no widened mediastinum, no tracheal
deviation.....generous, ok BIG heart.
38
LOUISVILLE MEDICINE