I agree with Jay regarding concern regarding thromboembolic disease especially with this child's
significant imobility, acute onset of chest pain. I think a Va/Q or a spiral CT scan would be
very appropriate. Addtionally the spiral CT would provide other information regarding presence of
effusion or vascular disease (aortic dissection). In our institution this would probably precede
the echo b/c of availability. Also I think the CT would help evaluate for two immediately
life-threatening etiologies (PE, dissection) while the echo would not.
I would be very cautious giving thrombolytics to a pediatric patient. I think most of us are
comfortable making risk-benifit decisions with adult patients b/c there are huge studies showing
significant overall improvement in mortality using the specific EKG criteria. We know that not
everyone with those changes will be having an MI, but overall the risk of not treating is much
higher than the risk of giving thrombolytics. However because the pre-test probability of AMI in
children is so much lower, I'm not sure we can apply these statistics to the same EKG findings in
children, and I am concerned that the risk of thrombolytics for any EKG criteria is probably quite
Jay Pershad wrote:
> I have been following the thread with keen interest. First of all I
> seriously doubt this is "food bolus obstruction" especially when you note
> that there is no real temporal relationship. It occurred 4 hours after the
> donut ingestion! If anything it is a red herring!
> Jeff and Jim: I am not convinced this is an acute coronary syndrome. DMD is
> associated with dilated cardiomyopathy. He is 12 years old. I see no reason
> for him to be at risk for CAD. This may be "bad" muscle but the "piping"
> should be fine. Given this, I am not sure about thrombolytics,
> catheterization etc. Also, why would he be at risk for dissection or
> vasculitis?? Obtaining right sided and posterior leads makes sense to me. It
> is easy to obtain and would clarify the diffuse ST changes further.
> I wholeheartedly agree with Jeff Mann's other line of thinking w.r.t such
> diffuse ST-T changes. The changes described affect his antero-septal,
> inferior & lateral wall. He does need an emergent echo-cardiogram to rule
> out pericarditis. Besides, if he has evidence of cardio-myopathy he is also
> at risk for development of ventricular aneurysm that could give such diffuse
> ST-T changes.
> If his echo is normal, given his symptoms of anxiety and chest pain, ST_T
> changes and an "immobile" state, I am very concerned about PTE. I would
> pursue that aggressively with an ABG, VQ scan etc..............
> Hugo, could you give us follow up on his case. What did his echo
> demonstrate? It would be nice if you could post his EKG on the list.
> Jay Pershad, MD
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