If his pain got better after vomiting, I would repeat the ekg to see if
there was any resolution in ekg changes. However if his chest pain and ekg
changes persisted or worsened--inferior MI, I would get right sided leads to
look for right ventricular infarct or ischemia and get an echo (cardiology
consult) asap looking for wall motion abnormalities. If this is truly
myocardial infarction, he meets adult criteria for thrombolytic therapy with
his ST elevation in more than 2 contiguous leads 2,3,F.
How the Duchenne's M.D. may play into this is interesting. These
patients may have cardiomyopathy at any stage which could possibly result in
ischemia. If the boy has very severe kyphoscoliosis--which some of these
patients are known to develop, it may also be a cause for chest pain in
itself, but may also compress and compromise the heart causing ischemia
(less likely). I wouldn't be exactly sure how to interpret cardiac enzymes
in the setting of Duchenne's but I think troponins would probably be more
specific than creatine kinase as these would probably already be elevated,
making the mb fraction low (?) and useless.
Jim Tsung, MD
Jacobi Medical Center
Albert Einstein College of Medicine
>From: Hugo Dowd <[log in to unmask]>
>Reply-To: Hugo Dowd <[log in to unmask]>
>To: [log in to unmask]
>Subject: 12 yo boy with chest pain
>Date: Sun, 3 Sep 2000 08:59:18 -0700
>12 year old Duchennes MD ( spontaneous mutation) who is chairbound for 3
>years attends Ped ER with chest pain 4 hours after eating a doughnut on his
>birthday. A stir fry was eaten by the whole family the night before and
>everyone else in the house is well.
>His mum is concerned he has dyspepsia but it has not settled on over the
>He is not on regular medication and has no known allergies.
>No family history of sudden death, IHD, hyperlipidaemia etc.
>In the dept while having an EKG his condition worsens. He becomes
>increasingly anxious. He denies palpitations.
>Immediately after being given gaviscon he vomits partially digested food
>feels immediately better.
>His ECG has an infero anterior ishcaemic pattern.4 mm depression V1, 3mm
>V2,St elevation of 5 mm on 1,2, 3mm on 3 and avF and 2 mm dep on avR
>His first BP is low ( sys 70) but with an appropriate sized cuff it is in
>within normal limits ( sys 110) for his age and weight. There is no
>dysparity in the arm BP and there is no radio-femoral delay
>What next folks?
>Paediatric Emergency Department
>Bristol Children's Hospital
>St. Micheal's Hill
>University Hospital of Wales
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