I had an interesting child present to me a few days ago and I wonder if
anyone in the list has seen something similar.
This 13 year old boy came in with severe right sided chest pain (upper
sternal), and demanding oxygen. He had minimal cough and no SOB
He described non-radiating pain, worse with breathing and when sitting up.
The HR 105, Afebrile, RR 20s, and sats 100% on RA.
He is known to have hyperesoniphilic syndrome and had been previously
admitted for a chest infection. He was discharged 10 days previously.
He was not on antibiotics but was on his usual doses of steroids and Imuran
Immediately on applying oxygen he seemed to settle for a short while. A few
minutes later he developed the pain again.
An EKG showed significant ST depressions in leads 3, aVF, and reciprocal
changes in the lateral leads.
We assumed some ischemic event was going on and prepared to start ASA,
Heparing, Morphine. While we did this, he became unconcious, and we noted
a short run of Vfib. The rhythm resolved spontaneously and he awoke and
began to fight. Again we noted a run of wide complex QRS on the monitor, but
with a pulse. Shortly therafter he went into a bradycardia with HR in the 40s.
CPR was maintained.
As we were preparing to intubate him, he would intermittently start moving,
and fighting the BMV. We noted his HR went upto 60 with one dose of
After intubation, he remained in a bradycardia with large ST elevations.
We attempted multiple doses of Atropine and then Epi but withtout the same
response and the patient finally succumbed.
An echo confirmed no
Our most likely diagnosis at that time was acute MI inferiolateral and
I was wondering if anyone has
A. Seen hyperesiniophilic syndrome present with AMI at this age. The primary
physician said he has seen such patients come with acute strokes, GI
ischemia. He states when they do thrombose, he describes it as an esonophilic
thrombus and they usually progress and do poorly.
B. used thrombolytics in this age? Our pediatric cardiologists had no experience
in this, and the adult cardiologists were very hesitant to attempt it. Their
concern was the age, size of the child and the dose of tPA. In addition, as for
PCI,their concerns were they couldn't offer appropriate back-up if there any of
the expected complications.
C. Any experience with dosing of tPA in children?
D. Any other ideas about how management could have been different?
King Faisal Specialist Hospital, Riyadh Saudi Arabia
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