Time to pace, no time to waste

Here is another post from one of our senior residents - Dr Gayathri Nadarajan.
It is 5am in the resuscitation room. And just when everyone was starting to space out, the nurse brings in a 18-year-old girl on a wheelchair, following a near-syncopal episode. She looked pale, diaphoretic and something didn’t seem quite right.
Presenting Complaint
Diarrhoea, vomiting  and dizziness for 2 days. No actual syncope or seizure like episodes. No fever. No HI and no headache. Has mild abdominal cramping sensation.
Past Medical History
NIL. Certain she is not pregnant
Vitals
BP 100/60     HR-45/min     Temperature- 36.7
Examination
Unremarkable. Abdomen was soft without any guarding or rebound.
ECG shows
Complete heart block
Figure-18-ECG-showing-third-degree-complete-AV-block-and-a-junctional-escape-rhythm

During the consult….
While talking to the patient, her eyes rolled upwards, her body went stiff and she appeared to have a tonic clonic seizure. I couldn’t feel a pulse and the cardiac monitor showed asystole. We immediately started chest compressions. Within a few seconds, she regained consciousness and was shocked to find all of us fussing over her.
Her heart rate was about 40-45. Hence we gave her atropine and prepared for transcutaneous pacing. While preparing for transcutaneous pacing, she had 2 more episodes of brief tonic clonic seizure following a sinus pause. Dopamine was prepared concurrently as the pacing wires were attached to the monitor.
We finally started pacing her and called for a cardiology consult.
That was not the only problem….
In view of the abdominal discomfort in a young girl with syncope, bedside FAST was done, which showed free fluid in the abdomen.
ruq1
Rapid urine HCG was done, which was negative. Hence a GS consult was called for.

Findings and progress
CT scan showed:
  • Moderate ascites
  • Mild diffuse thickening of the large bowel, which is nonspecific and could be associated with non-specific colitis.
  • Gallbladder is distended.
  • Bilateral pleural effusion with associated atelectasis/ consolidation
Troponin:
Her troponin T was 870 ng/L and CK-MB was 39.99.
FBC:
WCC was 15.4
Rest of her bloods were unremarkable and CXR was clear.

Progress
In ED, we concluded that she had symptomatic heart block and the most likely diagnosis was myocarditis. (after ruling out things like drug overdose, pregnancy)
The free fluid in the abdomen could have possibly been due to an inflammatory process such as colitis
In view of the complete heart block with syncope, she needed tranvenous pacing. Hence the cardiology team reviewed her in the ED.
Patient had the transvenous pacing wire inserted and she was admitted under the CGH cardiology team. Inpatient echo was normal. During her stay, family requested for transfer of care to NHC. She is currently recuperating there. She is currently off the transvenous wire and awaiting a pacemaker.

Learning points
  • It is important to check the pulse in patients with a seizure as the seizure could have been the result of hypoxia to the brain from a loss of cardiac output (such as VF/VT/ ventricular pause). This was probably the mechanism of her tonic clonic seizure.
  • Don’t hesitate to pace. When there is significant bradycardia / sinus pauses, indications to pace are:
    • hemodynamic instability (hypotension/ cold, clammy peripheries),
    • altered conscious level
    • syncope
  • Myocarditis can have various cardiac manifestations. Do not forget to include it in our list of differentials.
  • Free fluid in abdomen doesn’t always mean a surgical abdomen / cause. Clinical correlation is important.

Myocarditis in a nutshell (from Life in the Fast Lane)
Possible ECG changes:
  • Sinus tachycardia.
  • QRS / QT prolongation.
  • Diffuse T wave inversion.
  • Ventricular arrhythmias.
  • AV conduction defects.
  • With inflammation of the adjacent pericardium, ECG features of pericarditis can also been seen
Causes:
  • Viral – including coxsackie B virus, HIV, influenza A, HSV, adenovirus.
  • Bacteria – including mycoplasma, rickettsia, leptospira.
  • Immune mediated – including sarcoidosis, scleroderma, SLE, Kawasaki’s disease.
  • Drugs / toxins – including clozapine, amphetamines.