Hot Seat #86: 5yo with persistent tachycardia
Posted on: January 9, 2017, by : Nancy Gilchrist MD
Nancy Gilchrist MD, Children’s National Medical Center
with Shilpa Patel MD, Children’s National Medical Center
The Case
A 5 year old male is sent to your ED from his pediatrician’s office for tachycardia. The patient first noticed his heart beating very fast 3 days prior to presentation. He states he had intermittent episodes of feeling his heart beating much faster than usual over the past three days. The patient has had some cough and congestion, and had one tactile fever early on the morning of presentation that resolved with acetaminophen and has not recurred. He has otherwise been asymptomatic and eating well.
ROS:
HEENT: congestion, rhinorrhea
CVS: palpitations, no pallor or SOB
PULM: no SOB or wheezing
GI: no vomiting or diarrhea
Neuro: no dizziness/lightheadedness, no syncope
PE:
Temp 37, HR 142, RR 32, BP 102/ 69, SpO2 100% on RA
GEN: Well appearing, alert and responsive
HEENT: TM wnl, tacky mucous membranes, no pharyngeal lesions or erythema
CVS: Tachycardic to 150-160s, HR increases up to 20 bpm when he moves, no murmurs, rubs or gallops, 2+ upper and lower extremity pulses bilaterally
PULM: mild tachypnea, lungs CTAB, no retractions
GI: soft, nontender, nondistended, no HSM
EXT: brisk cap refill, normal strength and sensation bilaterally
An EKG was obtained which demonstrated tachycardia to the 140s with no ST elevation or other abnormalities. Patient took about 10-12 oz PO with no improvement in HR. HR remained in 150s.
Question:
Labs were significant for H/H 11.9/34.5, WBC 12, bicarb 22, BUN/Cr 9/0.36, TSH 1.79, UA wnl with SG 1.016. A CXR was obtained and was WNL without cardiomegaly. The patient received two NS boluses with no change in HR. He remained well appearing and continued to tolerate PO.
Another Question:
Cardiology was consulted; they performed an echocardiogram, which was wnl.
Last Question:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
Since no else has yet posted, I’ll just share my initial off the cuff thoughts that are not portrayed in the case…Part of my decision-making to admit or discharge goes to the course of the patient and family in the ED. To accomplish all the things that have been done thus far is likely 2-6 hours of watching this family.
I would gather pieces of info from other providers (nurses, techs, etc.) about how the interactions have been, watch the monitor periodically to see how low his HR gets, and from a distance watch the kid as well to see how he’s bothered by this.
Another discharge option becomes if Cards would consider a Holter to see if there is a dysrhythmia occurring on top of the tachycardia that could be captured. Again these are all conversations and interactions that can happen over the course of a prolonged stay in the ED….
Wow, this kid is pretty tachycardic and his presenting symptom was “I feel my heart beating faster”, so this is a new change. You’ve evaluated for almost all the causes of sinus tach in a well appearing child. The only other things I can think of are ingestion (so ask about all medications, including herbal and OTC) and a pheochromocytoma (any headaches or sweating?). I don’t think it would be wrong to send this child home since you’ve had a normal cardiology work up, but he needs follow up.
I am impressed that a five year-old 1. noticed his heart beating fast, 2. relayed that to a caregiver, and 3. the clinical findings/VS matched that concern. My main concern sending this child home was how confident can we be this is not myocarditis with possible rapid hemodynamic compromise. Given his history of recent illness, his persistent tachycardia, tachypnea, I would discuss with the cardiologist the sensitivity of ECHO for myocarditis (my gun instinct is that it is rather sensitive, at least for clinically significant cases). I believe ECHOs classically show left ventricular dysfunction in myocarditis. My follow up question to the consultants would then be: 1. would admission for a cardiac MRI be helpful in the setting of a normal ECHO and 2. would drawing cardiac biomarkers (troponin, CK-MD) add to the work-up?
normal BP. normal XR. sinus tachycardia. normal lytes. normal thyroid. no signs of pericarditis. no signs of dysrhythmia. no anemia. no hypovolemia. hmm. good one.
there are other paraneoplastic syndromes to think about. Pheo usually causes hypertension too.
i’d put some money on an herbal/OTC supplement. the ROS says the kid had congestion/cough so i’d ask a lot of questions about cough medicines, anti-histamines, liquid albuterol, etc.
i would’ve gotten LFTs. Stephen Freidman study of cases of myocarditis showed some consistent elevation of ALT (or AST, i forget which). Liver congestion and impaired venous return could cause tachycardia.
He’s not just tachycardic, he’s also a bit tachypneic. I’d probably push cardiology to echo in the ED in the absence of another cause of tachycardia. he’s pretty tachy for an afebrile kid without other reason especially getting up to 160 and everything else being fairly status quo….that’s highly abnormal. unless they say he chugged a bottle of cough syrup.
I wanted to say i’d do virtually nothing else and have the cards tech put a holter on him and have him f/u with cardiology clinic, but i don’t think a holter really does anything here. he’s showing you why he has palpitations so it’s not like you’re trying to capture an event or run of vtach etc. I also don’t think observation does anything. Not sure what we’d be observing for other than other kids giving him the flu.
good case.
I agree with what has already been said on this case. Also, I agree that a HR of 150s-160s on a 5 year old without fever, evidence of dehydration or anemia is something that makes you stop and think.
I’m going to use SPIT (which Sonny Tat, a former PEM fellow, introduced to us) to review the DDx.
S Serious
P Probable
I Interesting
T Treatable
DDX:
S: Serious
Arrhythmia – First of all these are very uncommon in children with structurally normal hearts. We know this child has no history of cardiac surgery, and additionally we have a normal ECHO. We also have an ECG without any changes except for sinus tachycardia and variability of HR on the exam (goes against SVT). Our patient is a bit young however, sometimes probing a bit at the presenting complaint can be helpful. As life threatening arrhythmias often suddenly start and stop and last seconds to minutes. Compared to persistent sense of palpitations or fast heart beat more commonly associated with fever, anemia, dehydration, tox, etc. For our patient, the lack of dizziness or syncope, chest pain and a negative family history of sudden cardiac death, with a normal ECG and persistent tachycardia, goes against palpitations due to a life threatening arrhthymia. Putting a holter on was mentioned however I think this is low yield as he is persistently tachycardic, it is not as if he had some intermittent rhythm (palpitations as mentioned) that you want to capture. Again – he is young, but you could ask if he is feeling that sensation of ‘racing heart’ while he is tachycardic in the ED and if now it’s ‘all the time’ vs ‘intermittent.’
Myocarditis – I agree with Jeremy. I worry about very early or mild viral myocarditis in this child and would definitely consider adding troponins, a BNP or LFTs as Dave suggests. I’m not sure the cardiologist would be able to rule it out based on the normal ECHO as there are no clinical signs of failure either (abdominal pain, hypoperfusion, gallop, HSM, fluid overload). Also it is common to have no ECG changes on myocarditis. Also, I don’t think we have much understanding on ‘mild’ viral myocarditis, and which of these patients do fine and which go on to fulminant myocarditis. A PubMed search resulted in one case series (not done in the US) finding that 90% patients discharged from their hospital over 8 years, had tachycardia and that it was the most common exam finding. This was a sicker group with majority admitted to the ICU. But I think, it’s important not to decrease the importance of tachycardia. Finally, Jamil I’m sure recalls, we had a patient who was in our ER who developed a gallop while in the ED. Earlier exams had tachycardia (she also had neck pain from a reported injury, but otherwise looked well). She ultimately ended up in the PICU and then CICU on ECMO. Granted this is one case, but we know that myocarditis and changes that occur causing heart failure occur sometimes suddenly and without warning.
Sepsis – This child is very well appearing, though I guess this could be early sepsis, it seems unlikely with the fever resolving and the child appearing well.
P: Probable
Increased metabolic rate from fever or anemia – already ruled out
Increased HR from anxiety, stress – it does not appear from the exam presented that this is the case – but putting him on the monitor and watching his HR when he is not in the presence of strangers is helpful.
Agree with Katie and Dave…I worry about OTC or herbal medications. He has had cough and perhaps he did get something from another family member who is not present in the ED.
Dehydration – While, a nml UA, labs and exam with no improvement with two NS boluses doesn’t completely take this off the list, it makes you think of other things.
I: Interesting
Pheochromocytoma and other paraneoplastic syndromes: He is not hypertensive and does not have other related symptoms (diaphoresis or headaches). Though I don’t believe that a lack of hypertension rules all of these out.
Hyperthyroidsim – nml TSH goes against this
T: Treatable
Of the list above…many are treatable….. I actually may continue IVF and admit to see if the HR improves (or gallop or liver/pulmonary congestion develop) with more fluid. That level of tachycardia just makes me pause and worry about sending him home. If it is toxin related or dehydration – it will resolve, and if it is more serious it will show itself.