Part 2 of the Conclusion to 15 year old male CC: fall from vehicle

This is Part 2 of the conclusion to 15 year old male CC: fall from vehicle. Be sure to read Part 1 of the conclusion to 15 year old male CC: fall from vehicle to catch yourself up!

Before we find out the answer, let's recap the specifics:

  • 15 year old male thrown from the bed of a pickup truck potentially at 45 mph
  • Unremarkable findings aside from bruising to lower extremities
  • No apparent chest trauma
  • Asymptomatic patient
  • More P-waves than QRS complexes on the 3-lead and 12-lead
  • Unremarkable history

As many of our readers pointed out, there exists some high degree AV block, whether it is a 2:1 AVB or a 3rd Degree AVB there was some disagreement.

The paramedics involved in this case had a similar disagreement and the ED staff did as well. Ultimately, a diagnosis of AV dissociation with an AVB of at least 2nd Degree was made and the patient was referred to a pediatric cardiologist.

Going back to the strips, some degree of AV dissociation is clear, and I've provided the following highlighting to one of the 3-leads:

The question then remains, what was the cause of the AV nodal disturbances? Many readers pointed out some very good possibilities, which I'll list below:

  • Traumatic etiology, likely myocardial contusion
  • Lyme disease from a recent tick bite
  • Congenital AV nodal abnormality

Exploring a traumatic etiology we have to reconcile our patient assessment with the mechanism of injury. Our findings are not suggestive of a traumatic cause. A pediatric patient with a new onset heart block secondary to trauma is not likely to be asymptomatic.

A review of the literature reveals multiple case studies of traumatic causes of heart block, however, every single patient had physical exam findings suggestive of myocardial contusion. I believe we can confidently place a traumatic etiology low on the list of probable causes.

A few readers pointed out Lyme disease, which is a common cause of AV nodal disturbances in otherwise healthy individuals. The carriers of this are Deer Ticks infected with the bacteria Borrelia burgdorferi with an overall incidence of 6 in 100,000 in the US. Findings include a bullseye rash, known as erythema migransarthritis, AV nodal disturbances, and a multitude of neurologic findings.

Erythema Migrans by Hannah Garrison licensed under CC-BY-SA-2.5

Given no rash upon physical examination and without clear evidence of a tick bite, it seems unlikely to be the cause. It may be prudent, however, to perform blood tests for B. burgdorferi if no other likely diagnosis exists.

Finally, we come to a congenital abnormality of the AV node, manifested as a high degree AV block with a junctional escape rhythm. Literature reports approximately 1 of every 20,000 to 25,000 live births are associated with some degree of congenital complete AV block (CCAVB).

Interestingly enough, patients have been known to survive beyond 60 years without intervention. In CCAVB, the body compensates for the decrease in heart rate with an increase in stroke volume. Therefore, given a functioning junctional escape rhythm, a patient may have no symptoms associated with their cardiac rhythm.

However, these patients often experience syncope or Stokes-Adams attacks usually due to uncompensated bradycardia. If left undiagnosed, their abnormality may only be found on autopsy after a sudden cardiac arrest. Follow-up with monitoring of patients diagnosed with CCAVB is important to identify the need for permanent pacemaker implantation. Any incidence of CHF, persistant bradycardia, or syncope indicates the need for definitive management.

So what was our patient's diagnosis?

The paramedics involved in this case relayed that a diagnosis of congenital complete heard block was made and the patient was scheduled for monitoring for possible pacemaker implantation.

References

  • Athreya BH, Rose CD. Lyme Disease. Cur Prob in Ped 1996; 26:189-207.
  • Dedeoglu F, Sundel RP. Emergency Department Management of Lyme Disease. Clin Ped Emerg Med 2004; 5:54-62.
  • Surawicz B, Kilans T (eds.). (2008) Chou's Electrocardiography in Clinical Practice: Adult and Pediatric (6th ed.). Saunders, Elsevier Health Scences.
  • Michaelsson, M. Congenital complete atrioventricular block. Prog in Ped Cardio 1995; 4:1-10. 

6 Comments

  • Kelly says:

    A very interesting case – would have loved to been the NP in the ER seeing this patient!

  • Baker says:

    Yes it is very interesting, and it was congenital after all, lucky guess on my part.

  • Andrew E. Spain says:

    Query–it does not list any findings related to indiciations of a head injury.  However, according to Marriott, there are a number of dysrhythmias that can occur secondary to a head injury.  Even without external signs of a head injury, it would seem possible that some brain injury could result.  Was this checked (eg CT scan?).  I would certainly have to agree that congenital causes are much more likely in this case, but if this cleared up after a few days, it could point to a head injury being the underlying cause. (Yes, it took me having a patient who exhibited this situation to learn about it.)

  • Christopher says:

    Andrew,
    As far as this case goes I don't know if the ED performed a head CT. However, the details relayed to me by the crew suggests that there was no indication of a head injury. Likely, without an indication no CT was performed.

  • Brandon O says:

    I don't have a lot of experience with cerebral-induced cardiac dysfunction but my understanding is that, like many similar syndromes, it manifests largely as some amount of heart failure — a myocardial "stunning" effect, presumably due to a catechol dump. I would be surprised to see an isolated heart block.

  • Heather says:

    Although he did not currently have the bullseye rash, he could still have Lymes Disease. This disease is very complex and the rash may or may not come back throughout  his life as he has "flares". if he was not diagnosed with lymes as it is often mistaken for the flu it will become cronic with all sorts of manifications.

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Comments
Stephen Smith
Conclusion: “And then I gave her a NTG…”
There is also no data I'm aware of that shows that, in the reperfusion era, nitroglycerine helps patients with STEMI who do not have elevated BP or pulmonary edema. Data is lacking in all regards.
2014-10-24 16:14:36
Kevin
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Why on earth would you risk VF, by giving Adenosine to rule out rhythms.. This is dangerous, and foolish. There might be a slight chance that this is WPW.. You might as well just give him Cardizem, they are both AV nodal blockers... I don't know why the AHA even added this stupid idea..
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Vince DiGiulio
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It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
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Bryan
The 360 Degree Heart – Part II
I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
2014-10-21 13:43:29
The 360 Degree Heart – Part II | EMS 12 Lead
The 360 Degree Heart – Part I
[…] first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane […]
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