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OBJECTIVE: We compare pediatric cardiac risk classification and management recommendations between emergency physicians (EPs) and pediatric cardiologists (PCs) in children with a suspected new cardiac disorder. METHODS: We prospectively compared the work-up, assessment, classification, and disposition of patients aged 0 to 21 years presenting to the emergency department with a potential cardiac etiology in whom an electrocardiogram (ECG) was performed. The criterion standard was a blinded assessment by the PC-electrophysiologist after review of the history, physical examination, ancillary tests, and ECG. RESULTS: In 508 subjects, the median age was 15 years (interquartile range, 11-17 years), with a slight female predominance (281, 55.3%). The most common reasons for obtaining an ECG were: chest pain (158, 31.1%) and syncope, presyncope, or possible seizure (146, 28.7%). The most common auxiliary study was a chest radiograph (432, 85% of subjects). A total of 617 electrocardiographic diagnoses were made by EPs and 984 diagnoses by PCs. Sensitivities and specificities varied by discrete class, but disposition decisions were concordant (home or admission). The EPs were highly accurate for the need for emergent cardiology involvement (area under the curve, 0.89). CONCLUSIONS: The EPs and PCs agreed on the evaluation and disposition of children at either low risk or high risk for an acute cardiac presentation in the emergency department. There was considerable variation in management recommendations in the intermediate risk children needing cardiology outpatient follow-up. We recommend the development and implementation of focused training modules on emergency pediatric cardiology and increased communication with pediatric cardiology to improve patient safety and resource utilization.
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Electrocardiografía/métodos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Cardiopatías/diagnóstico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Medición de Riesgo/métodos , Adolescente , Niño , Preescolar , Estudios de Cohortes , Femenino , Cardiopatías/terapia , Humanos , Lactante , Masculino , Médicos , Estudios Prospectivos , Riesgo , Sensibilidad y Especificidad , Adulto JovenRESUMEN
Palpitations are a common complaint, particularly in teenagers, with etiologies ranging from no detectable cardiac dysrhythmia to life-threatening dysrhythmias. Despite the fact that as many as 50% of children and adolescents may be asymptomatic prior to experiencing sudden cardiac arrest, the occurrence of palpitations may afford the opportunity to detect a potentially lethal arrhythmia condition. This article discusses the evaluation of palpitations in the pediatric population by focusing on the two most common life-threatening arrhythmia diagnoses that may initially manifest itself in the pediatric population with the chief complaint of palpitations-Wolff-Parkinson-White syndrome and the long QT syndrome.
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Arritmias Cardíacas/diagnóstico , Muerte Súbita Cardíaca , Paro Cardíaco/diagnóstico , Adolescente , Niño , Femenino , Humanos , MasculinoRESUMEN
Prolongation of the QT interval is a well-documented finding in adults with severe brain injury. However, QT prolongation has not been well documented in the pediatric population with brain injury. Our objective was to determine the range of QT intervals in children with the diagnosis of brain death, hypothesizing that the QT interval corrected for heart rate (QTc) is longer in this population than in a normal population. All previously healthy children (<18 years) dying in our hospital from 1995 to 2007 with a diagnosis of brain death and at least one electrocardiogram (ECG) with normal anatomy by echocardiogram were included. Admission details, past medical and family history, demographic data, and laboratory data were collected. The QT and preceding RR intervals from three sinus beats on a standard 12-lead ECG were measured. The QTc was calculated with the Bazett method, and the values were averaged. Thirty-seven patients met inclusion criteria. Five had event histories concerning for possible underlying rhythm disturbances; data analysis was performed with and without these patients. The QTc data were normally distributed. The mean (SD) QTc for the entire cohort was 452 (61) ms. Excluding the five patients, it was 449 (62) ms. On multivariate analysis, sex (QTc female < male) and hypokalemia were associated with QTc prolongation. QTc in children with brain death is normally distributed but significantly longer than QTc in normal children. Until rapid genetic testing for channelopathies is universally available, our findings suggest that potential pediatric cardiac donors with isolated prolongation of the QTc in this setting may be acceptable in the absence of other exclusionary criteria.
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Muerte Encefálica/fisiopatología , Lesiones Encefálicas/fisiopatología , Electrocardiografía , Adolescente , Niño , Preescolar , Femenino , Sistema de Conducción Cardíaco , Humanos , Lactante , Recién Nacido , Masculino , Valores de ReferenciaRESUMEN
OBJECTIVE: To evaluate the effect of diabetic ketoacidosis (DKA) on the QT interval corrected for heart rate (QTc) in children. Ketosis occurs in several conditions, including DKA and alcoholic ketoacidosis, and during use of very low-carbohydrate diets. Prolongation of the QTc has been described in a few children receiving ketogenic diets, but cardiac effects of ketosis have not otherwise been investigated. DESIGN: For this observational study, we performed electrocardiography during DKA and after recovery. We measured QTc as the QT interval divided by the square root of the R-R interval and correlated QTc with clinical variables. SETTING: The pediatric emergency department and intensive care unit of an academic medical center. PATIENTS: Thirty children with type 1 diabetes mellitus and DKA. MAIN OUTCOME MEASURE: The QTc during DKA. RESULTS: The mean (SD) QTc during DKA was 450 (38) milliseconds (range, 378-539 milliseconds). After recovery from DKA, the mean (SD) QTc decreased to 407 (36) milliseconds (range, 302-485 milliseconds; difference, 43 milliseconds; 95% confidence interval, 23-63 milliseconds) (P < .001). Fourteen of the 30 children (47%) had prolonged QTc during DKA (range, 450-539 milliseconds). After recovery from DKA, only 4 children (13%) had persistent QTc prolongation (range, 451-485 milliseconds). The anion gap was significantly associated with QTc prolongation (correlation coefficient, 0.49; P = .006). Most patients had no electrolyte abnormalities or hypoglycemia to account for QTc prolongation. CONCLUSIONS: Prolonged QTc occurs frequently during DKA and is correlated with ketosis. Current guidelines regarding cardiac monitoring of children during DKA should be strictly followed, and electrocardiographic screening of patients with other ketotic conditions should be considered.
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Complicaciones de la Diabetes/fisiopatología , Diabetes Mellitus Tipo 1/fisiopatología , Cetoacidosis Diabética/fisiopatología , Frecuencia Cardíaca , Síndrome de QT Prolongado/diagnóstico , Síndrome de QT Prolongado/fisiopatología , Niño , Electrocardiografía , Femenino , Humanos , Síndrome de QT Prolongado/etiología , Masculino , Proyectos Piloto , Factores de RiesgoRESUMEN
INTRODUCTION: Postural orthostatic tachycardia syndrome (POTS) is a rare disease characterized by syncope, sinus tachycardia, and orthostasis due to autonomic dysfunction. METHODS AND RESULTS: Two women aged 26 and 24 years with severe POTS became pregnant. Both women experienced hyperemesis gravidarum with subsequent marked improvement in their POTS symptoms until 6 months gestation, when their syncope and sinus tachycardia caused clinical decompensation. Both patients delivered healthy babies at 37 weeks by elective cesarean section. CONCLUSION: In long-term follow-up, both women reported improvement in their prepartum symptoms. We describe the first report, to our knowledge, of two successful pregnancy outcomes in severe POTS, including the first report of midodrine use in pregnant women.
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Mareo/terapia , Complicaciones Cardiovasculares del Embarazo/terapia , Síncope/terapia , Taquicardia/terapia , Adulto , Femenino , Humanos , Postura , Embarazo , Resultado del Embarazo , SíndromeRESUMEN
BACKGROUND: Concept mapping has the potential to measure important aspects of a student's evolving knowledge framework in a way that conventional examinations cannot. This is important because development of an elaborate and well-structured knowledge framework is a critical step toward becoming an expert in a particular field. Little is known about the best way to score concept maps in the setting of medical education. Therefore, as a preliminary step in addressing this question, we compared two different scoring systems for validity: a structural method based on the organization of a map's hierarchical structure and a relational method based, not on structure, but on the quality of each individual map component. METHODS: A total of 21 paediatric resident doctors completed concept map training, drew a preinstruction concept map about "seizures", completed a seizure education course, and then drew a postinstruction seizure map. Two raters using both structural and relational methods scored each map. RESULTS: Structural scores increased significantly after instruction and were higher in more experienced residents, but relational scores were not significantly different. Interrater scoring reliability for both methods ranged from moderate to strong, but was greater using the relational scoring method. CONCLUSIONS: These data suggest that scoring systems for evaluating concept maps in postgraduate medical education may need to account for structural features of maps, if scores are to reflect changes in the developing knowledge frameworks of resident doctors. More research to further evaluate reliability and validity is critical prior to any future use of concept mapping assessment in medical education.