DOI: 10.1097/PEC.0000000000000057

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PMID: 24196101

Issn Print: 0749-5161

Publication Date: 2013/11/01


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ECGs in the ED

Ronn E. Tanel

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Author Information: ronn.tanel@ucsf.edu

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Excerpt

A 16-month-old little girl presents to the emergency department after her parents noted her to be fussy and refusing to walk. She has been in her usual state of good health without intercurrent illnesses. There has been no fever, vomiting, diarrhea, upper respiratory symptoms, or lethargy. There has been no rash. She had been eating well and having normal urine output until this morning. The fussiness and refusal to walk began several hours prior to presentation. There is no history of trauma to the leg. There is no swelling, erythema, or warmth noticed on either leg. The child takes no medications and has no known drug allergies. The family history is noncontributory for congenital heart disease or sudden cardiac death. She is cared for primarily by her mother. There is a healthy 3-year-old sibling.
On arrival to the emergency department, the child’s heart rate is 84 bpm and the respiratory rate is 32 per minute. The temperature is 37.1°C. The blood pressure is 92/46. The weight is 10.6 kg. The child is acyanotic, without respiratory distress. She is fussy, but consolable. The head is atraumatic. The oropharynx and tympanic membrane exams are normal. The neck is supple. The chest is clear to auscultation. The cardiac exam reveals a normally active precordium with a slow, regular rhythm. There is a normal first heart sound, and a soft physiologically split second heart sound. There is no gallop or click. There is no significant murmur. The pulses are full and equal. The abdomen is soft without hepatomegaly. The extremities are warm and well perfused. There is point tenderness at the distal tibia. The skin has no rash. The neurologic exam is nonfocal.
An x-ray shows a pathologic fracture of the distal tibia withwidening, irregularity, and cupping of the distal tibial metaphysis.
An electrocardiogram is performed (Fig. 1).
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