,1
Coarctation of the aorta would likely show a differential between the upper and lower
extremity blood pressures.
Total anomalous pulmonary venous return is a cyanotic congenital cardiac
A mother brings in her 30-day-old baby girl because she is having trouble breathing. disease and would likely present with some degree of cyanosis or alteration in pulse
The baby was born at home at 37 weeks’ gestation. The mother received normal oximetry.
prenatal care, and there were no complications during the pregnancy or delivery. The Transposition of the great arteries also is a cyanotic congenital cardiac disease and
baby only recently returned to her birth weight of 6 pounds. She is formula fed 3 ounces would likely present with some degree of cyanosis or alteration in pulse oximetry.
every 2 to 3 hours and is noted to fall asleep during most feeds. The baby is awake and
responsive on examination with a palpable liver edge 2 cm below the costal margin. PEER POINT
Her hands and feet are cool and slightly mottled. A 3/4 harsh, holosystolic murmur is
noted at the left lower sternal border. Upper and lower extremity blood pressures are
symmetric. PEER REVIEW
What is the likely underlying cause of her symptoms?
Ventricular septal defect is the most common congenital cardiac defect.
Coarctation of the aorta
A large ventricular septal defect can present as congestive heart failure with tachycardia,
Total anomalous pulmonary venous return hepatomegaly, and poor weight gain.
Transposition of the great arteries
WHERE TO LEARN MORE
CORRECT ANSWER
Ventricular septal defect
https://www.merckmanuals.com/professional/pediatrics/congenital-cardiovascular-
anomalies/overview-of-congenital-cardiovascular-anomalies
Collapse All REFERENCES
WHY IS THIS THE CORRECT ANSWER? Tintinalli – Chapter 126 Congenital and Acquired Pediatric Heart Disease.
Rosens Chapter 171 – Cardiac Disorders.
In this case, the initial clinical clues to an underlying congenital cardiac disease include poor
weight gain (weight loss in some infants), tiring while feeding (sweating in some cases), and
signs of congestive heart failure (“trouble breathing,” as reported by the mother). Because 2
she does not have signs of cyanosis or a ductal-dependent lesion, other types of congenital
cardiac disease should be considered. Ventricular septal defect is the most common A 56-year-old man presents by ambulance, unresponsive and intubated, with stable
congenital cardiac lesion, and the degree of disease is dependent on the size of the defect. vital signs. Paramedics report that he collapsed in a mall, and bystanders performed
This can range from no issues to signs of congestive heart failure, such as enlarged liver, CPR and used an AED. “Shock advised” was noted on the AED, and bystanders said
which happens as the disease progresses. he showed signs of life. En route, a 12-lead ECG demonstrated an inferior wall STEMI.
A repeat ECG shows continued inferior STEMI.
WHY ARE THE OTHER CHOICES WRONG? Which of the following strategies for using therapeutic hypothermia is appropriate for
this patient in the emergency department?
,Consider starting it after the STEMI has been definitively managed Therapeutic hypothermia may be started in the prehospital setting, emergency
department, cardiac catheterization laboratory, or intensive care unit; the patient’s
CORRECT ANSWER clinical situation as well as the capabilities of the particular location dictate the most
appropriate time of initiation.
Start it with a target temperature of approximately 34°C (93.2°F)
PEER POINT
PEER REVIEW
Withhold it because of the patient’s ECG abnormality
Withhold it since it was not initiated in the prehospital setting Therapeutic hypothermia improves the chance of meaningful survival in patients
resuscitated from cardiac arrest, particularly those resuscitated in the prehospital setting
Collapse All with shockable initial rhythms who are stable and remain unresponsive.
Therapeutic hypothermia may be applied in a range of settings with minimal need for
WHY IS THIS THE CORRECT ANSWER? equipment.
Therapeutic hypothermia, also referred to as induced hypothermia and more recently as WHERE TO LEARN MORE
targeted temperature management, can reduce the negative sequelae of cardiac arrest.
Although the specific mechanism is unknown, therapeutic hypothermia likely involves the
reduction in metabolic rate throughout the body as well as reduced electrical activity in the Optimizing Post-Resuscitation Care in the Emergency Department, Part II: Key Interventions for
brain. This patient is a candidate because he had a shockable rhythm (either pulseless Reversing the Pathophysiological Manifestations of Post-Resuscitation Syndrome Cognitive
ventricular tachycardia or ventricular fibrillation) and was resuscitated in an out-of-hospital Function in Survivors of Out-of-Hospital Cardiac Arrest After Target Temperature Management at
setting. The optimal timing of initiation of therapeutic hypothermia is broad, but 33⁰C Versus 36⁰C
initiation within the first 4 to 6 hours after resuscitation is best. Earlier applications are likely
better. If clinically feasible, initiation as early as 15 to 30 minutes after resuscitation is
appropriate. The target temperature for therapeutic hypothermia is 32°C (89.6°F) to 34°C REFERENCES
(93.2°F), although temperatures as high as 36°C (96.8°F) have demonstrated benefit.
Additional postresuscitation therapies, including advanced critical care and PCI, may be
applied simultaneously with therapeutic hypothermia. AHA Guidelines 2015 on post-resuscitation care Callaway CW, Donnino MW, Fink EL, Geocadin
RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8:
post–cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S465–S482.
WHY ARE THE OTHER CHOICES WRONG? Brady WJ, Sochor M, O’Connor R: Cardiorespiratory Arrest in Adams,
The presence of a STEMI by itself does not preclude the initiation of therapeutic
hypothermia; in fact, STEMI and other ACS-related conditions are the most
appropriate patient presentations for targeted temperature management.
3
Another indication for therapeutic hypothermia is unresponsiveness or other very
significant mental status abnormality. Resuscitated patients who are alert or A 78-year-old man presents with worsening shortness of breath over the past 2 weeks.
medically unstable are not candidates. Patients experiencing noncardiogenic cardiac He has a history of hypertension and hyperlipidemia and is not compliant with
arrest are likely not candidates either. Again, the ECG finding of STEMI is a reason treatment. He says he is unable to do anything at home without becoming significantly
to start targeted temperature management, not withhold it. short of breath. He has no chest pain. An ECG is obtained (Figure 3.27).
, persisted from the time of infarction. The prevalence of LV aneurysm appears to have
declined with the improved reperfusion treatment of acute MI. Patients who experience
acute MI without prompt or appropriate therapy can have a completed infarction with a large
amount of infarcted myocardium; these patients can then develop a ventricular aneurysm.
Most LV aneurysms are anterolateral near the apex of the heart and are the result of
complete occlusion of the left anterior descending (LAD) artery. Small and moderate-sized
aneurysms are often associated with no symptoms, although the patient might experience
angina in other portions of adjacent myocardium.
WHY ARE THE OTHER CHOICES WRONG?
Late post-MI myopericarditis, often referred to as Dressler syndrome, typically
presents with pleuritic chest pain, fever, leukocytosis, and pericardial friction rub. It
usually occurs a few weeks after large acute MI. Typical ECG findings are similar to
pericarditis with diffuse ST-segment elevation and PR segment depression without
What is the most likely cause of this patient’s primary ECG abnormalities? reciprocal change of both the PR and ST segments. Of course, not all cases of
myopericarditis demonstrate these classic ECG abnormalities.
The electrocardiographic pattern of left ventricular hypertrophy (LVH) frequently has
Late post-MI myopericarditis repolarization abnormalities, which include ST-segment elevation and depression as
well as T-wave abnormalities. Approximately 75% to 80% of patients with
CORRECT ANSWER electrocardiographic LVH have these ST-segment and T-wave abnormalities, termed
the strain pattern. Electrocardiographic LVH should be considered if the sum of the S
Left ventricular aneurysm wave in lead V1 or V2 and the R wave in lead V5 or V6 is greater than 35 mm in a
patient older than 35 years.
In this patient, STEMI is less likely both clinically and electrocardiographically. He
has had persistent dyspnea for 6 weeks without apparent change in the pattern;
thus, no new major event appears to be occurring. Regarding the ECG, the
prominent Q waves with ST-segment elevation suggest possible aneurysm. Also, a
Left ventricular hypertrophy comparison of the height of the T wave to that of the QRS complex can also assist in
this distinction. With LV aneurysm, the T wave is often small or flattened compared
ST-segment elevation MI to a prominent QRS complex in the configuration of a Q wave. With STEMI, the T
wave is often quite prominent and near-equal to equal in amplitude to the
Collapse All accompanying QRS complex.
WHY IS THIS THE CORRECT ANSWER? PEER POINT
A left ventricular (LV) aneurysm is a focal area of infarcted myocardium that bulges outward
during both systole and diastole. The ECG changes associated with LV aneurysm, as seen Important ECG findings in left ventricular aneurysm A shows samples of the ST-segment
in this case, are typically ST-segment elevation in the anterior leads (V1-V5) with elevation, and B shows a comparison of ST-segment elevation associated with LVA (left)
accompanying Q waves. It can be difficult to distinguish LV aneurysm from anterior MI; and STEMI (right).
however, the presence of Q waves typically reveals a completed anterior infarction.
Approximately 10% to 30% of patients who survive an acute MI develop a left ventricular
aneurysm. Patients with large LV aneurysms can present with dyspnea that often has
Coarctation of the aorta would likely show a differential between the upper and lower
extremity blood pressures.
Total anomalous pulmonary venous return is a cyanotic congenital cardiac
A mother brings in her 30-day-old baby girl because she is having trouble breathing. disease and would likely present with some degree of cyanosis or alteration in pulse
The baby was born at home at 37 weeks’ gestation. The mother received normal oximetry.
prenatal care, and there were no complications during the pregnancy or delivery. The Transposition of the great arteries also is a cyanotic congenital cardiac disease and
baby only recently returned to her birth weight of 6 pounds. She is formula fed 3 ounces would likely present with some degree of cyanosis or alteration in pulse oximetry.
every 2 to 3 hours and is noted to fall asleep during most feeds. The baby is awake and
responsive on examination with a palpable liver edge 2 cm below the costal margin. PEER POINT
Her hands and feet are cool and slightly mottled. A 3/4 harsh, holosystolic murmur is
noted at the left lower sternal border. Upper and lower extremity blood pressures are
symmetric. PEER REVIEW
What is the likely underlying cause of her symptoms?
Ventricular septal defect is the most common congenital cardiac defect.
Coarctation of the aorta
A large ventricular septal defect can present as congestive heart failure with tachycardia,
Total anomalous pulmonary venous return hepatomegaly, and poor weight gain.
Transposition of the great arteries
WHERE TO LEARN MORE
CORRECT ANSWER
Ventricular septal defect
https://www.merckmanuals.com/professional/pediatrics/congenital-cardiovascular-
anomalies/overview-of-congenital-cardiovascular-anomalies
Collapse All REFERENCES
WHY IS THIS THE CORRECT ANSWER? Tintinalli – Chapter 126 Congenital and Acquired Pediatric Heart Disease.
Rosens Chapter 171 – Cardiac Disorders.
In this case, the initial clinical clues to an underlying congenital cardiac disease include poor
weight gain (weight loss in some infants), tiring while feeding (sweating in some cases), and
signs of congestive heart failure (“trouble breathing,” as reported by the mother). Because 2
she does not have signs of cyanosis or a ductal-dependent lesion, other types of congenital
cardiac disease should be considered. Ventricular septal defect is the most common A 56-year-old man presents by ambulance, unresponsive and intubated, with stable
congenital cardiac lesion, and the degree of disease is dependent on the size of the defect. vital signs. Paramedics report that he collapsed in a mall, and bystanders performed
This can range from no issues to signs of congestive heart failure, such as enlarged liver, CPR and used an AED. “Shock advised” was noted on the AED, and bystanders said
which happens as the disease progresses. he showed signs of life. En route, a 12-lead ECG demonstrated an inferior wall STEMI.
A repeat ECG shows continued inferior STEMI.
WHY ARE THE OTHER CHOICES WRONG? Which of the following strategies for using therapeutic hypothermia is appropriate for
this patient in the emergency department?
,Consider starting it after the STEMI has been definitively managed Therapeutic hypothermia may be started in the prehospital setting, emergency
department, cardiac catheterization laboratory, or intensive care unit; the patient’s
CORRECT ANSWER clinical situation as well as the capabilities of the particular location dictate the most
appropriate time of initiation.
Start it with a target temperature of approximately 34°C (93.2°F)
PEER POINT
PEER REVIEW
Withhold it because of the patient’s ECG abnormality
Withhold it since it was not initiated in the prehospital setting Therapeutic hypothermia improves the chance of meaningful survival in patients
resuscitated from cardiac arrest, particularly those resuscitated in the prehospital setting
Collapse All with shockable initial rhythms who are stable and remain unresponsive.
Therapeutic hypothermia may be applied in a range of settings with minimal need for
WHY IS THIS THE CORRECT ANSWER? equipment.
Therapeutic hypothermia, also referred to as induced hypothermia and more recently as WHERE TO LEARN MORE
targeted temperature management, can reduce the negative sequelae of cardiac arrest.
Although the specific mechanism is unknown, therapeutic hypothermia likely involves the
reduction in metabolic rate throughout the body as well as reduced electrical activity in the Optimizing Post-Resuscitation Care in the Emergency Department, Part II: Key Interventions for
brain. This patient is a candidate because he had a shockable rhythm (either pulseless Reversing the Pathophysiological Manifestations of Post-Resuscitation Syndrome Cognitive
ventricular tachycardia or ventricular fibrillation) and was resuscitated in an out-of-hospital Function in Survivors of Out-of-Hospital Cardiac Arrest After Target Temperature Management at
setting. The optimal timing of initiation of therapeutic hypothermia is broad, but 33⁰C Versus 36⁰C
initiation within the first 4 to 6 hours after resuscitation is best. Earlier applications are likely
better. If clinically feasible, initiation as early as 15 to 30 minutes after resuscitation is
appropriate. The target temperature for therapeutic hypothermia is 32°C (89.6°F) to 34°C REFERENCES
(93.2°F), although temperatures as high as 36°C (96.8°F) have demonstrated benefit.
Additional postresuscitation therapies, including advanced critical care and PCI, may be
applied simultaneously with therapeutic hypothermia. AHA Guidelines 2015 on post-resuscitation care Callaway CW, Donnino MW, Fink EL, Geocadin
RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8:
post–cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S465–S482.
WHY ARE THE OTHER CHOICES WRONG? Brady WJ, Sochor M, O’Connor R: Cardiorespiratory Arrest in Adams,
The presence of a STEMI by itself does not preclude the initiation of therapeutic
hypothermia; in fact, STEMI and other ACS-related conditions are the most
appropriate patient presentations for targeted temperature management.
3
Another indication for therapeutic hypothermia is unresponsiveness or other very
significant mental status abnormality. Resuscitated patients who are alert or A 78-year-old man presents with worsening shortness of breath over the past 2 weeks.
medically unstable are not candidates. Patients experiencing noncardiogenic cardiac He has a history of hypertension and hyperlipidemia and is not compliant with
arrest are likely not candidates either. Again, the ECG finding of STEMI is a reason treatment. He says he is unable to do anything at home without becoming significantly
to start targeted temperature management, not withhold it. short of breath. He has no chest pain. An ECG is obtained (Figure 3.27).
, persisted from the time of infarction. The prevalence of LV aneurysm appears to have
declined with the improved reperfusion treatment of acute MI. Patients who experience
acute MI without prompt or appropriate therapy can have a completed infarction with a large
amount of infarcted myocardium; these patients can then develop a ventricular aneurysm.
Most LV aneurysms are anterolateral near the apex of the heart and are the result of
complete occlusion of the left anterior descending (LAD) artery. Small and moderate-sized
aneurysms are often associated with no symptoms, although the patient might experience
angina in other portions of adjacent myocardium.
WHY ARE THE OTHER CHOICES WRONG?
Late post-MI myopericarditis, often referred to as Dressler syndrome, typically
presents with pleuritic chest pain, fever, leukocytosis, and pericardial friction rub. It
usually occurs a few weeks after large acute MI. Typical ECG findings are similar to
pericarditis with diffuse ST-segment elevation and PR segment depression without
What is the most likely cause of this patient’s primary ECG abnormalities? reciprocal change of both the PR and ST segments. Of course, not all cases of
myopericarditis demonstrate these classic ECG abnormalities.
The electrocardiographic pattern of left ventricular hypertrophy (LVH) frequently has
Late post-MI myopericarditis repolarization abnormalities, which include ST-segment elevation and depression as
well as T-wave abnormalities. Approximately 75% to 80% of patients with
CORRECT ANSWER electrocardiographic LVH have these ST-segment and T-wave abnormalities, termed
the strain pattern. Electrocardiographic LVH should be considered if the sum of the S
Left ventricular aneurysm wave in lead V1 or V2 and the R wave in lead V5 or V6 is greater than 35 mm in a
patient older than 35 years.
In this patient, STEMI is less likely both clinically and electrocardiographically. He
has had persistent dyspnea for 6 weeks without apparent change in the pattern;
thus, no new major event appears to be occurring. Regarding the ECG, the
prominent Q waves with ST-segment elevation suggest possible aneurysm. Also, a
Left ventricular hypertrophy comparison of the height of the T wave to that of the QRS complex can also assist in
this distinction. With LV aneurysm, the T wave is often small or flattened compared
ST-segment elevation MI to a prominent QRS complex in the configuration of a Q wave. With STEMI, the T
wave is often quite prominent and near-equal to equal in amplitude to the
Collapse All accompanying QRS complex.
WHY IS THIS THE CORRECT ANSWER? PEER POINT
A left ventricular (LV) aneurysm is a focal area of infarcted myocardium that bulges outward
during both systole and diastole. The ECG changes associated with LV aneurysm, as seen Important ECG findings in left ventricular aneurysm A shows samples of the ST-segment
in this case, are typically ST-segment elevation in the anterior leads (V1-V5) with elevation, and B shows a comparison of ST-segment elevation associated with LVA (left)
accompanying Q waves. It can be difficult to distinguish LV aneurysm from anterior MI; and STEMI (right).
however, the presence of Q waves typically reveals a completed anterior infarction.
Approximately 10% to 30% of patients who survive an acute MI develop a left ventricular
aneurysm. Patients with large LV aneurysms can present with dyspnea that often has
