Accepted Manuscript Title: Supraventricular tachycardia in a trauma patient masquerading as a wolf Parkinson white syndrome Author: Abdelghafour Elkoundi Amine Meskine Zakaria Lahlafi Mustapha Bensghir Salim Jaafar Lalaoui PII: DOI: Reference:
S2352-5568(17)30156-X http://dx.doi.org/doi:10.1016/j.accpm.2017.08.004 ACCPM 288
To appear in: Received date: Revised date: Accepted date:
21-6-2017 31-7-2017 2-8-2017
Please cite this article as: Abdelghafour ElkoundiAmine MeskineZakaria LahlafiMustapha BensghirSalim Jaafar Lalaoui Supraventricular tachycardia in a trauma patient masquerading as a wolf Parkinson white syndrome (2017), http://dx.doi.org/10.1016/j.accpm.2017.08.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Supraventricular tachycardia in a trauma patient masquerading as a wolf Parkinson white syndrome Abdelghafour Elkoundi (MD)1*, Amine Meskine (MD)1, Zakaria Lahlafi (MD) 2 , Mustapha Bensghir (PhD)1, Salim Jaafar Lalaoui (PhD)1 Department of Anaesthesiology and intensive care, Military Hospital Mohammed V 2 Department of Cardiology, Military Hospital Mohammed V Faculty of Medicine and Pharmacy of Rabat Mohammed V University Rabat Morocco
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1
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Authors:
us
Abdelghafour Elkoundi: MD; Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail: [email protected]
an
Amine Meskine: MD; Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail: [email protected]
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Zakaria Lahlafi: MD; Department of cardiology, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail: [email protected]
Ac ce pt e
d
Mustapha Bensghir: PhD, Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail : [email protected] Salim Jaafar Lalaoui: PhD, Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail : [email protected] Authors affiliation: Department of anaesthesiology and intensive care, Military Hospital Mohammed V of Rabat. Faculty of Medicine and Pharmacy of Rabat. University Mohammed V of Rabat. Correspondence*: Abdelghafour Elkoundi Mail: [email protected]
Acknowledgements: We want to thank Pr. Becky Johnston for his contribution in reviewing this article. All authors report no conflicts of interest. No funding sources
Page 1 of 8
Supraventricular tachycardia in a trauma patient masquerading as a Wolf Parkinson White syndrome
In a trauma patient, many causes could induce supraventricular tachycardia (SVT). This
ip t
report documents a case in which a healthy young trauma patient experiences the onset of Wolf Parkinson White (WPW) syndrome, a diagnosis made after ruling out all other causes of
cr
SVT. The authors found no evidence in medical literature that a diagnosis, as such, has
us
previously been documented.
an
A 34-year-old man with no past medical history was referred to our emergency department (ED) after being struck in a high-speed motor vehicle collision. On the scene, the patient was
M
conscious, and the neurologic examination was considered normal. He reported thoracic pain and pain in the lower limbs. He was treated with established protocols and was then brought
d
by ambulance to our hospital, arriving 30 min after the accident. Upon arrival to the ED, he
Ac ce pt e
was placed on a monitor, and his initial vital signs were: heart rate (HR) of 255; blood pressure (BP) of 82/52 mmHg; respiratory rate of 28; and oxygen saturation of 100% on room air.
A 12-lead ECG was obtained which revealed right bundle branch block, narrow complex QRS at a rate of 268, with a constant R-R interval consistent with SVT [figure 1]. FAST-echo initially showed no abdominal fluid, pericardial effusion, or organ rupture. The patient’s chest X-ray showed left sided 4th rib fracture (without hemopneumothorax) and radiographs of the lower extremities revealed bilateral closed thighbone fractures as well as bilateral fractures of the tibia. All routine biochemical tests and thyroid functions were normal as were the CT scan of the head and the radiographs of the spine and pelvis.
Page 2 of 8
Acute blood loss was considered to be the most likely cause of the continued tachycardia and hypotension. The patient was resuscitated with 1500 mL of normal saline solution, and a rapid transfusion protocol was initiated with three units of packed RBCs, but no further improvement in HR or BP was observed. Additionally, he was given intravenously (IV)
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fentanyl 50 mcg for pain and 0.1 mg.kg−1 of midazolam for anxiety. Despite these measures, his HR continued to be elevated at 220 bpm.
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A second transthoracic ultrasound was obtained which showed normal cardiac wall motion
us
and no right ventricular overload, dilatation, hypokinesis, or valvular heart disease. SpO2 was 100% on room air, which was inconsistent with massive pulmonary embolus causing
an
hypotension. Also, his Troponin I levels remained normal (
S2352-5568(17)30156-X http://dx.doi.org/doi:10.1016/j.accpm.2017.08.004 ACCPM 288
To appear in: Received date: Revised date: Accepted date:
21-6-2017 31-7-2017 2-8-2017
Please cite this article as: Abdelghafour ElkoundiAmine MeskineZakaria LahlafiMustapha BensghirSalim Jaafar Lalaoui Supraventricular tachycardia in a trauma patient masquerading as a wolf Parkinson white syndrome (2017), http://dx.doi.org/10.1016/j.accpm.2017.08.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Supraventricular tachycardia in a trauma patient masquerading as a wolf Parkinson white syndrome Abdelghafour Elkoundi (MD)1*, Amine Meskine (MD)1, Zakaria Lahlafi (MD) 2 , Mustapha Bensghir (PhD)1, Salim Jaafar Lalaoui (PhD)1 Department of Anaesthesiology and intensive care, Military Hospital Mohammed V 2 Department of Cardiology, Military Hospital Mohammed V Faculty of Medicine and Pharmacy of Rabat Mohammed V University Rabat Morocco
ip t
1
cr
Authors:
us
Abdelghafour Elkoundi: MD; Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail: [email protected]
an
Amine Meskine: MD; Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail: [email protected]
M
Zakaria Lahlafi: MD; Department of cardiology, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail: [email protected]
Ac ce pt e
d
Mustapha Bensghir: PhD, Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail : [email protected] Salim Jaafar Lalaoui: PhD, Department of anaesthesiology and intensive care, Military Hospital Mohamed V, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco. E-mail : [email protected] Authors affiliation: Department of anaesthesiology and intensive care, Military Hospital Mohammed V of Rabat. Faculty of Medicine and Pharmacy of Rabat. University Mohammed V of Rabat. Correspondence*: Abdelghafour Elkoundi Mail: [email protected]
Acknowledgements: We want to thank Pr. Becky Johnston for his contribution in reviewing this article. All authors report no conflicts of interest. No funding sources
Page 1 of 8
Supraventricular tachycardia in a trauma patient masquerading as a Wolf Parkinson White syndrome
In a trauma patient, many causes could induce supraventricular tachycardia (SVT). This
ip t
report documents a case in which a healthy young trauma patient experiences the onset of Wolf Parkinson White (WPW) syndrome, a diagnosis made after ruling out all other causes of
cr
SVT. The authors found no evidence in medical literature that a diagnosis, as such, has
us
previously been documented.
an
A 34-year-old man with no past medical history was referred to our emergency department (ED) after being struck in a high-speed motor vehicle collision. On the scene, the patient was
M
conscious, and the neurologic examination was considered normal. He reported thoracic pain and pain in the lower limbs. He was treated with established protocols and was then brought
d
by ambulance to our hospital, arriving 30 min after the accident. Upon arrival to the ED, he
Ac ce pt e
was placed on a monitor, and his initial vital signs were: heart rate (HR) of 255; blood pressure (BP) of 82/52 mmHg; respiratory rate of 28; and oxygen saturation of 100% on room air.
A 12-lead ECG was obtained which revealed right bundle branch block, narrow complex QRS at a rate of 268, with a constant R-R interval consistent with SVT [figure 1]. FAST-echo initially showed no abdominal fluid, pericardial effusion, or organ rupture. The patient’s chest X-ray showed left sided 4th rib fracture (without hemopneumothorax) and radiographs of the lower extremities revealed bilateral closed thighbone fractures as well as bilateral fractures of the tibia. All routine biochemical tests and thyroid functions were normal as were the CT scan of the head and the radiographs of the spine and pelvis.
Page 2 of 8
Acute blood loss was considered to be the most likely cause of the continued tachycardia and hypotension. The patient was resuscitated with 1500 mL of normal saline solution, and a rapid transfusion protocol was initiated with three units of packed RBCs, but no further improvement in HR or BP was observed. Additionally, he was given intravenously (IV)
ip t
fentanyl 50 mcg for pain and 0.1 mg.kg−1 of midazolam for anxiety. Despite these measures, his HR continued to be elevated at 220 bpm.
cr
A second transthoracic ultrasound was obtained which showed normal cardiac wall motion
us
and no right ventricular overload, dilatation, hypokinesis, or valvular heart disease. SpO2 was 100% on room air, which was inconsistent with massive pulmonary embolus causing
an
hypotension. Also, his Troponin I levels remained normal (
