December 13, 2013
Emergency medicine podcasts, reviews and curbside consults
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Rob First of all I wanted to give a shout out to my friends at St. Vs. I am indebted to you for many great experiences during residency. I wanted to make a few comments about the pediatric syncope interview with Dr. Moreno. First, I think that Ray did a great job on covering the salient points, especially of generally not doing much testing other than an ECG. The vast majority of pediatric syncope patients are fine, even in the setting of the cardiologists office. Regarding detection of murmurs, a certain portion of HOCM patients will not have a murmur, so absence of a murmur should not be used to rule out HOCM, but should raise your level of concern when present. The bottom line is, the money is in the history. I would also caution against trying to differentiate innocent from pathologic murmurs in the ED in potentially high risk scenarios such as syncope. The stills murmur does have a characteristic sound which may be easily recognized, but I have seen pediatric cardiology fellows about to graduate mis-characterize a murmur. Our pediatric cardiologists advised me not to use valsalva as a maneuver to differentiate type of murmur as there are several different phases which have differing hemodynamic effects, though we all learn it in med school and it is in all the books. At our place, the peds cardiologists tend to simply place the patient supine to increase venous return which should increase intensity of the Still’s murmur but decrease intensity of a HOCM murmur compared to the sitting or standing position. I also think that if you are considering an echocardiogram, you should probably be making a referral/consult to your freindly neighborhood pediatric cardiologists. My experience has been that many of the echo’s done by adult echo techs end up getting repeated by the peds folks, and they may identify a subset of patients who do not need any imaging at all. Thanks. Matt Hansen, OHSU PEM Fellow
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