18 YO sinus bradicardia anigma

[Tal]

20:00 a new 18 yo recruit come with his platoon's medic to my base's clinic with the complain of a general weakness.
the kid is cold and snuffled and very weak, skin look good.
V/S: fully alert, no breathing problems b.p 130/70, pulse 50 (athlete), SpO2 97.
I decide to watch him for an hour.

hout later vital signs:
fully alert, no breathing problems b.p 130/70, SpO2 97 and a pulse of 36.
ECG: Sinus bradicardia 36, normal pr int' and everything, but leads V1-V3 showing a negative T wave.
same complain same everything, no chest pains during any pose, no fever in the last few days, only the good all boot-camp trainings and food.

I got an IV access, O2 mask, monitoring (LP 10 without pacing abilities) and a to the ER we go. I only know he was hospitalized for sevrel days.

what do you think could be the cause of this?

my comnder (MD) and I trying to conect the unit that he was hospitalized in to get the full pic. when I'll know, I'll share.

 

[bstone]

Wow. That's really unusual for such a young guy to have such heart troubles. Labs would be really interesting to see.

 

[boingo]

Top of my list would be electrolytes, K and Na specifically.

 

[mikie]

Could it be a congenital condition...since it's appearing at such a young age?

 

[MSDeltaFlt]

A few questions.
1. What was his temp?
2. What was his FSBS?
3. What was he doing for the hour when his H R dropped to 36
4. Can you post ECG?

A young, athletic male with a H R of 36 (I think he's resting at that speed) without CP, only weakness, it might not be cardiac.

Not enough information to tell

 

[Tal]

A few questions.
1. What was his temp?
2. What was his FSBS?
3. What was he doing for the hour when his H R dropped to 36
4. Can you post ECG?

1. 37.0 PO
2. sadly we dont own this in our base
3. only lying down
4. i'll try

 

[Jay]

Negative T-Wave, PVC's, etc. w/ Sinus Braycardia in such a young person would make me think that it's dehydration along with an electrolyte imbalance. The slow rhythm is not that unusual but in conjunction with the above would make me think it could be a number of things electrolyte related such as +/- Mg, Ca, K, etc. Also, was he on any meds (which could be a cause)? Finally, it could be congenital but did he have a Hx of such a condition?

If I had to put my money on it, I would say dehydration w/ electrolyte imbalance. Let me know if you find out, I am curious. Beseder.

Kol Tuv!

 

[zmedic]

are we talking about an "enigma," or "angina?"

 

[Akulahawk]

Dehydration w/ electrolyte imbalance easily could cause the brady you noticed. Athletes tend to "run" a bit brady anyway, but you might see either a 1*AVB or a long but normal PRI in them. Since this new recruit is fairly new and still going through boot, I would wonder if he's truly an athlete at this point. Why? His PRI is normal. I'd be guessing that he's not drinking enough water nor is he eating enough of the right foods. Given the environment, how often does he have to urinate, and what color is it? Urine can be a wonderful indicator, but it's often a lagging one.

I would also wonder if he's been taking any dietary supplements that aren't for post-workout recovery...

I used to be a MUCH more active person than I am now. My HR still gets into the low 50's or high 40's when I'm at rest. It took a LONG time to get my heart to go that slowly. Many world-class athletes do brady down into the 30's and 40's at rest. Getting the heart to increase it's stroke volume to the point where cardiac output isn't adversely affected at such low rates doesn't happen overnight. Given his age and likely recent introduction to heavier exercise bouts than he's likely used to makes me think this isn't a congenital thing.

 

[clibb]

Hypothyroidism? I know that would be a VERY fast onset for that, but just thought I'd throw it out there.

If he's in boot camp you might want to keep depression in mind. Ask his fellow recruits if he's been depressed. Check his blood too for any depressant drugs.

 

[mgr22]

I would also wonder if he's been taking any dietary supplements that aren't for post-workout recovery...

Hmmm...GHB?

 

[Commonsavage]

18 yo Bradycardia

I'm having a hard time getting around the issue of your service not having basic glucometry available. Nonetheless, an initial bolus of IV fluid would help in narrowing the differential diagnosis. Heck, give the young man some oral glucose, or some matza with honey! However, with a HR of 36 (were there U-waves?) at such a young age, I will go with congenital coronary sinus disease.<_<

 

[MSDeltaFlt]

A young athletic male with a resting HR of 36 would not get me wound up unless there was something obvious on ECG or other clinical assessments.

 

[abckidsmom]

A young athletic male with a resting HR of 36 would not get me wound up unless there was something obvious on ECG or other clinical assessments.

I agree.

I am 31, mother of five, and a new runner. I had a minor surgical procedure yesterday and my resting heart rate was 48. I was so proud! All this hard work is paying off.

 

[para1medic]

20:00 a new 18 yo recruit come with his platoon's medic to my base's clinic with the complain of a general weakness.
the kid is cold and snuffled and very weak, skin look good.
V/S: fully alert, no breathing problems b.p 130/70, pulse 50 (athlete), SpO2 97.
I decide to watch him for an hour.

hout later vital signs:
fully alert, no breathing problems b.p 130/70, SpO2 97 and a pulse of 36.
ECG: Sinus bradicardia 36, normal pr int' and everything, but leads V1-V3 showing a negative T wave.
same complain same everything, no chest pains during any pose, no fever in the last few days, only the good all boot-camp trainings and food.

I got an IV access, O2 mask, monitoring (LP 10 without pacing abilities) and a to the ER we go. I only know he was hospitalized for sevrel days.

what do you think could be the cause of this?

my comnder (MD) and I trying to conect the unit that he was hospitalized in to get the full pic. when I'll know, I'll share.

I would NOT pace this kid. He's got a good blood pressure, he's awake, alert, and oriented. He's an athlete at rest, that could be his resting heart rate. Do NOT pace an asymptomatic patient.

 

[sdadam]

Sick Sinus Syndrome

 

[18G]

Sounds like a case of treat the patient and not the monitor. He was asymptomatic of the slow rate, had a good blood pressure and was perfusing well.

As far as cause.... could be his normal rate and the t-wave inversion in those leads could very well be normal for him. I would be interested to see what serial 12-leads showed and if they had the same t-wave inversion with new electrodes applied.

 

[usafmedic45]

Sick Sinus Syndrome

Sheep, not zebras.

 

[Tal]

So, the kid comes back with some checks done and after he saw a cardiologist:
all heart enzymes came back normal, CPK, Troponin the works.
the blood test for Q-fever, which is my comending MD main guess of what cause this, hav'nt come back yet.
he was hopitalized for suspected URTI.

the cardiologist said that the kid was a 10 years basketball player and still is an athlete, the extreme bradi is normal because his pulse rises while exercising.

A young athletic male with a resting HR of 36 would not get me wound up unless there was something obvious on ECG or other clinical assessments.

Personaly and with all due respect I really having a hard time accepting HR of 36 as normal. I've know that HR's of athlets is low, I can accept HR's of 50-40 but, 36 is 4 beats too low for not getting me high alert on the Pt.

What cause this will probably remain a mystery for us, I dont belive it's normal baketball-player HR.
maybe Q-fever will be it...who knows

p.s I didnt mange to get the ECG.

 

[Commonsavage]

36 BPM is NOT normal!!!

Tal, you are absolutely correct. A heart rate of 36 is not normal. As medics, we are never in a position to make a diagnosis of any brady less than 50, much less 40 bpm as normal under any circumstances. Basic ventricular rate is 20 to 40 and indicates nodal dysfunction. To not refer this patient to a cardiologist violates a basic standard of care.
So, the cardiologist was fine with this...OK. They ran a battery of tests to rule out pathology. I'm sure that the cardiologist would not have blown this kid off with only a field exam and assessment. Unfortunately, many medics take on a completely inappropriate cavalier attitude that can kill patients. If one believes that this is not an issue, they really need to go in for retraining.
Tal, thanks for the follow-up.