Needle in a Haystack

A 12-year-old African American male presented to the emergency department (ED) after an episode of syncope. While playing a “pick-up” game of football, he felt left-sided chest pain and became nauseous, so he sat down to rest. While walking home with friends, he fainted. His head struck the sidewalk and he lost consciousness. His friends carried him home where a neighbor noted a pulse. He appeared neither cyanotic nor in respiratory distress. He soon awoke but did not respond appropriately to his mother, so she called 911. On arrival to the ED, his vital signs were as follows: temperature, 98.6°F; heart rate, 82 beats per minute; respiratory rate, 20 breaths per minute; blood pressure, 115/73 mm Hg; oxygen saturation, 100% on room air; and Glasgow Coma Scale (GCS) rating 14 (1 point deducted for confused verbal responses). Blood glucose was 138 mg/dL. ED staff immobilized his cervical spine. His occiput was tender to palpation, but there was neither hematoma, nor palpable skull fracture. His cardiovascular, pulmonary, and abdominal exams were all within normal limits (WNL). He was slow to follow commands and still failed to respond appropriately to his mother’s questions. Otherwise, his neurological exam was WNL. A computed tomography (CT) study of the patient’s head showed no intracranial hemorrhage or skull fracture. Cervical spine and chest radiography (CXR), complete blood count, and comprehensive metabolic panel all returned WNL. Urine toxicological screen returned positive for amphetamines. Serum toxicological screen returned negative for salicylates, ethanol, and acetaminophen. His electrocardiogram (EKG) showed a normal sinus rhythm but also revealed a prolonged QTc interval of 456 ms (Figure 1). The patient’s mother reported that he was taking Adderall for attention-deficit hyperactivity disorder. She denied any family history of syncope, early-onset cardiac disease, or sudden cardiac death. She did not volunteer whether the patient had previously been treated for similar symptoms. Notwithstanding this, the patient’s medical records included a 2011 ED presentation for exertional syncope. During that episode, he had become cyanotic, prompting bystanders to perform chest compressions until emergency medical services arrived. His evaluation in the ED included a normal EKG, CXR, and urine toxicological screening. Importantly, the treating ED physician ordered an echocardiogram, which was interpreted as normal. He was diagnosed with a seizure and was discharged home with instructions to follow-up with a neurologist (although per his mother, this followup was never scheduled). After learning of this prior episode, ED staff reevaluated the patient. Although his mental status had since improved to a GCS of 15, his mother still believed that he looked sleepy. The patient stated that his “heart hurt” during the football game. He was admitted for a cardiology consult and further workup.