Onset Of Tachycardia Research Articles

Non-sustained wide complex tachycardia: an underappreciated sign to aid in diagnosis.

The electrocardiographic (ECG) signs used to differentiate ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrancy are specific but not highly sensitive. The purpose of this study was to define the utility of an underappreciated form of atrioventricular (AV) dissociation at the onset of tachycardia, a single dissociated P wave, in the differentiation of non-sustained monomorphic wide complex tachycardia (WCT) in hospitalized patients. We prospectively analysed tracings from 102 consecutive hospitalized patients who had an episode of non-sustained (≥5 beats, <30 s), monomorphic, WCT (≥100 b.p.m.) on telemetry. WCT was classified as VT, SVT with aberrancy, or undifferentiated WCT based on predefined criteria. Of 102 patients with WCT, 3 (3%) had SVT with aberrancy, 43 (42%) had an undifferentiated WCT, and 56 (55%) had VT. ECG evidence of a single dissociated P wave at the onset of tachycardia (i.e. AV dissociation at the onset) was identified in 29 patients (28%) compared with less frequent traditional signs of VT including second-degree ventriculoatrial (VA) block in 18 patients (18%), AV dissociation during tachycardia in 17 patients (17%), fusion beats in 10 patients (10%), and capture beats in 3 patients (3%). On multivariate analysis, only the prematurity index predicted the occurrence of AV dissociation at the onset of the tachycardia (odds ratio 1.239, 95% confidence interval 1.033-1.486, P = 0.021). When evaluating WCT in hospitalized patients, a single dissociated P wave at the onset of tachycardia is an easily recognizable diagnostic sign of VT, and is observed more frequently than the other accepted criteria for VT.

Sawtooth fetal heart rate pattern due to in utero fetal central nervous system injury

Case reports We present 3 cases of documented central nervous system (CNS) injury with a characteristic fetal heart rate (FHR) sawtooth-like pattern. In the first case, there was category I fetal heart tracing during labor, which was followed by a sudden onset of fetal tachycardia, unstable and indeterminate baseline, and episodes of a sawtooth FHR pattern (Figure 1). The Apgar scores after a vaginal delivery were 9/9 at 1 and 5 minutes. The magnetic resonance imaging of the neonate, which was performed 48 hours postpartum because of facial twitches, showed infarction of the left cerebral hemisphere because of a middle cerebral artery occlusion/thrombosis; the approximate timing of the fetal stroke coincided with the abrupt onset of the aforementioned FHR changes in labor (Figure 2). In the second case, the patient was admitted with indeterminate FHR baseline and sawtooth FHR pattern (Figure 3). Emergent cesarean delivery was performed and the Apgar scores were 0/3/3 at 1, 5, and 10 minutes; the umbilical artery cord pH was 6.87, partial pressure of CO2 was 186, and base excess was e27.7. Immediately after birth the electroencephalogram was abnormal, and the infant received brain cooling but unfortunately died. In the third case, late FHR decelerations, indeterminate baseline, and periods of sawtooth FHR pattern were noted during the second stage of labor because of excessive uterine activity (Figure 4). The Apgar scores were 3/6 at 1 and 5 minutes, the cord pH was 6.90, partial pressure of CO2 was 73 and base excess was e19.5. A cranial ultrasound of the neonate revealed grade II intraventricular hemorrhage.

Improving survival after out-of-hospital cardiac arrest requires new tools.

In the western world, ∼20% of all deaths among people between 20 and 80 years old are sudden and unexpected and this has not changed much during recent decades, whereas mortality from cardiac disease has diminished substantially.1 Sudden death is most often caused by the onset of ventricular fibrillation (VF) or ventricular tachycardia, interfering with the heart's function to pump blood into the circulation and thus causing a cardiac (and circulatory) arrest. We know that immediate termination of the life-threatening arrhythmia by means of defibrillation, thereby restoring spontaneous circulation, provides many cardiac arrest victims several ‘saved’ life-years of satisfactory quality.2 Over the years numerous articles have addressed two crucial questions: ‘Can we identify a person with increased risk of cardiac arrest before the event?’ and, ‘How to optimize the resuscitation attempt and the management of the victim after return of a stable cardiac rhythm?’ Regarding the first question, we know that our current methods of risk stratification identify only a small fraction of the victims before the event.3–6 Also, no new methods have been published that provide cardiac arrest predictors with sufficient sensitivity and specificity to both identify a substantial portion of all arrest victims in advance and to be specific enough to make preventive action (defibrillator implantation) practical and cost-effective. This somewhat disappointing conclusion forces us to concentrate on the second question. Several recent articles discussed our current insights into incidence of cardiac arrest, profile of the victim, rhythm at arrest, and results of the resuscitation attempt.7–10 They show that outcomes of witnessed cardiac arrests have improved in recent years due to greater emphasis on resuscitation …

Evaluation of the necessity for cardioverter-defibrillator implantation in elderly patients with Brugada syndrome.

The clinical characteristics and prognosis of elderly patients with Brugada syndrome (BrS) are largely unknown. The purpose of this study was to evaluate the risks and benefits of implantable cardioverter defibrillator (ICD) in elderly patients with BrS based on a long follow-up. A total of 120 BrS patients with ICD (90 for aborted sudden cardiac arrest or syncope, mean age, 46.6±12.2 years; 50 with age ≥60 years at the last follow-up) were included in this study. During 102±68 months of follow-up, 31 patients (26%) experienced appropriate shocks. Age at the first attack of ventricular fibrillation (VF) was <70 years in all patients (mean, 45.0±12.1 years), the incidence of VF decreased with age, and VF did not recur after 70 years of age except in 2 patients with ischemic heart disease. Eleven of 28 patients with supraventricular tachycardia experienced inappropriate shocks. These inappropriate shocks increased with age and reached a peak in patients who were in their sixties. Lead failures occurred in later stages after implantation in 10 of 120 patients (8%). Long-term follow-up of high-risk BrS patients with ICD showed a low incidence of VF in those aged >70 years. Considering the increasing risk of inappropriate shocks because of the relatively late onset of supraventricular tachycardia and lead failures, avoidance of ICD implantation, or replacement may be considered in elderly BrS patients who remain free from VF until 70 years of age.

Variations of heart rate variability parameters prior to the onset of ventricular tachyarrhythmia and sinus tachycardia in ICD patients. Results from the heart rate variability analysis with automated ICDs (HAWAI) registry

The HAWAI registry evaluated the role of heart rate variability in predicting the occurrence of ventricular tachycardia and fibrillation (VT/VF) and sinus tachycardia in patients with an implantable cardioverter-defibrillator (45 patients with 155 RR recordings). A significant decrease of the mean value of all RR intervals (MeanNN) was observed in the period starting 20 and 40 min prior to VT/VF and sinus tachycardia, respectively. The standard deviation of RR intervals (SDNN) and the power at low frequency (LF) were the only parameters with significant changes prior to VT/VF. For sinus tachycardia, the root mean square of successive differences of all successive RR intervals (r-MSSD) and the power at low and high frequency (HF) decreased, whereas SDNN and the power at very low frequency increased. Comparison of RR recordings preceding VT/VF and sinus tachycardia revealed significant differences of the MeanNN, SDNN, r-MSSD, LF and HF. Based on a classification and regression tree analysis, MeanNN, SDNN and r-MSSD showed a sensitivity of 94.4% and a specificity of 50.6% as predictors of VT/VF. Our results suggest that the temporal changes in heart rate before an arrhythmic event can be used to predict the occurrence of VT/VF. These parameters may be used to optimize pacing therapies designed to prevent VT/VF recurrences as well as for improving device-based discriminators for VT/VF and sinus tachycardia.

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA MANAGED WITH ACUPRESSURE OF NEI-GUAN (PC6): THE REPORT OF A CASE IN THE EMERGENCY DEPARTMENT

Background: We described a 75-year-old man with a history of recurrent attacks of paroxysmal supraventricular tachycardia (PSVT). The patient presented to the emergency department (ED) with complaints of palpitations and chest tightness. Vagal stimulation maneuvers failed to convert the rhythm&#x0D; Materials and Methods: Acupressure was applied on Nei-Guan (PC6). &#x0D; Results: Acupressure applied on PC6 immediately converted the tachycardia to a normal sinus rhythm, thus successfully terminated an episode of PSVT complicated with hypotension and chest pain in the patient reported&#x0D; Conclusion: Acupressure of PC6 is easy to perform and safe, and can be done when other resuscitative measures are ongoing the same time. It is harmless and appropriate for certain groups of patients such as the elderly, children and pregnant women and worth trying before the administration of medication.

A Brugada syndrome proband with compound heterozygote SCN5A mutations identified from a Chinese family in Singapore.

Brugada syndrome (BrS) is a rare heritable ventricular arrhythmia. Genetic defects in SCN5A, a gene that encodes the α-subunit of the sodium ion channel Nav1.5, are present in 15-30% of BrS cases. SCN5A remains by far, the highest yielding gene for BrS. We studied a young male who presented with syncope at age 11. This proband was screened for possible disease causing SCN5A mutations. The inheritance pattern was also examined amongst his first-degree family members. The proband had a baseline electrocardiogram that showed Type 2 BrS changes, which escalated to a characteristic Type I BrS pattern during a treadmill test before polymorphic ventricular tachycardia onset at a cycle length of 250 ms. Mutational analysis across all 29 exons in SCN5A of the proband and first-degree relatives of the family revealed that the proband inherited a compound heterozygote mutation in SCN5A, specifically p.A226V and p.R1629X from each parent. To further elucidate the functional changes arising through these mutations, patch-clamp electrophysiology was performed in TSA201 cells expressing the mutated SCN5A channels. The p.A226V mutation significantly reduced peak sodium current (INa) to 24% of wild type (WT) whereas the p.R1629X mutation abolished the current. To mimic the functional state in our proband, functional expression of the compound variants A226V + R1629X resulted in overall peak INa of only 13% of WT (P < 0.01). Our study is the first to report a SCN5A compound heterozygote in a Singaporean Chinese family. Only the proband carrying both mutations displayed the BrS phenotype, thus providing insights into the expression and penetrance of BrS in an Asian setting.

An integrated index for detection of Sudden Cardiac Death using Discrete Wavelet Transform and nonlinear features

Early prediction of person at risk of Sudden Cardiac Death (SCD) with or without the onset of Ventricular Tachycardia (VT) or Ventricular Fibrillation (VF) still remains a continuing challenge to clinicians. In this work, we have presented a novel integrated index for prediction of SCD with a high level of accuracy by using electrocardiogram (ECG) signals. To achieve this, nonlinear features (Fractal Dimension (FD), Hurst’s exponent (H), Detrended Fluctuation Analysis (DFA), Approximate Entropy (ApproxEnt), Sample Entropy (SampEnt), and Correlation Dimension (CD)) are first extracted from the second level Discrete Wavelet Transform (DWT) decomposed ECG signal. The extracted nonlinear features are ranked using t-value and then, a combination of highly ranked features are used in the formulation and employment of an integrated Sudden Cardiac Death Index (SCDI). This calculated novel SCDI can be used to accurately predict SCD (four minutes before the occurrence) by using just one numerical value four minutes before the SCD episode. Also, the nonlinear features are fed to the following classifiers: Decision Tree (DT), k-Nearest Neighbour (KNN), and Support Vector Machine (SVM). The combination of DWT and nonlinear analysis of ECG signals is able to predict SCD with an accuracy of 92.11% (KNN), 98.68% (SVM), 93.42% (KNN) and 92.11% (SVM) for first, second, third and fourth minutes before the occurrence of SCD, respectively. The proposed SCDI will constitute a valuable tool for the medical professionals to enable them in SCD prediction.

The relationship between seizure onset zone and ictal tachycardia: An intracranial EEG study

ObjectivesSeizures are often accompanied by ictal tachycardia, which, when pronounced, is one of the cardiac arrhythmias associated with sudden unexpected death in epilepsy (SUDEP). We examined the relationship between the lateralization and localization of seizure onset and development of ictal tachycardia. MethodsWe identified patients who underwent bi-hemispheric intracranial EEG recording over a period of 18months. Two to four consecutive seizures were reviewed for each patient. ResultsFifty-seizures from 19 consecutive patients were analyzed. Forty seizures (80%) developed tachycardia (>20% increase from baseline), but laterality at seizure onset did not predict its occurrence (p=0.168).Bi-laterality at ictal onset was associated with early ictal tachycardia (<10s) (p=0.0208).Seizures out of sleep developed tachycardia faster (mean 19.7s vs. 68.2s, p=0.0067), but the state of alertness was not predictive of the development of tachycardia within 10s of seizure onset.Temporal and/or orbito-frontal lobe involvement was associated with tachycardia when compared to any other lobar combinations at ictal onset (p=0.0073). ConclusionLaterality at seizure onset does not predict the occurrence of ictal tachycardia. Involvement of the temporal and orbito-frontal cortex, spread to the contralateral hemisphere and state of alertness, may define the degree and rate of autonomic changes. SignificanceOur results help clarify the autonomic control during seizures and offer potential use for future studies in SUDEP risk and automatic seizure detection.

Antenatally diagnosed fetal cardiac tumor associated with tuberous sclerosis

Term male baby was born by normal vaginal delivery. The mother was followed-up in fetomaternal unit. Ultrasound report showed a huge mass arising externally from left ventricle free wall with multiple intracardiac masses with moderate pericardial effusion. A possibility of rhabdomyoma was considered. Baby was born with poor respiratory effort needed resuscitation and mechanical ventilation. Immediate postnatal echocardiography confirmed the presence of the extra and intra cardiac masses. Baby remained hemodynamically stable, developed one attack of supraventricular tachycardia and heart failure for which medical treatment given. Investigations confirmed the presence of tuberous sclerosis complex in this baby including magnetic resonance imaging and computed tomography (CT) scan that showed multiple subcortical and periventricular tubers'. CT abdomen showed angiomyolipoma of the left kidney, which disappeared completely after that. Baby remained free from neurological symptoms, discharged home on oral propranolol with multidisciplinary outpatient follow-up. His cardiac masses regressed significantly over his 2 years of life

Stretch Activated Channel Activation can Promote or Suppress Cardiac Alternans

Alternans has been linked to the onset of ventricular fibrillation and ventricular tachycardia, leading to life-threatening arrhythmias. Experimentally electromechanical alternans can be either concordant (Long/Short APD corresponds to a Large/Small Ca transient on alternate beats) or discordant (Long/Short APD corresponds to a Small/Large Ca transient). Our previous studies have shown that these phenomena depend on the underlying instability mechanisms (voltage driven or Ca driven) and bi-directional coupling between voltage and Ca cycling. The Large Ca transients also cause larger contractions which can activate mechanically (or stretch) activated currents (SACs). Here, we show how SAC activation can feed back to alter cardiac alternans, using a physiologically detailed rabbit AP and Ca cycling model coupled with SAC (either as Cl current or nonselective cation current). We found that (1) SAC suppresses electromechanically concordant alternans, because SAC shortens longer APD more than the shorter APD and limits the difference between successive APDs, (2) SAC enhances electromechanically discordant alternans, because SAC shortens the Short APD more than Long APD which amplifies the difference of two successive APDs. Qualitatively similar results were found for Cl-selective and non-selective cation current (and also Ca-activated K current). These results suggest that mechano-electric feedback can play an important role in development and stability of cardiac alternans.

Trauma and syncope-evidence for further sleep study? A case report

We report on an 83-year-old male with traumatic brain injury after syncope with a fall in the morning. He had a history of seizures, coronary artery disease and paroxysmal atrial fibrillation (AF). No medical cause for seizures and syncope was determined. During rehabilitation, the patient still complained of seizures, and also reported sleepiness and snoring. Sleep apnea diagnostics revealed obstructive sleep apnea (SA) with an apnea-hypopnoea index of 35/h, and sudden onset of tachycardia with variations of heart rate based on paroxysmal atrial fibrillation. Additional tests showed nocturnal AF which spontaneously converted to sinus rhythm mid-morning with an arrest of 5 s (sick sinus syndrome) and seizures. A DDD-pacer was implanted and no further seizures occurred. SA therapy with nasal continuous positive airway pressure was refused by the patient. Our findings suggests that screening for SA may offer the possibility to reveal causes of syncope and may introduce additional therapeutic options as arrhythmia and SA often occur together which in turn might be responsible for trauma due to syncope episodes.

Multilead Template‐Derived Residua of Surface ECGS for Quantitative Assessment of Arrhythmia Risk

Contemporary electrocardiographic (ECG) markers including ventricular ectopy and arrhythmias have not proved reliable in risk assessment for life-threatening arrhythmias. We developed the "Multilead ECG Template-Derived Residua" approach to remove intrinsic morphologic differences and allow calculation of pathologic ECG heterogeneities among spatially separated leads. Prediction by R-wave and T-wave heterogeneity (RWH, TWH) analysis was tested in simulated and clinical ECGs. An enabling description of the Residua algorithm is provided. Simulated ECGs with but not without Residua produced a linear relationship (correlation coefficient r(2) = 0.999) between input and output RWH and TWH values. In heart failure patients, Residua disclosed a marked crescendo in RWH from 164.1 ± 33.1 at baseline to 299.8 ± 54.5 μV and TWH from 134.5 ± 20.6 at baseline to 239.2 ± 37.0 μV at 30-45 minutes before the arrhythmia (both, P < 0.05), which remained elevated until arrhythmia onset. Without Residua, mean RWH and TWH were elevated at 1061.0 ± 222.9 and 882.5 ± 375.2 μV, respectively, throughout the recording and were not different prior to ventricular tachycardia onset. Calculation of ECG-template derived Residua provides a highly accurate means for assessing arrhythmia risk from standard ECGs. Potential widespread applications include resting diagnostic 12-lead, ambulatory, and exercise ECGs, electrophysiologic study laboratory recordings, and implantable devices.

G.P.146: Cardiac manifestations and gastro-intestinal sequelae in children with LMNA-CMD

Congenital muscular dystrophy secondary to variants in the lamin A/C gene (LMNA-CMD) typically present with hypotonia at birth, poor axial and truncal control, progressive joint contractures (sparing the elbow) and spinal rigidity. Patients with the congenital onset form can be divided into 2 severity classes: early severe (no ambulation and need for ventilator support in early childhood) and a later onset (brief period of ambulation, ventilator support in late childhood to early teenage years). We present 3 children with LMNA-CMD; all developed cardiac sequelae, diarrhea, and generalized edema. First manifestations of cardiac disease was asymptomatic atrial dysrhythmia. Cardiac disease progressed in early teenage years, in spite of appropriate rate control medication with the onset of cardiomyopathy and ventricular tachycardia. Automatic implantable cardiac defibrillators were recommended, though optimal timing of placement remains unclear. Gastro-intestinal (GI) symptoms, including diarrhea and abdominal distention may herald the onset of worsening cardiac function prior to the onset of overt cardiomyopathy. The etiology of gastrointestinal symptoms is likely multifactorial, including protein loss and gut hypo-perfusion. GI symptoms may respond to steroid therapy and a high protein diet, in spite of a negative work up for protein losing enteropathy.

Detection of T-wave beat-by-beat variations prior to ventricular arrhythmias onset in ICD-stored intracardiac electrograms: the Endocardial T-Wave Alternans Study (ETWAS).

The aim of the Endocardial T-Wave Alternans Study was to prospectively assess the presence of T-wave alternans (TWA) or beat-to-beat repolarization changes on implantable cardioverter-defibrillator (ICD)-stored electrograms (EGMs) immediately preceding the onset of spontaneous ventricular tachycardia (VT) or fibrillation (VF). Thirty-seven VT/VF episodes were compared to 116 baseline reference EGMs from the same 57 patients. A Bayesian model was used to estimate the T-wave waveform in each cardiac beat and a set of 10 parameters was selected to segment each detected T wave. Beat-by-beat differences in each T-wave parameter were computed using the absolute value of the difference between each beat and the following one. Fisher criterion was used for determining the most discriminant T-wave parameters, then top-M ranked parameters yielding a normalized cumulative Fisher score > 95% were selected, and analysis was applied on these selected parameters. Simulated TWA EGMs were used to validate the algorithm. In the simulation study, TWA was detectable even in the case of the smallest simulated alternans of 25 μV. In 13 of the 37 episodes (35%) occurring in nine of 16 patients, significant larger beat-to-beat variations before arrhythmia onset were detected compared to their respective references (median one positive episode per patient). Parameters including the T-wave apex amplitude seem the more discriminant parameters. Detection of beat-by-beat repolarization variations in ICD-stored EGMs is feasible in a significant subset of cases and may be used for predicting the onset of ventricular arrhythmias.

PP-238 Double-Outlet Right Ventricle that presented with Tachycardia Attacks

PP-238 Double-Outlet Right Ventricle that presented with Tachycardia Attacks

Pediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training

IntroductionPrevious studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e. “Milestones”. We developed a simulation-based teaching approach “Rapid Cycle Deliberate Practice” (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e. “first-five minutes” (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to “try again” over lengthy debriefing. ParticipantsPediatric residents from an academic medical center. MethodsProspective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation. ResultsSeventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5–100%) vs. post: 34% (26–53%); p<0.001)], no-blow fraction: [pre: 39% (22–64%) median (IQR) vs. post: 30% (22–41%); p=0.01], and pre-shock pause: [pre: 84s (26–162) vs. post: 8s (4–18); p<0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0–7.2)] and defibrillating within 2min: [HR: 1.7 (95% CI: 1.03–2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2min: [HR: 2.8 (95% CI: 1.5–5.1)]. ConclusionsImplementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.

Patients with drug-refractory atrioventricular nodal reentrant tachycardia: Clinical features, electrophysiological characteristics, and predictors of medication failure

Background and purposeDrug responses vary markedly from patient to patient in atrioventricular nodal reentrant tachycardia (AVNRT), the most common form of paroxysmal regular supraventricular tachycardia in adults. However, clinical and electrophysiological (EP) characteristics of patients with AVNRT whose tachycardia attacks could not be adequately controlled by antiarrhythmic agents have not been studied in a large patient cohort. We aimed to define the clinical and EP features of patients with drug-refractory AVNRT. Methods and resultsA total of 266 consecutive patients with AVNRT undergoing catheter ablation after a period of medical treatment were analyzed: 144 patients with drug-refractory AVNRT (Group 1) and 122 patients with drug-responsive AVNRT (Group 2). Age was significantly higher (p=0.027) and the presence of hypertension (p=0.030), diabetes mellitus (p=0.047), and valvular heart diseases (p=0.008) was more frequent in Group 1 compared to Group 2. Among the EP features, atrial-His jump (81% vs 69%, p=0.028) and atrial vulnerability (26% vs 14%, p=0.018) were significantly higher, echo zone was significantly more long-lasting (44±24ms vs 38±22ms, p=0.018), and tachycardia cycle length (TCL) was significantly longer (348±41ms vs 329±38ms, p=0.000) in Group 1 than in Group 2. Multivariate analysis showed that hypertension (p=0.036), valvular heart disease (p=0.014), atrial vulnerability (p=0.037), TCL (p=0.003), and wide echo zone (p=0.028) were independent predictors for drug-refractory AVNRT. ConclusionIn the presence of hypertension, valvular heart disease, atrial vulnerability, long-lasting echo zone, and relatively slow AVNRT, medical treatment is less likely to prevent the tachycardia episodes.

Paroxysmal supraventricular tachycardia in children

Introduction: Cardiac rhythm disturbances in children are rare and do not have to be associated with structural damage to the heart muscle. The most common are paroxysmal atrial tachycardia with an incidence of 1:500. These tachyarrhythmias in children are characterised by the number of strokes ranging 160- 360. Aim: The aim of this paper is to present the quality of life in children with paroxysmal supraventricular tachycardia (PSVT), and the role of Emergency Department (ED) in the treatment of attacks of tachycardia. Case report: A girl aging 7 was taken by her mother to the Emergency Department of Health Care Centre (HCC) Bečej on 1st November 2008 at 17:09 for palpitations. The attack occurred in the child for the first time, in an effort, half hour earlier. Clinical examinations revealed that the patient was hypotensive (TA 85/50 mmHg), tachycardia (300 beats/min) with oxygen saturation in the peripheral blood of 100%. On electrocardiogram (ECG) recorded the reading in sinus rhythm 300/min in frequency, levogram, the displacement of the ST segment in all leads of 3-5mm. Accompanied by a nurse, the patient was transported and diagnosed with Tachycardia Parohysmalis ( I 47.) without any pre-hospital therapy applied. She was hospitalized for ten days at the Cardiology Department of the Institute for Health Care of Children and Youth, Novi Sad (Novi Sad IZZZDiO). She was discharged with the diagnosis of Tachycardia Paroxysmalis Supraventrikularis (I 47.1) and Propranolol therapy was recommended. In spite of the treatment, attacks of PSVT were still being recorded in the patient. The therapy was replaced by the cardiologist. The applied therapy included Presolol, then Amiodarone, and then combinations Amiodarone and Presolol and since Avgusta 2011 she started using Propafen tablets. Until 10th February 2013 the patient had 27 attacks of tachycardia in total. The patient was treated at the Children's Medical Centre Bečej for five times, four times the ED HCC were invited to take her from the CMC and for18 times she was brought directly to the ED. In most cases, when the patient was cared for at ED HCC, PSVT was converted to sinus rhythm by Presolol or a combination of Presolol and Amiodaron. In two cases PSVT was converted by Valsalva maneuver. In two thirds of the visits, the patient was sent back home after the therapy and converting PSVT to a sinus rhythm. Nine times she was sent to IZZZDiO in Novi Sad, where he was hospitalized. Conclusion: If the PSVT attacks in children older than one, with a severe clinical course and frequent, continual medical therapy is applied. The highest efficiency is demonstrated by Amiodarone preventing the attacks in even 85% cases. However, in our patient the attacks continued despite of continuous drug therapy. They are frequent, with severe clinical course, limiting the child's daily activities. ED HCC physicians manage to convert most of the attacks to the sinus rhythm, so she does not have to be sent each time to a tertiary health institution and hospitalised.

Dyspnea, tachycardia, and new onset seizure as a presentation of wilms tumor: a case report.

Wilms tumor is found in 1 in 10,000 children and most commonly presents in asymptomatic toddlers whose care givers notice a nontender abdominal mass in the right upper quadrant. This case of Wilms tumor presented as a critically ill eleven-year old with significant tachypnea, dyspnea, vague abdominal pain, intermittent emesis, new onset seizure, metabolic acidosis, and hypoxemia. This is the first case in the literature of Wilms Tumor with cavoatrial involvement and seizure and pulmonary embolism resulting in aggressive resuscitation and treatment. Treatment included anticoagulation, chemotherapy, nephrectomy, and surgical resection of thrombi, followed by adjunctive chemotherapy with pulmonary radiation.