Pemckw.com

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Pediatric Cardiology Emergencies

• Esmail Redha,MD,FAAP
• Consultant Pediatric Cardiologist

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Age specific Emergencies

• Newborn Emergencies
• Infant Childhood Emergencies

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Newborn Problems

• Cyanosis
• Low Cardiac Output

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Newborn Problems - Cyanosis

• Cardiac Cyanosis
• Does not respond to oxygen
• Does not respond to ventilation
• Usually no respiratory distress

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Newborn Problems - Cyanosis

• Evaluation
• Chest x-ray
• Arterial blood gasses(Hyperoxytest)
• Echocardiogram Obstructive
• Lesion/Abnormal Circulation

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Newborn Problems - Cyanosis

• Right sided obstructive lesions
• Pulmonary atresia
• Tricuspid atresia
• Tetralogy of Fallot

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Tricuspid Atresia
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Newborn Problems - Cyanosis

• Abnormal Circulations
• Transposition of the great arteries
• Total anomalous pulmonary venous return

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Transposition of the Great Arteries
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TAPVR
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Newborn Problems - Cyanosis

• Treatment
• PGE1
• Restoration of acid/base balance
• Surgical Evaluation

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Newborn Problems - Cyanosis

• PGE1
• 0.05-0.1 mcg/kg/min starting dose
• Any intravenous site
• UAC
• UVC
• Peripheral
• Interosseous

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Newborn Problems Low Cardiac Output

• Shock
• Metabolic acidosis
• Circulatory shutdown

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Newborn Problems Low Cardiac Output

• Evaluation
• Chest x-ray
• Arterial blood gasses
• Echocardiogram
• Electrocardiogram

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Newborn Problems Low Cardiac Output

• Left Sided Obstructive lesions
• Hypoplastic left heart
• Critical aortic stenosis
• Critical coarctation of the aorta

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Hypoplastic Left Heart
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Severe Coarctation
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Ductal-DependentLesion
Without a PDA there is no blood flow to the
abdomen and lower extremities. (Blue blood is
better than no blood.)
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Newborn Problems Low Cardiac Output

• Muscle diseases
• Myocarditis
• Cardiomyopathies
• Sepsis
• Asphyxia

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Newborn Problems Low Cardiac Output

• Heart Rate Problems
• Supraventricular tachycardias
• Complete heart block

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Newborn Problems Low Cardiac Output

• Supraventricular Tachycardia
• Narrow Complex
• Heart Rate gt 220 bpm
• Usually gt 240 bpm

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Narrow Complex Tachycardia
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Newborn Problems Low Cardiac Output

• Complete Heart Block
• Heart rate below 60 bpm
• No relationship between P waves and QRSs

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Complete Heart Block
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Newborn Problems

• Treatment
• Left heart obstructive lesions
• Muscle diseases
• Heart rate problems
• PGE1
• Inotropic support , afterload reduction
  Diuretics.
• Slow down or speed up

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Infant and Childhood Problems

• Hypercyanotic spells
• Congestive heart failure
• Arrhythmias

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Infant and Childhood Problems

• Hypercyanotic Spells
• Tetralogy of Fallot
• Pulmonary Atresia

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Tetralogy of Fallot
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Infant and Childhood Problems

• Hypercyanotic Spells
• Sudden decrease in pulmonary blood flow, usually
  in the morning
• Provocation

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• Raised apex

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Hypercyanotic Spells

• Treatment
• Calming
• Oxygen
• Morphine
• Positioning
• Beta Blocker
• Phenylepherine

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Hypercyanotic Spells

• Phenylepherine
• Increase systemic vascular resistance which leads
  to less R - gt L shunting and improved saturation

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Hypercyanotic Spells

• Long Term Treatment with Propranolol
• Indication for surgery, either palliative shunt
  or total repair

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Congestive Heart Failure

• Differing etiology at different ages

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Congestive Heart Failure

• Presentation in Infancy
• Structural Diseases Left Heart Obstructions
• First days Hypoplastic Left Heart Syndrome
• Critical aortic stenosis
• First month Coarctation of the aorta
• First 2 months Left-to-right Shunts
• VSD, PDA, Truncus Arteriosus

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Congestive Heart Failure

• Presentation after infancy
• Progression of structural heart disease
• Arrhythmias
• Infectious diseases
• Later onset myopathies
• Toxins
• Anthracyclines
• Diphtheria

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Congestive Heart Failure
Pre-load
Contractility
Heart Rate
Determinants of Cardiac Output
Afterload
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CHF Management

• Sites of action of drugs used to treat heart
  failure

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Congestive Heart Failure

• Preload reduction
• Diuretics
• Fluid Restriction
• High caloric density

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Congestive Heart Failure

• Afterload reduction
• ACE inhibitors
• Nitroprusside

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Congestive Heart Failure

• Heart Rate modification
• Beta Blockers(eg.Carvedilol)
• Also treats diastolic dysfunction remodeling

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Contractility

• Acute Treatment
• Beta Agonists
• Dobutamine
• Afterload reduction also
• Epinepherine
• Dopamine
• Increased myocardial demands
• Milrinone(makes wonders)

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Contractility

• Milrinone increases contractility and reduces
  afterload without increasing myocardial oxygen
  demand

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Contractility

• Chronic Treatment
• Digoxin
• New Treatments Biventricular Pacing, Assist
  Device.

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Arrhythmias

• Narrow Complex Tachycardias

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Arrhythmias

• Supraventricular Tachycardia

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Arrhythmias

• Re-entrant Tachycardias
• AV node re-entry
• Wolff-Parkinson-White

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Wolff-Parkinson White
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Wolff-Parkinson White S (WPW)
1. Short PR interval. 2. Delta wave (initial
slurring of the QRS complex).3. Wide QRS
duration.
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Arrhythmias

• Treatment
• Pre-hospitalization
• Diving reflex
• Ice Bag to the face
• Valsalva
• Carotid Massage(no longer recommended)

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Arrhythmias

• Hospitalization
• Adenosine
• Diagnostic and therapeutic

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Arrhythmias

• Adenosine
• 100 mcg/kg IV rapid push
• Repeat every 5 minutes with increasing doses

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Arrhythmias

• Shock requires Shock
• Synchronized cardioversion
• 1 joule/kg

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Arrhythmias

• Digoxin Loading
• Beta Blocker
• Calcium Channel Blocker(not indicated in
  infants).
• Felcainide
• Amiodarone
• Procainamide loading
• Repeat adenosine

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Wide QRS Tachycardia
Image 3
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Ventricular arrhythmias

• Common cause of sudden death in repaired
  congenital heart disease and acquired pediatric
  heart disease and cardiomyopathy
• 0.001 annual risk in general pediatric
  population
• 1-3 annual risk in many repaired CHD
• 4-6 risk in HCM
• 25-30 risk in dilated cardiomyopathy
• Final common pathway for cardiac arrest in many
  conditions

From Cardiac Arrhythmias in Children and Young
Adults with Congenital Heart Disease. Walsh, et
al. (2001).
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This pt.C/O recurrent fainting attacks
Remember Prolonged QT interval
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Ventricular tachycardia

• Differential diagnosis
• Ventricular tachycardia
• Supraventricular rhythm with aberrant conduction
• Rate related
• Permanent bundle branch block
• Preexcited rhythm
• Supraventricular rhythm with preexcitation
• Antidromic tachycardia
• Two-pathway tachycardia
• Paced rhythm
• Treatment depends on appropriate diagnosis!

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Wide Complex Tachycardias

• Treat all as if Ventricular Tachycardia

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Wide Complex Tachycardias

• Unstable rhythm requires Cardioversion 2
  joules/kg(shock requires shock).

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Ventricular Fibrillation
Image 4
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Ventricular tachycardia

• Treatment
• Address treatable causes
• Electrolytes
• Acidosis
• Pharmacotherapy
• Class Ib lidocaine
• Class III amiodarone
• Electrical therapy
• Cardioversion
• Implantable defibrillator

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Wide Complex Tachycardias

• Surgical Therapy
• Automatic Implantable Cardioverter-Defibrillator

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• Remember
• 1- Sinus tachycardia
• 2- Supraventricular tachycardia
• 3- Ventricular tachycardia
• 4- Atrial flutter
• 5- Atrial fibrillation

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Ventricular fibrillation

• nuff said

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Automated External Defibrilator
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Step I
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Step II
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Step III
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Step IV
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Step VI
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Messages to Take

• Neonatal Screening Upper Lower Extremities O2
  Sat. check.
• Dont Panic with Arrhythmias Shock when in
  Shock.
• Introduce Autamated External Defibrilator.

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THANK YOU