Paediatric Emergency cardiology

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Paediatric Emergency cardiology

• Gavin Burgess R5, PEM

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General

• Review common presentations
• Uncommon
• Paediatric ECG
• Congenital heart disease
• Rhythm disturbances
• Long QT
• HOCM
• Rheumatic fever
• Carditis myo, endo, peri

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General

• Innocent murmurs
• Kawasaki disease

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Fetal circulation
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Normal
Age Respiratory rate Pulse rate Systolic BP
O-1mo 30-60 120-160 50-70
1-12mo 20-40 80-140 70-100
1-5y 20-30 80-130 80-110
6-12y 20-30 70-110 80-120
adolescents 12-20 60-100 110-120
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Normal

• Ball-park BP?
• Neonate?
• Older?

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Normal

• Gestational age should equal MAP
• Systolic BP 70 (2 x age)

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Normal ECG

• Typically have shorter PR, QRS, QT
• RV dominance, RAD

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RVH

• Causes
• Tetralogy of Fallot
• PS
• Coarct
• ASD
• TAPVD
• Large VSD with Pulm HT

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LVH

• Causes
• AS
• VSD
• PDA
• Complete AV block
• Cardiomyopathy

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Diagnosis?
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Superior or north west axis

• Endocardial cushion defect
• 2 of congenital heart disease
• Down syndrome account for 70
• Fatal due to pulm HT
• Banding in infancy

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Myocardial infarction

• AT III
• Cardiomyopathy
• Congenital heart disease
• CAD (ALCAPA)
• Drugs (cocaine)
• Homocystinuria
• Hyperlipidaemia and cholesterolaemia
• Kawasaki
• Leukaemia
• Marfans
• Haemoglobinopathies
• Tumours (myxoma)
• Rheumatic fever
• SLE

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Diagnosis?
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Diagnosis?
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Diagnosis?
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Which lesions give cyanosis?

• Tetralogy of Fallot
• Tricuspid atresia
• Transposition of the great arteries (IDM)
• Truncus arteriosus
• Total anomalous pulmonary venous drainage
• Hypoplastic left heart
• Ebsteins anomaly (lithium)
• Pulmonary atresia/severe stenosis

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Pulmonary markings

• Decreased
• Pulmonary atresia/stenosis
• Tetralogy
• Tricuspid atresia
• Ebsteins anomaly
• Increased
• TGA
• TAPVD
• Truncus

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Whats the hyperoxia test?

• ABG
• Give 100 O2
• Repeat ABG after 10 min
• If rises by gt10, likely pulmonary lesion

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When does the ductus close?

• 10-14 days after birth, it is physiologically
  closed

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Neonatal and infant presentations to ED

• What are the 4 presentations in and infants
  neonates?
• 1) shock
• 2) cyanosis
• 3) cardiac failure
• 4) murmur

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What are the ductal-dependent lesions?

• Systemic
• Coarct/interrupted arch
• Aortic stenosis
• HLH
• Pulmonary
• PS/atresia
• Tricuspid atresia

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Shock

• L ventricular outflow obstruction
• Coarct
• AS
• HLH

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Shock

• Management
• ABCs
• Start prostin
• CXR
• ECG

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Whats prostin?

• Prostaglandin E1
• Rate 0.05-0.2 mcg/kg/min
• Side effects?
• Apnoea
• Fever
• Flushing
• Hypotension
• Prostin has an all or nothing action
• Should work in 15min

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Time to presentation of cyanotic lesions
Age ECG X-ray
0-1 week TGA RVH Increased
1st week TAPVD RVH Increased
1-4weeks Tricuspid Atresia LVH Decreased
Severe PS RVH Decreased
1-12weeks TOF RVH Decreased
Anytime in infancy Truncus arteriosus BVH Increased

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Cyanosis

• What is a tetralogy of Fallot?
• RVH
• Overriding aorta
• VSD
• RV outflow obstruction

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Whats a tet spell?

• Change in the balance of pulmonary and systemic
  flow
• Hypoxic and cyanotic event
• Decreased system vascular resistance or increased
  RV outflow obstruction
• Increasing hypoxia

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How do I treat it?

• O2
• Chest-knee (why?)
• Analgesia
• B-blocker (why?)

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Cardiac failure

• History
• Fussy
• Sweating
• FTT
• Short frequent meals
• Physical
• HSM
• Murmur
• FTT
• You will NOT see a JVP
• AVM auscultate the head

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Murmurs

• Features of an innocent murmur
• 80 of children will have a murmur at some time
  in their lives
• All have normal ECG and X-rays
• Never diastolic

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Common innocent murmurs
Type Description Age
Stills LLSB, 2/6, twang 3-6y
Pulmonary flow ULSB, blowing, transmits Gone in 3-6mo
Venous hum Supra clavicular, rotate head, supine goes 3-6y
Carotid bruit Over carotid Any age

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Arrhythmia

• SVT
• Very common
• Tolerated well, occasional LOC change
• Child is fussy
• Newborn gt220 bpm
• lt12y often accessory pathway

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Arrhythmia

• SVT treatment
• In shock vs stable
• Vagal stim
• Adenosine
• Amiodarone ,verapamil use extreme caution.
  Frequently develop profound hypotension and die

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Arrhythmia

• Long QT
• History
• Deafness
• Single person MVC
• Swimming syncope
• Exercise syncope
• Family history of sudden death
• Seizure of unknown etiology
• Recurrent syncope/lightheadedness
• Sibling with SIDS
• Physical
• Infant with bradycardia

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Arrhythmia

• All first degree family members should be
  screened with ECG

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HOCM

• 2 under 2 y, 7 under 10y
• Variable history
• CP
• Palpitations
• SOB
• Syncope
• Sudden death
• High risk if syncope
• Sudden death with strenuous exercise

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HOCM

• Physical
• S4 gallop, mid systolic murmur
• Increased PVR decreases murmurs

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Rheumatic fever

• Who was Jones?
• What where his criteria?
• What do you need to make a diagnosis?
• Which valve?
• Then?

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Rheumatic fever

• What about Sydenhams chorea?
• And the rash?

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Rheumatic fever

• Treatment
• ASA 75-100mg/kg
• Prednisone 1-2mg/kg
• Benzathine (Pen G) 600 000U (27kg), 1.2 million U
  (27kg)
• Prophylaxis
• Age questioned

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Myocarditis

• Various causes, most notably viral
• Coxsackie A,B, ECHO, flu
• Non-specific viral prodrome
• Non-specifc fussiness, lethargy etc
• Heart failure
• IVIG may be indicated

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Infective endocarditis

• Rheumatic fever, congenital heart defects,
  catheters, IVD
• S. aureus, viridans are the usual suspects
• Fungi in neonates, usually in the NICU

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Infective endocarditis

• Major
• 2 BC, (viridans, s. bovis, HACEK, S. aureus,
  enterococci
• Persistently BC (1 hr between multiple, or 12h
  or 3h )
• echo mass at typical sites
• Intracardiac abscess
• Prosthesis failure
• New regurgitant murmur

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Infective endocarditis

• Minor
• Fever (38C)
• Predisposing condition/IVD
• Vascular phenomena
• Non-specific echo findings

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Prophylaxis -1997

• High risk amp and gent
• Prosthesis
• Previous IE
• Complex CHD
• Surgical systemic-pulmonary shunts
• Medium risk - amp
• Other congenital heart malformation
• Acquired valve dysfunction
• HOCM
• MVP
• Negligible risk no Rx
• Isolated secundum repaired ASD, VSD, PDA bypass
  graft MVP (no regurge) innocent murmurs KD
  with normal valves RF with no valve dysfunction
  pacemakers

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Prophylaxis

• High risk
• Prosthesis
• Previous IE
• Transplants
• Complex CHD
• Dropped from the list.
• Moderate risk (PDA,VSD,primumASD,coarct,bicuspidAV
  )
• Calcified AS,RF,HOCM,MVP

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Pericarditis

• Classic chest pain worse when lying flat
• Radiation to L shoulder
• Friction rub
• Most often viral causes
• Diffuse ST changes, saddleshaped
• CXR important
• Cefotaxime, ASA, prednisone, colchicine

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Kawasaki disease

• Etiology unkown, presumed infectious
• More common in Asian and Pacific islanders
• Peaks around 1-2years, 80 under 4y, 50 under 2y
• Slight male preponderance
• 3mo-8y is typical range

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Kawasaki disease

• 3 phases
• Acute phase (10 days)
• High fever for 5 days
• 4 of
• rash (ANY rash, no bullae/vesicles),
• oedema of extremities/ peeling of extremities
• Non-exudative bulbar conjuctivitis
• Mucosal changes (cracked lips, strawberry tongue
  even on HISTORY)
• Cervical LN (1.5cm)
• Carditis, other organs (arthritis, pyuria,
  gallbladder/liver, menigitis, irritable

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Kawasaki disease

• Acute
• ESR, CRP
• WCC, plt
• Lipids, LFTs
• Echo coronary artery aneurysms unusual before 10d
• Subacute phase
• Desquamation
• Coronary disease
• Rash, fever, LN disappear
• plt

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Kawasaki disease

• Convalescent phase
• ESR, plt normalise
• Beaus lines

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Kawasaki disease

• Rx
• IVIG
• ASA
• Vaccinations
• Steroid of no benefit
• Reduces CAD from 25 to 5
• Untreated mortality 1-5