Pediatric Cardiac Emergencies No Colour

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Pediatric Cardiac Emergencies Gavin Greenfield Peggy Thomsen

 

• 4 year old female presents with fast breathing, “grunting, cough ! " days • seen # days earlier and started on steroids and bronchodilators • initial vitals$ %& '"(, )P '((*+", && -, T ./"

 

• ' month old with irritability, poor feeding 0fatigues1, failure to thrive, fast breathing • no fever or runny nose • physical e!am$ %& '-(, && -( with minimal respiratory distress, gallop rhythm, rales

 

2nfant Cardiac 3isease eading to E& Presentation • Congenital

•  5c6uired  7 Cardiomyopathy  7 8yocarditis 0usually with C%91  7 3ysrhythmias

 

Congestive %eart 9ailure • the physiologic state in which cardiac output is unable to meet tissue metabolic demands 0&osen1 • C: ; %& ! <= • <= dependent upon preload, afterload, contractility

 

C%9 > Presentation • infants$ irritable, poor feeding 0early fatigue1, failure to thrive, respiratory symptoms • always consider in patients with respiratory symptoms  7 often misdiagnosed as respiratory illness * infection

 

C%9 > Etiology •

2ncreased Preload  7  to & shunts 0=<3, P35, 5= fistula1  7 severe anemia



2ncreased 5ft 5fterload erload  7 %T?  7 Congenital 0aortic stenosis, coarctation of aorta1



3ecreased Contractility  7  7  7  7  7  7



myocarditis, pericarditis with tamponade cardiomyopathy 0dilated or hypertrophic1 @awasaAi syndrome 0early phase1 metabolic$ electrolyte, hypothyroid myocardial contusion to!ins$ dig, calcium channel blocAers, beta blocAers

3ysrhythmia

 

C%9 > Etiology • presents immediately at birth  7 anemia, acidosis, hypo!ia, hypoglycemia, hypocalcemia, sepsis

• presents at ' day 0congenital1 0 congenital1  7 P35 in premature infants

• presents in first month 0congenital1  7 %P=, aortic stenosis, coarctation, =<3 presents later

• presents later 0ac6uired1

 7 myocarditis, myocarditis, cardiomyopa cardiomyopathy thy 0dilated or hypertrophi hypertrophic1, c1, <=T, severe anemia, rheumatic fever 

 

8yocarditis • leading cause of dilated cardiomyopathy and one of the most common causes of C%9 in children • etiology$ idiopathic, viral, bacterial, parasitic • hallmarA is C%9 • failure to respond to bronchodilators in wheeBing child • treatment includes inotropes, afterload reduction, diuretics, antibiotics, antivirals

 

Pericarditis • sharp stabbing precordial pain • worse with supine and better leaning forward • no sensory innervation of the pericardium  7 pain referred from diaphragmatic and pleural irritation

 

Etiology • infectious  7 viral  7 bacterial  7 T)  7 fungal  7 parasitic

• Connective tissue  7 &5  7 &heumatic fever   7 <E

• 8etabolic * Endocrine  7 uremia  7 hypothyroid

• %ematology * :ncology  7 bleeding diathesis  7 malignancy

• Trauma • 2atrogenic

 

Pericarditis • usually a benign course • virulent bacteria 0%/ flu, E/ coli1 can cause constrictive pericarditis and subse6uent constrictive tamponade 7 may need urgent pericardiocentesis • uncomplicated pericarditis usually responds to rest and anti>inflammatori anti>inflammatories es

 

Chest Pain • 4 of children will have a cardiac origin • remainder$ 8<@, pulmonic 0asthma, bronchitis, pneumonia1, G2 • Cardiac causes$ myocarditis, m yocarditis, pericarditis, structural abnormalities such as congenital heart disease or hypertrophic cardiomyopathy

 

• '4 year old male collapses at school while in class • non>responsive for one minute • feels fine in the department •  5pproachD

 

<yncope • #(>"( of adolescents e!perience at least one episode of syncope  7 most cases benign

• Pathophysiology  7 vascular 

 7 hypovolemia  7 orthostatic, neurally mediated  7 hypo!ia$ PE, C?< depression from :3, C:  7 cardiac

 

Cardiac <yncope • 3ysrhythmias  7 tachy  7 brady

• :utflow obstruction • 8yocardial 3ysfunction • cardiac syncope often precedes future sudden cardiac death

 

<udden Cardiac 3eath • includes those causes that directly relate to cardiovascular dysfunction • one third of all sudden deaths

 

<udden Cardiac 3eath • Etiology  7  7  7  7  7  7  7  7  7

myocarditis cardiomyopathy (hypertrophic) cyanotic and noncyanotic congenital heart disease valvular heart disease congenital complete heart blocA P long FT syndrome 8arfan syndrome coronary artery disease

 7 anomalous coronary arteries

 

&isA 9actors for <erious Cause of <yncope • history of cardiac disease in patient • 9% of sudden death, cardiac disease, or deafness • recurrent episodes • recumbent episode • e!ertional • prolonged loss of consciousness • associated chest pain or palpitations • medications that can alter cardiac conduction

 

hat to looA for in the 3epartment$ • ong FT syndrome

[email protected]

 7 congenital or ac6uired  7 get paro!ysmal v tach with torsades de pointes  7 congenital long FT associated with hypertrophic cardiomyopathy  7 long FT defined as corrected FT longer than (/44 s  7 T wave alternans sometimes present  7 can have normal ECG in the department  7 two clinical syndromes not associated with structural heart disease$ &omano>ard and ervell>ange> ?ielsen

 

:ther dysrhythmias • P and other <=THs •  5  5= = blocA  7 usually ac6uired, rarely congenital

• <icA sinus syndrome

 

2diopathic %ypertrophic • aAa 2%<< Cardiomyopathy • both a fi!ed and dynamic subvalvular s ubvalvular obstruction • characteriBed by ventricular hypertrophy with principle involvement of the ventricular septum • associated with long FT • autosomal dominant • often presents with e!ertional syncope • '( year mortality is "( for children diagnosed by age '4

 

:ther structural cardiac diseases

• dilated cardiomyopathy

 7 usually secondary to myocarditis  7 syncope and death secondary to ventricular dysrhythmias or severe myocardial dysfunction

• arrhythmogenic &= dysplasia • congenital cyanotic and non>cyanotic heart disease • valvular diseases  7 aortic stenosis

• coronary artery anomalies  7 e!ertional syncope or sudden death  7 aberrant artery passes between aorta and pulmonary artery

 

• # weeA old infant brought in by parents with difficulty breathing • %& '+(, )P "(*P, && +(, T ./" • history and physical • investigations • repeat vitals$ %& (, no )P, && '# • “definitive treatment$

 

• 4 year old male presents with # weeAs history of cough, fast breathing, fatigue, decreased e!ercise tolerance, “puffy eyes • :n e!am$ tachypneic, moderate respiratory distress, :# sats I#, bilateral cracAles

 

• - month male presents with failure to thrive, fast breathing, blue lips • :n e!am tachypnea but no respiratory distress, lips and e!tremities blue, o!ygen saturations .(

 

Congenital %eart 3isease • 9etal to ?eonatal Circulation

 

 5natomic ClassificationJ ClassificationJ 4 • Right to Left Shunt

groups • Stenotic

 7 Tetralogy of 9allot  7 Tr Transposition ansposition of of the Great 5rteries  7 Tricuspid 5tresia

 7 5ortic valve valv e stenosis  7 Pulmonic valve stenosis  7 5ortic coarctation coarctatio n • Mixing

• Left to Right Shunt

 7 5<3  7 =<3  7 P35

 7 Truncus  7 Total 5nomalous Pulmonary =enous &eturn  7 %ypoplastic left heart syndrome left heart

 

C%3 Classified as Cyanotic vs/  5cyanotic  5cyano tic

• Cyanotic 0& to  shunt and mi!ing lesions1  7 tetralogy of 9allot  7 transposition of great vessels  7 tricuspid atresia  7 total anomalous pulmonary venous return  7 truncus arteriosus  7 hypoplastic left heart syndrome

 

C%3 Classified as Cyanotic vs/  5cyanotic  5cyanotic •  5cyano  5cyanotic tic 0 to & shunts, shunts, stenotic stenotic lesions1  7 5<3  7 =<3  7 P35  7 aortic valve stenosis  7 pulmonic valve stenosis  7 aortic coarctation

 

Cyanosis • Classified as central or peripheral • Central cyanosis 0always abnormal1  7 mucous membranes, trunA, e!tremities  7 classified as cardiac 0& to  shunt1 or pulmonary

• Peripheral cyanosis 0acrocyanosis1  7 no involvement of mucous membranes  7 involv involves es hands, feet, circumoral area  7 common in neonates from vasomotor instability instability  7 C%9, P=3, shocA, cold e!tremities

 

Congenital %eart 3isease • %istory  7 feeding difficulties  7 tachypnea  7 diaphoresis  7 syncope  7 cyanotic episodes  7 failure to thrive

 

Congenital %eart 3isease • Physical E!amination  7 colour$ pinA, blue, gray  7 vitals$ tachypnea, tachycardia, )P  7 symptoms suggestive of infection  7 palpation and auscultation of precordium  7 chest auscultation  7 survey for organomegaly  7 pulses in all e!tremities

 

Cyanotic Congenital %eart 3isease • & to  shunts • mi!ing lesions

 

Tetralogy of 9allot 7 the classic cyanotic• lesion &= outflow obstruction • &=% • =<3 • overriding aorta • CK& reveals boot shaped heart with decreased pulmonary blood flow

 

• # month old female with Anown tetralogy of 9allot brought in with #4 hour history of vomiting and diarrhea • :n e!am$ moderate dehydration • during 2= attempts patient becomes irritable and cyanotic

 

Treatment of Tet <pell • 6uiet, calm environment • Anee>chest or s6uatting position  7 increases afterload thus decreasing & to  shunting

• :!ygen • 8orphine  7 to treat hyperpnea and decrease systemic catecholamines

• Phenylephrine  7 increases afterload thereby decreasing & to  shunt

• 8anual e!ternal aortic compression below level of renal arteries • Propranolol  7 to blocA beta receptors r eceptors in infundibulum therefore lessening &= outflow obstruction

 

Consider  • consider small volume challenge 0">'( cc*Ag1 to increase preload and reduce dynamic outflow obstruction • D?a%C: for correction of acidosis • may need general anesthesia if severe and*or prolonged spell • interim prophylactic treatment with propranolol while awaiting surgery

 

 5cyanotic Congenital %eart 3isease •  to & shunts

• stenotic lesions

 

=<3 •Most common congenital lesion •Large VSD’s may be silent and  become symptomatic in first few weeks as pulmonary resistance ↓ •SOB and diaphoresis w feeds •oor weight gain •Systolic murmur  •!"# demonstrates !

%$  

• # weeA old infant brought in by parents with difficulty breathing • %& '+(, )P "(*P, && +(, T ./" • history and physical • investigations • repeat vitals$ %& (, no )P, && '# • “definitive treatment$

 

3ifferential 3! of 2nfant <hocA • infection 0septic shocA* meningitis1  7 bacterial$ G)<, E/ coli, </ aureus  7 virus$ enteroviruses, %/ simple!

• metabolic$ amino*organic acidopathies, urea cycle defect • Lhypo!ic shocAH$ s hocAH$ eg/ &<=, &<=, C/?/</ depression • heart disease$ congenital or ac6uired

 

:utfl tflow ow = :u :bstruction

 

= :utflow :bstruction •  5ortic coarctation • %ypoplastic left heart syndrome •  5ortic stenosis 0presents later1 • &osen$ “any neonate in shocA that does not respond to fluids or pressors has = outflow obstruction until proven otherwise • complete obstruction incompatible with life

unless there is shunting

 

Coarctation of the aorta •Most often distal to L subcla&ian •!an be diagnosed anytime • 'eonates present as acutely ill( gray shocky )from D* closure+ •Systolic murmur at the back  •$epatomegaly •Diminished femoral pulses •B difference difference b,t arms and legs •!"# demonstrates !$% •-reatment of !$% •rostaglandin ./

 

3uct 3ependant esions • 3uct needed to perfuse lungs or periphery • ungs  7 Tetralogy of 9allot, transposition of great arteries, tricuspid or pulmonary atresia • a patent ductus arteriosus results in preserved pulmonary blood flow

• Periphery

 7 5ortic coarctation 0severe1 and %ypoplastic left heart

 

Treatment of acute decline in patients with ductal dependant lesions

• :pen the closed duct • Prostaglandin E' (/' ug*Ag*min infusion • reduce dosage as perfusion and colour return • &osen$ “any infant in the first weeA of life with decreased perfusion, hypotension, or acidosis should be considered a candidate for PGE' administration

 

hat do you need to Anow about PGE D • it functions by dilating vascular smooth muscle, both systemically and in the pulmonary vascular bed • itHs use in C%3 ptsH is to maintain patency of the P35, whether to maintain P)9 or to maintain systemic blood flow past a

 

Classification &eview • pinA child in respiratory distress suggests acyanotic chd 0 to & shunt, coarct, aortic stenosis1 • blue cyanotic child in little respiratory distress suggests & to  shunt or mi!ing lesions • gray, shocAy baby suggests outflow tract obstruction

 

)radyarrhythmias • Etiology  7 hypo!ia, acidosis, hypoglycemia  7 e!cess vagal stimulation 0e!/ intubation1

  • Treatment  7 Epinephrine  7 5tropine if Anown Anown vagally mediated or heart heart blocA

 

Congenital )radyarrhythmias • complete 5= blocA  7 autoimmune inMury to fetal conduction system secondary to maternal autoimmune disease  7 atropine, isoproteronol, epinephrine may be tried temporarily prior to pacing

 

Tachyarrhythmias • <upraventr <upraventricular icular Tachycardia  7 re>entrant with accessory pathway 05= nodal or P1  7 re>entrant without accessory pathway 0re> entry occurs within sinus node or within atrium1  7 ectopic

• nonspecific presentations in infants

 

8urmurs •  5reas  7 aortic$ & #nd intercostal space  7 pulmonic$  #nd intercostal space  7 mitral$ ape!  7 tricuspid and =<3$  lower lower sternal border 

• Pathologic  7 diastolic, holosystolic, late systolic, continuous

 

2nnocent %eart 8urmurs • %istory  7 normal growth and develop development, ment, normal e!ercise tolerance  7 no history of cyanosis

• Physical E!amination  7 Grade 22 or less, localiBed  7 varies with position 0decreased with upright posture1  7 normal precordium  7 normal pulses

• ab  7 normal [email protected], normal CK&

 

 innocent murmurs • <tillHs  7 short eMection systolic murmur  7 musical or vibratory 6uality  7 heard best between ape! and left sternal border 

• physiologic pulmonary flow murmur   7 harsh, located at pulmonic area

• peripheral arterial stenosis  7 low>intensity low>intensity systolic eMection murmur best heard in a!illa and bacA

 

• + year old male presents with fever, arthralgias • mother mentions that he had a sore throat  weeAs ago for a few days with spontaneous resolution • a throat swab was done and positive for G5< but patient better so did not taAe the prescribed antibiotics

 

 5cute &heumatic 9ever  • school aged children • associated with certain strains of Group 5 beta> hemolytic streptococcal infections • the streptococcal organism stimulated antibody production to host tissues  7 CT of heart, Moints, C?<, subcutaneous tissues, sAin

• carditis is an endomyocarditis with valvulitis involving mitral and aortic valves • # to - weeAs post streptococcal pharyngitis

 

ones Criteria • 8aMor   7 carditis • new or changing murmur  • cardiomegaly, C%9 • pericarditis

 7 migratory polyarthritis  7 chorea  7 erythema marginatum  7 subcutaneous nodules

• 8inor   7 fever   7 arthralgia  7 history of previous  5&9  7 elevated E<&, C&P  7 prolonged P& on [email protected]  7 &ising titer of antistreptococcal antibodies

 

E& Treatme Treatment nt • management of complicating features of carditis 0C%91  7 significant carditis or C%9 managed with glucocorticoids

• high>dose 5<5 .">'(( mg*Ag*day • pencillin • long term management of rheumatic heart disease

 

Pediatric [email protected] General Principles • &= 3ominance at birthJ gradually changes to = dominan dominance ce • a!is up to N'+( in normal newborn • T waves negative in right precordial leads until adolescence 0e!cept they are upright in first weeA of life1

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