1 / 90

Pediatric Cardiac Emergencies

Pediatric Cardiac Emergencies. Graham Thompson Francois Belanger Feb 26 th 2004. Objectives. Review transitional changes in pediatric cardiology CHD – presentations in ED, blue vs pink, ED Tx Post-op issues presenting to the ED Pacers SVT in the PED Acquired Cardiac Disease

finnea
Télécharger la présentation

Pediatric Cardiac Emergencies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Pediatric Cardiac Emergencies Graham Thompson Francois Belanger Feb 26th 2004

  2. Objectives • Review transitional changes in pediatric cardiology • CHD – presentations in ED, blue vs pink, ED Tx • Post-op issues presenting to the ED • Pacers • SVT in the PED • Acquired Cardiac Disease • Pericarditis • KD • ARF • MIs in the pediatric world • Cardiac Arrest • PALS Guidelines (attached)

  3. Neonatal Circulation

  4. Changes at Birth • Decreased PVR from expansion of lung and high PaO2 • Increased SVR from stopping placental circulation • Functional closure of PFO from high LA pressures • Reversal of flow and then closure of PDA • Closure of ductus venosus • Slow change from R dominant to L dominant circulation • (Malformations often cause changes to this pattern (can be life saving i.e. PDA in CoA!!)

  5. Normal Vitals for Children

  6. Case #1 • 4 do boy with central cyanosis • Term baby of 17 yo girl, minimal prenatal care • ROM 6 hrs, uncomplicated delivery • Left hospital w/in 24 hrs • Bottle feeding well until today, now only 1 oz/feed • WOB increased over the day

  7. Brought into resusc room Hr 165 RR 75 BP 65/28 LA SpO2 79% R/A, cyanosed 100% supplied SpO2 – 84% IV started, NS bolus 70 cc A/E good, clear, mild-moderate WOB S1 S2 (? Single) IV/VI systolic murmur Pulses good, liver 2cm BCM Font flat, soft, neuro intact Bld wk, ECG and CXR pending Case (cont)

  8. Congenital Heart Disease • 0.5-0.8% of live births (not including PDA or bicuspid aorta) • Increased in syndromes • T21 – endocardial cushion defects, ASD, VSD • XO – CoA, bicuspid AV • Increased with maternal prenatal drugs • Lithium – Ebstein anomaly • VPA – CoA, HLHS, VSD, AS • 40-50% dx in 1st wk, 50-60% by 1st month

  9. VSD 25–30 ASD (sec) 6–8 PDA 6–8 CoA 5–7 TOF 5–7 PS 5–7 AS 4–7 d-TGA 3–5 HLHS 1–3 HRHS 1–3 Truncus 1–2 TAPVR 1–2 Tricuspid atresia 1–2 Single ventricle 1–2 DORV 1–2 Others 5–10 * Excluding PDA in preterm neonates, bicuspid AV, physiologic PPS, and MVP Frequency of major CHD (% of total)

  10. Presentations • Most complex CHD are picked up on routine prenatal ultrasound (up to 75%) • Complex CHD is often picked up prior to D/C from the nursery with cyanosis or abnormal heart sounds • BUT…….Timing and symptoms relate to physiologic changes of newborn and the lesion (obstruction vs shunt) so they may show up in the ED!!! • Any newborn looking comfortably cyanotic is probably cardiac!! – mixing lesion

  11. 0-2 wks • Duct dependant lesions • Takes 2-14 days for duct closure • May present to the ED more often, because of early D/C (duct hasn’t closed yet!) • Most common are Left outflow tract obstructions (CoA, interrupted arch, AS, HLHS), TGA, TOF • In the words of Dr. Patton • “Beware of the “septic”-like 2 wk old infant with poor pulses: is it possibly CoA or critical AS?”

  12. In 1st year • CHD that presents in failure (tachypnea, sweating with feeds, feeds >30 min, FTT, pallor) • Most commonly related to L-to-R shunt (ie VSD) • At birth, R pressures are high, shunt is minimal so defect may not present itself • Drop in R side pressures and increased L pressures occurs over 6-8 wks causing shunt and symptoms • Murmurs are not heard in nursery because lack of shunt • Late TOF presentations that are relatively protected from failure by RVOT obstruction. May present with tet spells.

  13. Childhood • Restrictive L-to-R shunts • ASD, Small VSD • Mild CoA, mild AS – may present with fatigue or leg pain/wkness or HTN • The very rare TOF

  14. Presentation of CHD

  15. Approach to CHD Dx • Cyanotic • Increased Pulmonary flow • Decreased pulmonary flow (RV outflow obstruction) • Acyanotic • Increased volume load (ASD, VDS, PDA) • Increased pressure load (LV outflow obstruction)

  16. Approach to CHD

  17. Cyanotic episodes Central vs peripheral Feeding pattern diaphoresis Stopping frequently Prolonged (>30 min) FTT Gestational age Maternal Hx of medications, infections Prenatal U/S Genetic D/O Previous child with CHD Exercise intolerance Syncope R/O sepsis stuff!!! Hx in CHD

  18. VS Tachypnea Arrhythmias 4 limb BPs (SBP in legs N > by 10, if not look for LVOT obstruction) 4 limb SpO2 T0C – hypermetabolic Colour Diaphoresis Wt gain Heart sounds and murmurs (don’t forget to listen to the back – CoA) Distal pulses, R/F delay Precordium Abdomen – HSM Clubbing Px in CHD

  19. Cyanotic Heart Disease • Central vs Peripheral • Central • 50 g/l of non-oxygenated Hgb • Level of hypoxia varies according to hct, so polycythemic kids can look cyanotic at higher SpO2s • Peripheral • Perfusion issues

  20. Hyperoxic test • Technically • Do gas • Give 100% O2 • After 10 min, redo gas • Mixing cardiac lesion won’t be able to get PaO2 > 100-150 • Practically • SpO2 won’t get into 90% in mixing cardiac lesion

  21. Cyanotic Heart Disease • The 5 T’s • Tetralogy Of Fallot (TOF) • Truncus Arteriosus • Tricuspid Lesions (atresia, Ebstein’s) • Transposition of the Great Arteries (TGA) • Total Anomalous Pulmonary Venous Return (TAPVR) • + PA/severe PS

  22. TOF • Tetralogy • RV outflow obstruction • Overriding aorta • VSD (usually non restrictive) • RVH

  23. TOF clinical • 5 - 10% of CHD • Most common cyanotic CHD after infancy • Cyanotic or acyanotic depending on degree of RVOT obstruction • Blue if ++ obstruction = R-L shunt (present earlier) • Pink if minimal obstruction = L-R shunt • RVH (felt under xyphoid) • Loud, probably single S2 • III-V/VI SEM at LSB

  24. TOF - Dx • Boot shaped heart • Decreased pulm. Vasc. • 20% R sided arch • RVH

  25. “Tet” Spells • Most frequent in 1st 2 yrs (peak at 2-4 mo) • After startle, crying or upon waking • Hyperpnea, restless, increasing cyanosis, syncope • Sudden decrease in pulmonary flow, increased R-L shunt • Prolonged spells can lead to LOC, acidosis, szs • Tx • Calm child • Knee to chest or Squat position • O2 • Morphine 0.1-0.2mg/kg SC • HCO3 if prolonged • ketamine • Phenylephrine to increase systemic pressures

  26. TGA • d-TGA is 2 systems in parallel • l-TGA is physiologically corrected (lung-LA-RV-aorta-body-RA-LV-lung)

  27. TAPVR • A – supracardiac • B – cardiac • C – cardiac • D - infracardiac

  28. Truncus

  29. Tricuspid atresia • No RA outflow • Requires ASD (natural or balloon) to have R-L shunt. • Requires PDA or VSD to allow L-R shunt • RV usually really small, so Fontan works well • Usually Dx at birth, but may be later

  30. Ebstein’s Anomaly • Downward displacement of an abnormal TV • Atrialization of RV

  31. Evaluation of Cyanotic Infant • ABC • IV access • Physical exam • Labs, hyperoxic test • CXR • Consider meds • Call cardio

  32. PGE1 • Relaxation of ductal smooth muscle • Infusion of 0.05-0.2 ug/kg/min • 80 cc NS in 500ug vial run at BW = 0.1ug/kg/min (or 36cc in 225ug vial) • Side effects • Jitteriness • Fever • Hypotension • Apnea • Relative contraindication • TAPVR – may worsen systemic perfusion

  33. CXR in CHD • Egg on a string – TGA • Snowman – TAPVR • Boot – TOF • Super huge heart – Ebstein’s • Backward E – CoA – notched ribs by collaterals

  34. Acyanotic Heart Disease • RVOT obstruction presents with shock • CoA • VSD • ASD

  35. Surgical Procedures

  36. Post-op issues in the ED • Shunts • Can obstruct, especially passive flow (glenn) • Think of this child presents with URTI or gastro causing dehydration • BT shunts are active flow, and when obstructing have increased cyanosis and changed shunt murmur • Glenn shunts are passive flow and present with SVC syndrome and decreased murmur • Can flood lungs • If R-L shunt is too high, then may present similar to failure – tachypnea, crackles, wet chest

  37. Post-op issues in the ED • MI – especially in atrial or arterial switches for TGA • Arrhythmias • AV block for TGA, VSDs, ASDs • WPW in Ebstein’s anomaly • Atrial flutter

  38. Post-op issues in the ED • Post pericardotomy syndrome • Sustained febrile period 1 wk – 2 months (mean 3-4 wks) after sx • Thought to be related to autoimmune response • Pericarditis symptoms, CXR and ECG • Tamponade may occur • Usually self limiting in 2-3 wks • Tx • Bed rest • NSAIDs • Steroids • Pericardiocentesis if needed.

  39. CHD presentations to ED • 5 yr retrospective study at UCLA ED • Only 8 new CHD presentations • Age ranged from 1 wk to 5 months • ASD – 3 • VSD – 1 • AS – 1 • ALCAPA – 1 • CoA – 1 • TAPVR – 1 • Savitsky E J.Emerg Med 2003, 24(3):239

  40. CHD in the ED • Really great references on CHD • Woods WA et al Emerg Med Reports 2003 24(6) – CHD in the ED • Woolridge DP et al Ped Emerg Med Reports 2002 7(7) – CHD in the PED Pt 1 • Woolridge DP et al Ped Emerg Med Reports 2002 7(8) – CHD in the PED pt 2

  41. Case • 3 mo boy to ED with grey spells • Has happened 3 times in past 2 days • Hasn’t taken more than 1 oz for past 3 feeds • Intermittent WOB, no URTI sympt. • Had been seen last month for decreased feeding, difficulty breathing, stuffy nose and pallor– dx – bronchiolitis

  42. Case (cont) • Looked dusky at triage • Taken directly to resusc. room • O2 and monitors, IV started immediately • Pinked up with O2, SpO2 = 99% • ECG

  43. SVT

  44. Post Adenosine Child had echo showing Ebstein’s Anomaly

  45. Non-pharmacologic Tx for SVT • Interrupts about 25% of SVT • Cooperative children • Blow against straw • Crouch down • Uncooperative or Small Children and Infants • Push legs into chest • Carotid sinus massage • Ocular pressure • Diving reflex

  46. Carotid massage for SVT • Randomized X-over trial of carotid massage vs valsalva maneuver • 148 episodes • No difference in efficacy • Total of 25% responded to one of the therapies • Carotid massage is not recommended in young patients (but no reason given!) Lim SH et al Ann Emerg Med 1998 31(1):30 Paed Drugs 2000 2(3):171

More Related