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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

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Pediatric Cardiac Emergencies

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  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

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