Post on 14-Apr-2018
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Tips and Tricks in Pediatric Emergency
Prakul Chanthong MDDivision of CardiologyDepartment of Pediatrics
Faculty of Medicine, Siriraj Hospital
Hypoxic spells
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Tips and Tricks in Pediatric Emergency
Case 1
A 1 year old child came with severecyanosis with respiratory distress withbreathing at 40/min this morning. His
mother noted these symptoms for 2months. He was diagnosed Tetralogy of
Fallot since 6 months of age.
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Tips and Tricks in Pediatric Emergency
Case 1
Physical examination showed:
T 37 C, HR = 150/min,
RR = 40/min, BP 80/50 mmHg.
Oxygen saturation = 60%
GA: Irritability, severe cyanosis,
dyspnea CVS: Normal S1 and single S2
No murmur
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Tips and Tricks in Pediatric Emergency
Case 1
Physical examination showed:
Chest: Normal breath sound withoutadventitious sound
Abdomen: liver 1 cm below right costalmargin
Other exam was unremarkable
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Tips and Tricks in Pediatric Emergency
Questions
What is the most likely diagnosis?
What are the appropriate management?
Can we prevent these symptoms?
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Tips and Tricks in Pediatric Emergency
Hypoxic spells
Paroxysmal hypoxemic spells Hypercyanotic spells
Tetralogy spells
Paroxysmal dyspnea
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Tips and Tricks in Pediatric Emergency
Signs and symptoms
Increase cyanosis
Increase rate and depth of respiration
systolic murmur
Softer
Disappear
Hypotension
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Tips and Tricks in Pediatric Emergency
Initial Presentation
Episode of loss of consciousness
Convulsion
Episode of going pale of floppy
Deeply cyanosis then loss ofconsciousness or sleep
Rapid deep respiration or hyperpnea
High pitch abnormal cry
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Tips and Tricks in Pediatric Emergency
Hypoxic spells
Common seen - infants and young children
Usually self-limited
Less than 15-30 min. in length
Occur in the infant mild to moderatedesaturation
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Tips and Tricks in Pediatric Emergency
Hypoxic spells
More common and severe CyanoticCHD with iron def. anemia
Spontaneous improvement 18-24
months
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Tips and Tricks in Pediatric Emergency
Hypoxic spells
Occur spontaneously
More frequently
In the morning
After feeding
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Tips and Tricks in Pediatric Emergency
Hypoxic spells
May be precipitated by
Crying
Defecation
Exercise
Sudden fright
Injury Hot weather
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Tips and Tricks in Pediatric Emergency
Hypoxic spells
Cardiac conditions PA flow depends onthe ratio of pulmonary-systemic resistance
Decrease SVR
Increase right to left shunt
Decrease aortic saturation
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Tips and Tricks in Pediatric Emergency
Hypoxic spells
Tetralogy of Fallot
Pulmonary atresia/ VSD
Transposition of great arteries
Tricuspid atresia
Eisenmenger syndrome
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Tips and Tricks in Pediatric Emergency
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Tips and Tricks in Pediatric Emergency
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Tips and Tricks in Pediatric Emergency
Mechanisms
Infundibular spasm
Decreased SVR
Tachycardia
Hyperpnea
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Tips and Tricks in Pediatric Emergency
Sympathetic NS or circulating
catecholamine
Infundibular spasm
Pulmonary blood flow
right to left shunt
hypoxia
Systemic vasodilatation
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Tips and Tricks in Pediatric Emergency
Oxygen saturation
Poor delivery of oxygen to tissue
Metabolic acidosis
Hyperventilation
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Tips and Tricks in Pediatric Emergency
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Tips and Tricks in Pediatric Emergency
Mechanisms
Infundibular spasm
Decreased SVR
Tachycardia
Hyperpnea
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Tips and Tricks in Pediatric Emergency
Differential diagnosis
Breath holding spells
Seizure
CNS disorder
Colic
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Tips and Tricks in Pediatric Emergency
Treatment
Decrease RVOT obstruction
Increase SVR
T
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Tips and Tricks in Pediatric Emergency
Treatment
Knee-chest position
Increase PVR in lower extremities
Oxygen
IV line
T t t
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Tips and Tricks in Pediatric Emergency
Treatment
Medication
Morphine
0.1 mg/kg IM, IV or SC
Ketamine 0.5-1 mg/kg
T t t
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Tips and Tricks in Pediatric Emergency
Treatment
NaHCO3 Beta blocker
Propranolol
Esmolol
Volume expansion
Peripheral vasoconstrictor Phenylephrine
T t t
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Tips and Tricks in Pediatric Emergency
Treatment
General anesthesia
Systemic to pulmonary artery shunt
h l i
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Tips and Tricks in Pediatric Emergency
Prophylaxis
Propranolol
1-4 mg/kg
3-4 divided doses
C 1
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Tips and Tricks in Pediatric Emergency
Case 1
A 1 year old child came with severecyanosis with respiratory distress withbreathing at 40/min this morning. His
mother noted these symptoms for 2months. He was diagnosed Tetralogy ofFallot since 6 months of age.
Case 1
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Tips and Tricks in Pediatric Emergency
Case 1
Physical examination showed:
T 37 C, HR = 150/min,
RR = 40/min, BP 80/50 mmHg.
Oxygen saturation = 60% GA: Irritability, severe cyanosis,
dyspnea CVS: Normal S1 and single S2
No murmur
Case 1
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Tips and Tricks in Pediatric Emergency
Case 1
Physical examination showed:
Chest: Normal breath sound withoutadventitious sound
Abdomen: liver 1 cm below right costalmargin
Other exam was unremarkable
Questions
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Tips and Tricks in Pediatric Emergency
Questions
What is the most likely diagnosis?
What are the appropriate management?
Can we prevent these symptoms?
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Tips and Tricks in Pediatric Emergency
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Tips and Tricks in Pediatric Emergency
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Tips and Tricks in Pediatric Emergency
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Tips and Tricks in Pediatric Emergency