Pediatric Cardiology Emergencies

Esmail Redha,MD,FAAP

Consultant Pediatric Cardiologist

Age specific Emergencies:

Newborn Emergencies

Infant & Childhood Emergencies

Newborn Problems

Cyanosis

Low Cardiac Output

Newborn Problems - Cyanosis

Cardiac CyanosisDoes not respond to oxygenDoes not respond to ventilationUsually no respiratory distress

Newborn Problems - Cyanosis

EvaluationChest x-rayArterial blood gasses(Hyperoxytest)Echocardiogram : Obstructive

Lesion/Abnormal Circulation

Newborn Problems - Cyanosis

Right sided obstructive lesionsPulmonary atresiaTricuspid atresiaTetralogy of Fallot

Tricuspid Atresia

Newborn Problems - Cyanosis

Abnormal CirculationsTransposition of the great arteriesTotal anomalous pulmonary venous

return

Transposition of the Great Arteries

TAPVR

Newborn Problems - Cyanosis

TreatmentPGE1Restoration of acid/base balanceSurgical Evaluation

Newborn Problems - Cyanosis

PGE10.05-0.1 mcg/kg/min starting doseAny intravenous site

UACUVCPeripheral

Interosseous

Newborn Problems: Low Cardiac Output

ShockMetabolic acidosisCirculatory shutdown

Newborn Problems Low Cardiac Output

EvaluationChest x-rayArterial blood gassesEchocardiogramElectrocardiogram

Newborn Problems Low Cardiac Output

Left Sided Obstructive lesionsHypoplastic left heartCritical aortic stenosisCritical coarctation of the aorta

Hypoplastic Left Heart

Severe Coarctation

Without a PDA there is no blood flow to the abdomen

and lower extremities.

(Blue blood is better than no blood.)

Ductal-DependentLesion

Newborn Problems: Low Cardiac Output

Muscle diseasesMyocarditisCardiomyopathiesSepsisAsphyxia

Newborn Problems :Low Cardiac Output

Heart Rate ProblemsSupraventricular tachycardiasComplete heart block

Newborn Problems Low Cardiac Output

Supraventricular TachycardiaNarrow ComplexHeart Rate > 220 bpmUsually > 240 bpm

Narrow Complex Tachycardia

Newborn Problems Low Cardiac Output

Complete Heart BlockHeart rate below 60 bpmNo relationship between P waves and

QRS’s

Complete Heart Block

Newborn Problems

TreatmentLeft heart obstructive lesionsMuscle diseasesHeart rate problemsPGE1 Inotropic support , afterload reduction &

Diuretics.Slow down or speed up

Infant and Childhood Problems:

Hypercyanotic spells

Congestive heart failure

Arrhythmias

Infant and Childhood Problems

Hypercyanotic Spells

Tetralogy of FallotPulmonary Atresia

Tetralogy of Fallot

Infant and Childhood Problems

Hypercyanotic Spells

Sudden decrease in pulmonary blood flow, usually in the morning

Provocation

Raised apex

Hypercyanotic Spells

TreatmentCalmingOxygenMorphinePositioningBeta BlockerPhenylepherine

Hypercyanotic Spells

Phenylepherine

Increase systemic vascular resistance which leads to less R - > L shunting and improved saturation

Hypercyanotic Spells

Long Term Treatment with Propranolol

Indication for surgery, either palliative shunt or total repair

Congestive Heart Failure

Differing etiology at different ages

Congestive Heart Failure

Presentation in InfancyStructural Diseases: Left Heart Obstructions

First days: Hypoplastic Left Heart Syndrome Critical aortic stenosis

First month: Coarctation of the aortaFirst 2 months: Left-to-right Shunts

VSD, PDA, Truncus Arteriosus

Congestive Heart Failure

Presentation after infancyProgression of structural heart diseaseArrhythmias Infectious diseasesLater onset myopathiesToxins:

AnthracyclinesDiphtheria

Congestive Heart Failure

Pre-load

Afterload

Contractility Heart RateDeterminants of Cardiac Output

Heart FailureHeart Failure

Sympathetic ToneSympathetic Tone

Renin & Renin & angiotensionangiotension

Arterial & Arterial & venous venous

constrictionconstriction++HR & coronary HR & coronary

vasoconstrictionvasoconstriction

Ventricular preload Ventricular preload & afterload& afterload

Myocardial Myocardial blood flowblood flow

Worsening heart failureWorsening heart failure

CHF Management

Sites of action of drugs used to treat heart failure:

Congestive Heart Failure

Preload reduction

DiureticsFluid RestrictionHigh caloric density

Congestive Heart Failure

Afterload reduction

ACE inhibitors

Nitroprusside

Congestive Heart Failure

Heart Rate modification

Beta Blockers(eg.:Carvedilol)Also treats diastolic dysfunction & remodeling

Contractility

Acute TreatmentBeta Agonists

Dobutamine Afterload reduction also

EpinepherineDopamine Increased myocardial demandsMilrinone(makes wonders)

Contractility

Milrinone increases contractility and reduces afterload without increasing myocardial oxygen demand

Contractility

Chronic TreatmentDigoxinNew Treatments: Biventricular Pacing,

Assist Device.

Arrhythmias

Narrow Complex Tachycardias

Arrhythmias

Supraventricular Tachycardia

Arrhythmias

Re-entrant TachycardiasAV node re-entryWolff-Parkinson-White

Wolff-Parkinson White

Wolff-Parkinson White S (WPW)

1. Short PR interval. 2. Delta wave (initial slurring of the

QRS complex).3. Wide QRS duration.

Arrhythmias

TreatmentPre-hospitalization

Diving reflex Ice Bag to the face

ValsalvaCarotid Massage(no longer recommended)

Arrhythmias

HospitalizationAdenosine

Diagnostic and therapeutic

Arrhythmias

Adenosine100 mcg/kg IV rapid pushRepeat every 5 minutes with increasing

doses

Arrhythmias

Shock requires ShockSynchronized cardioversion1 joule/kg

Arrhythmias

Digoxin Loading

Beta Blocker

Calcium Channel Blocker(not indicated in infants).

Felcainide

Amiodarone

Procainamide loading

Repeat adenosine

Image 3

Wide QRS Tachycardia

Ventricular arrhythmiasCommon cause of sudden death in repaired congenital heart disease and acquired pediatric heart disease and cardiomyopathy0.001% annual risk in general pediatric

population1-3% annual risk in many repaired CHD4-6% risk in HCM25-30% risk in dilated cardiomyopathy

Final common pathway for cardiac arrest in many conditions

From From Cardiac Arrhythmias in Children and Young Adults with Cardiac Arrhythmias in Children and Young Adults with Congenital Heart Disease.Congenital Heart Disease. Walsh, et al. (2001) Walsh, et al. (2001).

Remember: Prolonged QT

interval

This pt.C/O recurrent fainting attacks

Ventricular tachycardiaDifferential diagnosisVentricular tachycardiaSupraventricular rhythm with aberrant conduction

Rate relatedPermanent bundle branch block

Preexcited rhythmSupraventricular rhythm with preexcitationAntidromic tachycardiaTwo-pathway tachycardia

Paced rhythm

Treatment depends on appropriate diagnosis!

Wide Complex Tachycardias

Treat all as if Ventricular Tachycardia

Wide Complex Tachycardias

Unstable rhythm requires Cardioversion 2 joules/kg(shock requires shock).

Image 4

Ventricular Fibrillation

Ventricular tachycardiaTreatmentAddress treatable causes

ElectrolytesAcidosis

PharmacotherapyClass Ib – lidocaineClass III – amiodarone

Electrical therapyCardioversion Implantable defibrillator

Wide Complex Tachycardias

Surgical TherapyAutomatic Implantable Cardioverter-

Defibrillator

Remember:

1- Sinus tachycardia

2- Supraventricular tachycardia

3- Ventricular tachycardia

4- Atrial flutter

5- Atrial fibrillation

Ventricular fibrillation

‘nuff said

Automated External Defibrilator

Step I

Step II

Step III

Step IV

Step VI

Messages to Take

Neonatal Screening: Upper & Lower Extremities O2 Sat. check.

Don’t Panic with Arrhythmias: Shock when in Shock.

Introduce Autamated External Defibrilator.

You are more blessed than the million who will not survive this week.

You are more blessed than the million who will not survive this week.

I f you woke up this morning with more health than illness ...I f you woke up this morning with more health than illness ...

THANK YOU