Pediatric Cardiology Emergencies

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Pediatric Cardiology Emergencies Esmail Redha,MD,FAAP Consultant Pediatric Cardiologist
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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 Cyanosis - PowerPoint PPT Presentation

Transcript of Pediatric Cardiology Emergencies

  • Pediatric Cardiology EmergenciesEsmail Redha,MD,FAAPConsultant 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 - CyanosisPGE10.05-0.1 mcg/kg/min starting doseAny intravenous siteUACUVCPeripheralInterosseous

  • Newborn Problems: Low Cardiac Output

    ShockMetabolic acidosisCirculatory shutdown

  • Newborn Problems Low Cardiac OutputEvaluationChest 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 QRSs

  • Complete Heart Block

  • Newborn ProblemsTreatmentLeft heart obstructive lesionsMuscle diseasesHeart rate problemsPGE1Inotropic 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 SpellsTreatmentCalmingOxygenMorphinePositioningBeta 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 FailurePresentation in InfancyStructural Diseases: Left Heart ObstructionsFirst days:Hypoplastic Left Heart Syndrome Critical aortic stenosis

    First month: Coarctation of the aortaFirst 2 months: Left-to-right ShuntsVSD, PDA, Truncus Arteriosus

  • Congestive Heart FailurePresentation after infancyProgression of structural heart diseaseArrhythmiasInfectious diseasesLater onset myopathiesToxins: AnthracyclinesDiphtheria

  • Congestive Heart FailurePre-loadAfterloadContractilityHeart RateDeterminants of Cardiac Output

  • 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

  • ContractilityAcute TreatmentBeta AgonistsDobutamineAfterload reduction alsoEpinepherineDopamineIncreased 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.

  • ArrhythmiasTreatmentPre-hospitalizationDiving reflexIce Bag to the faceValsalvaCarotid Massage(no longer recommended)

  • Arrhythmias

    HospitalizationAdenosineDiagnostic and therapeutic

  • Arrhythmias

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

  • Arrhythmias

    Shock requires ShockSynchronized cardioversion1 joule/kg

  • ArrhythmiasDigoxin LoadingBeta BlockerCalcium Channel Blocker(not indicated in infants).FelcainideAmiodaroneProcainamide loadingRepeat adenosine

  • Image 3Wide 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 cardiomyopathyFinal common pathway for cardiac arrest in many conditionsFrom Cardiac Arrhythmias in Children and Young Adults with Congenital Heart Disease. Walsh, et al. (2001).

  • Remember: Prolonged QT intervalThis pt.C/O recurrent fainting attacks

  • Ventricular tachycardiaDifferential diagnosisVentricular tachycardiaSupraventricular rhythm with aberrant conductionRate relatedPermanent bundle branch blockPreexcited rhythmSupraventricular rhythm with preexcitationAntidromic tachycardiaTwo-pathway tachycardiaPaced rhythmTreatment 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 4Ventricular Fibrillation

  • Ventricular tachycardiaTreatmentAddress treatable causesElectrolytesAcidosisPharmacotherapyClass Ib lidocaineClass III amiodaroneElectrical therapyCardioversionImplantable defibrillator

  • Wide Complex Tachycardias

    Surgical TherapyAutomatic Implantable Cardioverter-Defibrillator

  • Remember:

    1- Sinus tachycardia2- Supraventricular tachycardia3- Ventricular tachycardia 4- Atrial flutter5- 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.Dont Panic with Arrhythmias: Shock when in Shock.Introduce Autamated External Defibrilator.

  • THANK YOU

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

    If you woke up this morning with more health than illness ...

    **