Transcript My Girls - NCCPeds

Cardiac emergencies
and the Pediatrician
Thomas R. Burklow, MD
Asst C., Pediatric Cardiology
Walter Reed Army Medical Center
National Capital Consortium
Cardiac emergencies
Congestive
heart failure
Hypercyanotic spells
Tachyarrhythmias
Hypertensive crisis
How do you know
you are dealing with
a cardiac emergency?
Case Presentation #1
4
month old presents to ER with cc: “cold
symptoms”
 5 day history of increasing cough; afebrile, no
rhinorrhea, no ill contacts.
 PMH: unremarkable. vigorous feeder (2530oz/d) until the last couple of days.
 FHx: father had a “leaky valve” but was cleared
to join the Marines
Physical Examination
VS: HR 165, RR 60, normal BP throughout; RA O2
sat mid 80’s, increases to 97% on 1/4 L/ O2
 Small for age male, nondysmorphic, mild cyanosis,
moderate increased work of breathing
 Left chest prominent
 Prominent PMI, RRR, S2 obscured by murmur, gr III
pansystolic SRM over apex to left axilla
 Liver edge 4 cm below RCM
 1+ pulses throughout

Electrocardiogram
Chest X ray
What is the pathological
condition which is present in
this infant?
What information supports this
supposition?
What do you do?
Clinical manifestations
 Infant
 feeding
difficulties
 failure to thrive
 diaphoresis
 tachycardia
 tachypnea
 Child
 breathlessness
 tachycardia
 tachypnea
 peripheral
edema
 cardiomegaly
What causes congestive heart failure?
Excessive
work load: pressure or
volume
Normal workload faced by a
damaged myocardium
Etiologies
 Neonate
 dysfunction
 volume
 pressure
 Infant
 Volume
 Dysfunction
 Child
 Palliated
congenital
heart disease
 AV valve regurgitation
 Acute rheumatic fever
 Myocarditis
 Endocarditis
Neonatal congestive heart failure
 Dysfunction




Myocarditis
Cardiomyopathy—think inborn error of metabolism
Coronary artery anomaly
Arrhythmias
 Volume


Unrestrictive ventricular septal defect(s)
Truncus arteriosus
 Pressure—think
obstruction



ductal-dependent left-sided
Hypoplastic left heart syndrome
Critical aortic stenosis
Critical coarctation of the aorta
CHF in infants and children
 Dysfunction





Myocarditis
Cardiomyopathy—think inborn error of metabolism
Coronary artery anomaly
Palliated congenital heart disease
Arrhythmias
 Volume




Unrestrictive ventricular septal defect(s)
Severe atrioventricular valve dysfunction
Truncus arteriosus
Palliated congenital heart disease
How do you know what entity
you are dealing with?...






Age
 An apparently well neonate who develops CHF at 1-2
weeks...consider a ductal-dependent lesion
 An apparently well child without known heart disease
develops CHF…consider myocarditis
Fetal history of “irregular heart beats”
Duration of symptoms
Prior history of surgery
Family history
Travel history
Assessment--physical examination
 Identify
signs and symptoms of congestive heart
failure
 Blood pressures
 Pulse oximetry
 Presence of murmur MAY be helpful
Treatment
 Digitalis




oral: 8-10 mcg/kg/day
I.V.: 80% of oral dose
Because of varying metabolism, appropriate dose varies
by age
Rapid digitalization
 May be performed over 12-24 hours, 6-12 hours in
dire situations
 Calculate TDD (varies by age); administer 1/2 of
TDD, followed by 1/4, then 1/4 of TDD
 Case
example: patient weight is 5.5 kg
Case example
5.5 kg in a 4 month old
 Oral TDD for 1 month-2 years is 30-50 mcg/kg
 TDD is 220 mcg

Administer 110 mcg now, then 55 mcg in 12 hours, then
55 mcg in 6 hours
 IV dose is 80% of the above amounts


Maintenance digoxin is approximately 1/4 of TDD,
divided b.i.d., or at 50 mcg/cc, 0.1 cc/kg per dose b.i.d.
Digoxin toxicity




Levels are helpful only in cases of suspected toxicity, not for
management
GI symptoms are common presenting symptoms: nausea,
vomiting, anorexia
Most common sign of cardiac toxicity is arrhythmia:
bradycardia, AV block, PVCs
Treatment includes holding doses for 1-2 half lives, atropine for
sinus bradycardia, and “FAB” fragments in cases of significant
toxicity
Other medications
 Diuretics
 Furosemide (Lasix); 0.5-1.0 mg/kg/dose
 Chlorothiazide (Diuril); 20-50 mg/kg/day
 Spironolactone (Aldactone); 1-2 mg/kg/day
 Afterload reduction
 Captopril (Capoten); 0.1-0.5 mg/kg/dose t.i.d.
 Enalapril (Vasotec); 0.1 mg/kg/day
 Beta-blocker
 Labetolol
 Carvediolol
A couple words regarding critical left
sided obstructive lesion…
Critical obstruction to cardiac output
 Hypoplastic
left heart syndrome
 Critical aortic stenosis
 Critical coarctation of the aorta
The common endpoint for these three lesions is
loss of systemic cardiac output when the ductus
closes….
Physiology of
hypoplastic
left heart
STOP
Prostaglandin
 PGE1
 Powerful
ductal dilator
 Mechanism of ductal closure



High oxygen tension
Circulating prostaglandins
Genetic predetermination
Prostaglandin dosing
Starting dose: 0.1 mcg/kg/min
Or…



One ampule is 500 mcg/1 cc
Mix one amp in 82 cc of normal saline
Run resulting mixture at 1 cc/kg/hr, this will be
equivalent to 0.1 mcg/kg/min
Case presentation #2
 Two
month old African-american infant
presents to the 2 month well baby visit
 Mother has no concerns: feeding well, no
tachypnea.
 Family history is unremarkable
Physical Examination
 VS:
HR 180; RR 25, BP 85/45, room air
oxygen saturations 84%
 Ht 25th percentile, Wt 25th percentile
 General features: non-dysmorphic infant
female
 Abdomen: Liver edge palpable at RCM
 Ext: 2+ radial and femoral pulses
Cardiovascular examination
Prominent right ventricular impulse, subxiphoid
 Normal S1 with a single S2
 Harsh systolic murmur noted at the left mid-upper
sternal border, with radiation to back and axilla
 Diastole: quiet
 Extra cardiac sounds: none

Electrocardiogram
Chest radiograph
While discussing the most likely diagnosis with
the parents, you are called away. However, you
are urgently called back to the examination
room by the clinic nurse. The parents state
that while the infant was crying, her complexion
became intensely dark (“she’s never done this
before”) and becamely listless…
The pulse oximeter is reading a HR of 170 and
an pulse oximetry reading of less than 70%.
Upon auscultation, you note the murmur is
diminished in intensity.
Hypercyanotic spell
a.k.a. “Tet spell”, “paroxysmal hyperpnea”
 Etiology uncertain
 “Infundibular spasm”
 Decrease in systemic vascular resistance

 Goal
of therapy is to increase
pulmonary blood flow
PVR
SVR
Recognition of hypercyanotic spell
 Symptoms
include: irritability, crying,
loss of consciousness
 Physical examination may demonstrate
tachypnea, deepening of cyanosis, and
loss of systolic ejection murmur
 Laboratory data would reveal metabolic
acidosis
Treatment
Soothing
 Knee-chest positioning
 Morphine, 0.1-0.2 mg/kg IV or SC
 Oxygen (perhaps limited value)
 Intravenous volume expansion, 10 cc/kg isotonic
 Sodium bicarbonate 1-2 mEq/kg/dose
 Propanolol, 0.15-0.25 mg/kg IV over 2-5 minutes
 Phenylephrine, 0.1 mg/kg IM or SC
 General anesthesia

The End…for
now