Transcript Low Cardiac Output

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
 Does
not respond to oxygen
 Does not respond to ventilation
 Usually no respiratory distress
Newborn Problems Cyanosis
Evaluation
 Chest
x-ray
 Arterial blood gasses(Hyperoxytest)
 Echocardiogram : Obstructive
Lesion/Abnormal Circulation
Newborn Problems Cyanosis
Right sided obstructive lesions
 Pulmonary
atresia
 Tricuspid atresia
 Tetralogy of Fallot
Tricuspid Atresia
Newborn Problems Cyanosis
Abnormal Circulations
 Transposition
of the great arteries
 Total anomalous pulmonary venous
return
Transposition of the
Great Arteries
TAPVR
Newborn Problems Cyanosis
Treatment
 PGE1
 Restoration
of acid/base balance
 Surgical Evaluation
Newborn Problems Cyanosis
PGE1
 0.05-0.1
mcg/kg/min starting dose
 Any intravenous site
 UAC
 UVC
 Peripheral
 Interosseous
Newborn Problems:
Low Cardiac Output
 Shock
 Metabolic
acidosis
 Circulatory shutdown
Newborn Problems
Low Cardiac Output
Evaluation
 Chest
x-ray
 Arterial blood gasses
 Echocardiogram
 Electrocardiogram
Newborn Problems
Low Cardiac Output
Left Sided Obstructive lesions
 Hypoplastic
left heart
 Critical aortic stenosis
 Critical coarctation of the aorta
Hypoplastic Left Heart
Severe Coarctation
Ductal-Dependent
Lesion
Without a PDA there is no
blood flow to the abdomen
and lower extremities.
(Blue blood is better than no
blood.)
Newborn Problems:
Low Cardiac Output
Muscle diseases
Myocarditis
 Cardiomyopathies
 Sepsis
 Asphyxia

Newborn Problems :
Low Cardiac Output
Heart Rate Problems
 Supraventricular
tachycardias
 Complete heart block
Newborn Problems
Low Cardiac Output
Supraventricular Tachycardia
Narrow Complex
 Heart Rate > 220 bpm
 Usually > 240 bpm

Narrow Complex
Tachycardia
Newborn Problems
Low Cardiac Output
Complete Heart Block
Heart rate below 60 bpm
 No relationship between P waves and
QRS’s

Complete Heart Block
Newborn Problems
Treatment
Left heart obstructive lesions
 Muscle diseases
 Heart rate problems
 PGE1
 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 Fallot
 Pulmonary 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
Treatment
 Calming
 Oxygen
 Morphine
 Positioning
 Beta
Blocker
 Phenylepherine
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 Infancy

Structural Diseases: Left Heart
Obstructions

First days: Hypoplastic Left Heart Syndrome

Critical aortic stenosis
First month: Coarctation of the aorta
 First 2 months: Left-to-right Shunts


VSD, PDA, Truncus Arteriosus
Congestive Heart
Failure
Presentation after infancy
Progression of structural heart disease
 Arrhythmias
 Infectious diseases
 Later onset myopathies
 Toxins:

Anthracyclines
 Diphtheria

Congestive Heart
Failure
Pre-load
Contractility
Determinants of Cardiac Output
Afterload
Heart Rate
Heart Failure
Sympathetic Tone
HR & coronary
vasoconstriction
Myocardial
blood flow
Arterial &
Renin &
venous
+
angiotension constriction
Ventricular preload
& afterload
Worsening heart failure
CHF Management
Sites of action of drugs used to treat heart failure:
Congestive Heart
Failure
Preload reduction
Diuretics
 Fluid Restriction
 High 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 Treatment

Beta Agonists

Dobutamine


Afterload reduction also
Epinepherine
Dopamine
 Increased myocardial demands
 Milrinone(makes wonders)

Contractility
Milrinone increases contractility and
reduces afterload without increasing
myocardial oxygen demand
Contractility
Chronic Treatment
Digoxin
 New Treatments: Biventricular Pacing,
Assist Device.

Arrhythmias
Narrow Complex Tachycardias
Arrhythmias
Supraventricular Tachycardia
Arrhythmias
Re-entrant Tachycardias
AV node re-entry
 Wolff-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
Treatment

Pre-hospitalization

Diving reflex

Ice Bag to the face
Valsalva
 Carotid Massage(no longer recommended)

Arrhythmias
Hospitalization

Adenosine

Diagnostic and therapeutic
Arrhythmias
Adenosine
100 mcg/kg IV rapid push
 Repeat every 5 minutes with increasing
doses

Arrhythmias
Shock requires Shock
Synchronized cardioversion
 1 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 arrhythmias
Common cause of sudden death in
repaired congenital heart disease and
acquired pediatric heart disease and
cardiomyopathy
0.001% annual risk in general pediatric
population
 1-3% annual risk in many repaired CHD
 4-6% risk in HCM
 25-30% risk in dilated cardiomyopathy

Final common pathway for cardiac arrest
From Cardiac Arrhythmias in Children and Young Adults with Congenital Heart Disease. Walsh, et al.
(2001).in many conditions
This pt.C/O recurrent fainting attacks
Remember:
Prolonged QT
interval
Ventricular tachycardia
Differential diagnosis
Ventricular tachycardia
 Supraventricular rhythm with aberrant
conduction

Rate related
 Permanent bundle branch block


Preexcited rhythm
Supraventricular rhythm with preexcitation
 Antidromic tachycardia
 Two-pathway tachycardia


Paced rhythm
Treatment depends on appropriate
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 tachycardia
Treatment

Address treatable causes
Electrolytes
 Acidosis


Pharmacotherapy
Class Ib – lidocaine
 Class III – amiodarone


Electrical therapy
Cardioversion
 Implantable defibrillator

Wide Complex
Tachycardias
Surgical Therapy

Automatic Implantable CardioverterDefibrillator
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.
THANK YOU
If you woke up this morning with more
health than illness ...
You are more blessed
than the million who will
not survive this week.