PEPP Cardiovascular Emergencies
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Transcript PEPP Cardiovascular Emergencies
Cardiovascular
Emergencies
Objectives
• Understand the causes and management
priorities of bradycardia in children.
• Identify risk factors for serious causes of
syncope in children.
• Describe the resuscitation and stabilization
of a child presenting with cardiopulmonary
failure.
• List the strategies for prevention of
submersion injuries in infants and children.
Case Presentation
• You are called to a suburban home for
toddler found submerged in backyard
pool.
• A sobbing mother is performing CPR on
15-month-old girl on pool deck.
• As you take over resuscitation, the
mother tells you, “The phone rang; I was
only gone for 5 minutes!”
General Assessment: PAT
Appearance
Unconscious,
unresponsive;
poor muscle tone
Work of Breathing
No spontaneous
respirations
Circulation to Skin
Ashen, cyanosis of hands and lips
What is your general impression?
General Impression and
Management Priorities
• General impression:
– Sick: respiratory arrest; possible
cardiorespiratory failure
Unresponsive, apneic, abnormal
circulation to skin
– Physiologic problem: global
hypoxemic–ischemic event
• Immediate management:
– Start oxygenation and ventilation while
assessing for spontaneous circulation.
Initial Assessment: ABCDEs
• Airway — patent
• Breathing —good air movement with bagmask ventilation; wet crackles on auscultation
• Circulation — HR 20; femoral pulse barely
palpable; capillary refill > 5 seconds; BP not
obtained
• Disability — pupils dilated, sluggishly reactive;
unresponsive to pain
• Exposure — no bruises, no signs of injury
What is your overall assessment?
Case Progression
• Cardiopulmonary failure due to hypoxemia.
– Chest compressions are indicated for
HR < 60.
• No evidence of associated injuries.
– Consider spinal injury.
Less likely in toddler submersion than
with adolescent diving injury.
– Consider nonaccidental trauma.
No “red flags”
What are your management priorities?
Management Priorities
• BLS:
– Place on spine board.
– Open airway; begin bag-mask ventilations,
100% 02.
– Perform chest compressions.
– Dry to prevent further heat loss/hypothermia.
• ALS:
– IV access, consider endotracheal intubation.
– Epinephrine, 0.01 mg/kg IV/IO, or 0.1 mg/kg
by endotracheal tube; repeat every 3–5
minutes.
Transport Decision: Stay or Go?
• BLS:
– Rapid transport to nearest appropriate
ED.
– Continuous reassessment for return of
pulse and circulation en route.
• ALS:
– Transport after airway/ventilation is
secure, IV/IO access is established,
and the first dose of epinephrine is
given.
– Do not delay transport if vascular
access fails.
Key Concepts: Bradycardia
• Treatable causes of bradycardia with
poor perfusion:
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–
–
–
–
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Hypoxemia
Hypothermia
Hypovolemia
Heart block
Toxins, poisoning, drugs
Tampondae, cardiac
Tension pneumothorax
Trauma (Head injury)
Key Concepts: Bradycardia
with Submersion Event
• Bradycardia in near-drowning reflects
significant hypoxia and myocardial
ischemia.
– The brain and other vital organs may
also have suffered ischemic injury.
– Rapid support of ventilation and
oxygenation will reduce the risk of
secondary injury.
– The drug of choice is oxygen,
followed by epinephrine.
Key Concepts: Drowning Prevention
• Pool drowning prevention:
– Close supervision
– Four-sided pool fence
– Self-locking gate
– Pool alarms
• Open water drowning prevention:
– Supervision of all age groups.
– Use of personal floatation devices.
– Educate teens about dangers of alcohol
and water sports.
• Risk awareness, as toddler drownings may
occur in shallow water.
Key Concepts: Injury Prevention
• Multiple strategies are
necessary for an effective
injury prevention program.
– Passive strategies
– Legislative action
– Enforcement of laws
– Education
Case Progression
• Oxygen provided by bag-mask device,
compressions continued.
– After 30 seconds, the heart rate increases
to 80 per minute and compressions are
discontinued.
– After 1 minute, the heart rate is 120 per
minute; spontaneous respirations return.
Case Progression
• En route:
– Supplemental oxygen is
delivered by mask.
– Blankets are applied to
prevent heat loss.
ED Course
• In the ED:
– The child shows progressive improvement in
level of consciousness, asking for her mommy.
– She remains hemodynamically stable.
– SaO2 is 94% on 100 % O2, and chest X-ray
shows diffuse infiltrates.
– She is admitted to the pediatric intensive care
unit and transferred to a ward the next morning.
• Diagnosis: near drowning; pulmonary edema
• Outcome: weaned from oxygen on day 2; home on
day 4 with normal neurologic exam.
Summary
• Submersion results in hypoxia, leading to
bradycardia, tissue ischemic injury, and
eventually, cardiac arrest.
• Early oxygenation and ventilation are the
most effective ways to restore spontaneous
circulation.
• Prehospital management is a major
determinant of outcome in children with
submersion injury.
• Submersion injuries are predictable —
prevention is the best treatment!
Case Presentation
• You are dispatched to a middle-school
athletic field for a child with loss of
consciousness.
• A 13-year-old boy is lying on the grass,
receiving CPR by his coach.
• The coach tells you that the child collapsed
while running for a ball, and that “this has
happened before.”
What is the first thing you will do on arrival?
General Assessment: PAT
Work of Breathing
No spontaneous
respirations
Appearance
Unresponsive
Circulation to Skin
Pale, cyanotic
What is your general impression?
General Impression and
Management Priorities
• General impression:
– Sick: cardiopulmonary failure
Scenario suggests primary cardiac
event.
• Management:
– BLS: apply AED.
– ALS: “quick look” on
monitor/defibrillator.
Initial Assessment: ABCDEs
• Since this was a witnessed collapse, attach the
AED as soon as available.
– Airway: patent
– Breathing: no chest movement
– Circulation: absent pulses, no heart sounds;
shockable rhythm on AED, ventricular
fibrillation (VF) on monitor
– Disability: unresponsive to pain
– Exposure: no bruising or signs of injury
What is your overall assessment?
Case Progression
• VF cardiac arrest
– Possible mechanisms:
Primary cardiac disease
Trauma (direct blow to precordium)
Toxin/drugs
What are your management priorities?
Management Priorities
• BLS:
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Establish absence of respirations, pulse.
Turn on AED.
Attach AED electrode pads.
Analyze rhythm.
Shock if advised, then resume CPR
immediately for five cycles (2 minutes).
If no shock is advised, resume CPR for five
cycles (2 minutes).
– Check for signs of circulation and rhythm every 2
minutes and repeat sequence from analyze
rhythm.
Management Priorities
•
ALS: BLS priorities plus:
– Place on monitor, check rhythm.
– Defibrillate.
2 joules/kg
Resume CPR for five cycles (2 minutes), check
rhythm; if VF, defibrillate with 4 joules/kg.
– Resume CPR immediately.
– Intubate, secure airway (optional).
– Obtain vascular access.
– Epinephrine 0.01 mg/kg (1:10,000) IV or 0.1 mg/kg ETT
(1:1000); repeat every 3-5 minutes.
– After five cycles (2 minutes); check rhythm. If shockable:
– Defibrillate (4 joules/kg).
– Resume CPR immediately.
– Consider antiarrhythmic.
Lidocaine 1mg/kg IV/IO/ET
Amiodarone 5 mg/kg IV/IO
Transport Decision: Stay or Go?
• Stay on scene and treat until a pulse is
established or the child is asystolic.
• As in adults, the outcome is strongly
linked to resuscitation in the field.
– Survival statistics are poor for a child
brought to the ED in asystole.
Key Concepts:
Ventricular Fibrillation
• Airway management and correction of hypoxia
while making rhythm diagnosis is critical.
• Although pediatric VF is uncommon, early
recognition and treatment improve the chance
of successful resuscitation.
– Early defibrillation increases the survival rate.
• Increased availability and use of AEDs in
community can improve outcomes for both
pediatric and adult VF victims.
Key Concepts:
High-risk Groups/Causes for VF
• Cardiomyopathies
• Coronary artery abnormalities:
– Post-Kawasaki disease aneurysms,
thrombi
– Congenital anomalies
• Direct blow to chest
• Dysrhythmia syndromes
Key Concept:
Identifying Cardiac Syncope
• Most fainting spells are benign, but “red flags”
can identify serious cardiac causes.
– Was the episode associated with chest
pain?
– Was there a brief or absent aura?
– Were there palpitations prior to fainting?
– Did it occur during exercise?
– Is there a family history of sudden death?
Case Progression
• At scene:
– Rescue breathing and cardiac
compressions started.
– AED shows VF — converted to
NSR on second shock.
– Vascular access obtained
• En route:
– Lidocaine bolus 1 mg/kg IV and
then 20 micrograms/kg/min
infusion or bolus every 15
minutes
– Continues in sinus rhythm
ED Course
• In the ED:
– Lead 2 rhythm strip shows QTc = 0.52
– The mother arrives and reports three
prior brief episodes of exerciseassociated syncope; sudden death at
the age of 28 in uncle.
• Outcome: child diagnosed with long QTc
syndrome. A pacemaker is placed. The
patient is discharged neurologically intact
5 days later.
Summary
• Most episodes of syncope in children are
benign.
• Ventricular fibrillation is a rare cause of loss
of consciousness in pediatrics.
• Early recognition of VF and defibrillation
improve survival rates.
• When VF is diagnosed, standard cardiac
resuscitation protocols should be followed,
regardless of the age of the patient.
Summary
• The primary cause of cardiopulmonary arrest in
children is severe hypoxia associated with respiratory
failure.
– Asystole or profound bradycardia is the most
common arrest rhythm on EMS arrival.
• Rapid intervention and return of vital signs in the field
are associated with good outcome.
– Patients with ventricular fibrillation who have
return of sinus rhythm have good survival rates.
– Children with asystole as the presenting rhythm on
scene rarely survive.