Pediatric Cardiology Emergencies Jeffrey D. Schuster, M.D. Texas Tech University-El Paso

Newborn Problems Cyanosis Low Cardiac Output

Cyanosis

Low Cardiac Output

Newborn Problems - Cyanosis Cardiac Cyanosis Does not respond to oxygen Does not respond to ventilation Usually no respiratory distress

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 Echocardiogram

Evaluation

Chest x-ray

Arterial blood gasses

Echocardiogram

Newborn Problems - Cyanosis Right sided obstructive lesions Pulmonary atresia Tricuspid atresia Tetralogy of Fallot

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

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

Treatment

PGE1

Restoration of acid/base balance

Surgical Evaluation

Newborn Problems - Cyanosis PGE1 0.1 mcg/kg/min Any intravenous site UAC UVC Peripheral Interosseous

PGE1

0.1 mcg/kg/min

Any intravenous site

UAC

UVC

Peripheral

Interosseous

Newborn Problems Low Cardiac Output Shock Metabolic acidosis Circulatory shutdown

Shock

Metabolic acidosis

Circulatory shutdown

Newborn Problems Low Cardiac Output Evaluation Chest x-ray Arterial blood gasses Echocardiogram Electrocardiogram

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

Left Sided Obstructive lesions

Hypoplastic left heart

Critical aortic stenosis

Critical coarctation of the aorta

Hypoplastic Left Heart

Severe Coarctation

Newborn Problems Low Cardiac Output Muscle diseases Myocarditis Cardiomyopathies Sepsis Asphyxia

Muscle diseases

Myocarditis

Cardiomyopathies

Sepsis

Asphyxia

Newborn Problems Low Cardiac Output Heart Rate Problems Supraventricular tachycardias Complete heart block

Heart Rate Problems

Supraventricular tachycardias

Complete heart block

Newborn Problems Low Cardiac Output Supraventricular Tachycardia Narrow Complex Heart Rate > 220 bpm Usually > 240 bpm

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

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 and afterload reduction Slow down or speed up

Treatment

Left heart obstructive lesions

Muscle diseases

Heart rate problems

PGE1

Inotropic support and afterload reduction

Slow down or speed up

Infant and Childhood Problems Hypercyanotic spells Congestive heart failure Arrhythmias

Hypercyanotic spells

Congestive heart failure

Arrhythmias

Infant and Childhood Problems Hypercyanotic Spells Tetralogy of Fallot Pulmonary Atresia

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

Hypercyanotic Spells

Sudden decrease in pulmonary blood flow, usually in the morning

Provocation

Hypercyanotic Spells Treatment Calming Oxygen Morphine Beta Blocker Phenylepherine

Treatment

Calming

Oxygen

Morphine

Beta Blocker

Phenylepherine

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

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

Long Term Treatment with Propranolol

Indication for surgery, either palliative shunt or total repair

Congestive Heart Failure Differing etiology at different ages

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

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

Presentation after infancy

Progression of structural heart disease

Arrhythmias

Infectious diseases

Later onset myopathies

Toxins:

Anthracyclines

Diphtheria

Congestive Heart Failure Pre-load Afterload Contractility Heart Rate Determinants of Cardiac Output

Congestive Heart Failure Preload reduction Diuretics Fluid Restriction High caloric density

Preload reduction

Diuretics

Fluid Restriction

High caloric density

Congestive Heart Failure Afterload reduction ACE inhibitors Nitroprusside

Afterload reduction

ACE inhibitors

Nitroprusside

Congestive Heart Failure Heart Rate modification Beta Blockers Also treats diastolic dysfunction

Heart Rate modification

Beta Blockers

Also treats diastolic dysfunction

Contractility Acute Treatment Beta Agonists Dobutamine Afterload reduction also Epinepherine Dopamine Increased myocardial demands Milrinone

Acute Treatment

Beta Agonists

Dobutamine

Afterload reduction also

Epinepherine

Dopamine

Increased myocardial demands

Milrinone

Contractility Milrinone increases contractility and reduces afterload without increasing myocardial oxygen demand

Milrinone increases contractility and reduces afterload without increasing myocardial oxygen demand

Contractility Chronic Treatment Digoxin New Treatments

Chronic Treatment

Digoxin

New Treatments

Arrhythmias Narrow Complex Tachycardias

Narrow Complex Tachycardias

Arrhythmias Supraventricular Tachycardia

Supraventricular Tachycardia

Arrhythmias Re-entrant Tachycardias AV node re-entry Wolfe-Parkinson-White

Re-entrant Tachycardias

AV node re-entry

Wolfe-Parkinson-White

Wolfe-Parkinson White

Arrhythmias Treatment Pre-hospitalization Diving reflex Ice Bag to the face Valsalva Carotid Massage

Treatment

Pre-hospitalization

Diving reflex

Ice Bag to the face

Valsalva

Carotid Massage

Arrhythmias Hospitalization Adenosine Diagnostic and therapeutic

Hospitalization

Adenosine

Diagnostic and therapeutic

Arrhythmias Adenosine 100 mcg/kg IV rapid push Repeat every 5 minutes with increasing doses

Adenosine

100 mcg/kg IV rapid push

Repeat every 5 minutes with increasing doses

Arrhythmias Shock requires Shock Synchronized cardioversion 1 joule/kg

Shock requires Shock

Synchronized cardioversion

1 joule/kg

Arrhythmias If adenosine fails: Calcium Channel blockers Not in infants!

If adenosine fails:

Calcium Channel blockers

Not in infants!

Arrhythmias Digoxin Loading Procainamide loading Repeat adenosine

Digoxin Loading

Procainamide loading

Repeat adenosine

Ventricular Tachycardia Image 3

Wide Complex Tachycardias Treat all as if Ventricular Tachycardia

Treat all as if Ventricular Tachycardia

Wide Complex Tachycardias Unstable rhythm requires Cardioversion 2 joules/kg

Unstable rhythm requires Cardioversion 2 joules/kg

Ventricular Fibrillation Image 4

Wide Complex Tachycardias Medical therapy Lidocaine Amiodarone

Medical therapy

Lidocaine

Amiodarone

Wide Complex Tachycardias Surgical Therapy Automatic Implantable Cardioverter-Defibrillator

Surgical Therapy

Automatic Implantable Cardioverter-Defibrillator