Pediatric Cardiology Emergencies

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

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

Evaluation
Chest x-ray
Arterial blood gasses
Echocardiogram

Right sided obstructive lesions
Pulmonary atresia
Tricuspid atresia
Tetralogy of Fallot

Tricuspid Atresia

Abnormal Circulations
Transposition of the great arteries
Total anomalous pulmonary venous return

Transposition of the Great Arteries

Treatment
PGE1
Restoration of acid/base balance
Surgical Evaluation

PGE1
0.1 mcg/kg/min
Any intravenous site
UAC
UVC
Peripheral
Interosseous

Newborn Problems Low Cardiac Output
Shock
Metabolic acidosis
Circulatory shutdown

Evaluation
Chest x-ray
Arterial blood gasses
Echocardiogram
Electrocardiogram

Left Sided Obstructive lesions
Hypoplastic left heart
Critical aortic stenosis
Critical coarctation of the aorta

Hypoplastic Left Heart

Severe Coarctation

Muscle diseases
Myocarditis
Cardiomyopathies
Sepsis
Asphyxia

Heart Rate Problems
Supraventricular tachycardias
Complete heart block

Supraventricular Tachycardia
Narrow Complex
Heart Rate > 220 bpm
Usually > 240 bpm

Narrow Complex Tachycardia

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

Infant and Childhood Problems
Hypercyanotic spells
Congestive heart failure
Arrhythmias

Hypercyanotic Spells
Tetralogy of Fallot
Pulmonary Atresia

Tetralogy of Fallot

Sudden decrease in pulmonary blood flow, usually in the morning
Provocation

Treatment
Calming
Oxygen
Morphine
Beta Blocker
Phenylepherine

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

Long Term Treatment with Propranolol
Indication for surgery, either palliative shunt or total repair

Congestive Heart Failure
Differing etiology at different ages

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 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

Preload reduction
Diuretics
Fluid Restriction
High caloric density

Afterload reduction
ACE inhibitors
Nitroprusside

Heart Rate modification
Beta Blockers
Also treats diastolic dysfunction

Contractility
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

Contractility
Chronic Treatment
Digoxin
New Treatments

Arrhythmias
Narrow Complex Tachycardias

Arrhythmias
Supraventricular Tachycardia

Arrhythmias
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

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
If adenosine fails:
Calcium Channel blockers
Not in infants!

Arrhythmias
Digoxin Loading
Procainamide loading
Repeat adenosine

Ventricular Tachycardia Image 3

Wide Complex Tachycardias
Treat all as if Ventricular Tachycardia

Unstable rhythm requires Cardioversion 2 joules/kg

Ventricular Fibrillation Image 4

Medical therapy
Lidocaine
Amiodarone

Surgical Therapy
Automatic Implantable Cardioverter-Defibrillator

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Pediatric Cardiology Emergencies

by Ülger Ahmet on Mar 23, 2009

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Pediatric Cardiology Emergencies — Presentation Transcript