Approach to Common Cardiac Emergencies Agustin E. Rubio, MD Sibley Heart Center Cardiology Children’s Healthcare of Atlant...
Topics <ul><ul><li>Cyanosis & Ductal Dependent </li></ul></ul><ul><ul><li>Emergency Room Diagnoses: </li></ul></ul><ul><ul...
Epidemiology <ul><li>Cardiac malformations  </li></ul><ul><ul><li>10% of infant mortality </li></ul></ul><ul><li>Incidence...
Circulatory Transitions <ul><li>Conversion from  right sided  (placental oxygenation) to  left sided circulation  (pulmona...
Cyanosis <ul><li>Typically, 2 g/dL of  reduced  hemoglobin </li></ul><ul><ul><li>5g/dL of reduced Hb     clinical cyanosi...
Ductal Dependent Lesions Cyanosis   CHF/Shock  <ul><li>Rt to Lt shunting: </li></ul><ul><li>Tricuspid atresia </li></ul><u...
Left Ventricular Outflow Tract Obstruction <ul><li>Major source of neonatal M&M from CHD   </li></ul><ul><ul><li>Accounts ...
Symptoms  Timeline of Clinical Diagnosis Week #1 HLHS Coarctation of aorta TAPVR - obstucted Week #2-6 Transposition of Gr...
Tetralogy of Fallot
Tetralogy of Fallot <ul><li>Prevalence : </li></ul><ul><li>- 10% of CHD </li></ul><ul><li>Most common cyanotic heart defec...
Tetralogy of Fallot <ul><li>+/- Cyanosis </li></ul><ul><li>Small to Nl cardiac silhouette </li></ul><ul><li>pulmonary vasc...
Tetralogy of Fallot <ul><li>“ Tet spell” </li></ul><ul><ul><li>Hyperpnea </li></ul></ul><ul><ul><li>Worsening cyanosis </l...
Tetralogy of Fallot <ul><li>“ Tet spell” </li></ul><ul><ul><li>Treatment objectives: </li></ul></ul><ul><ul><ul><li>Revers...
Tetralogy of Fallot Surgical Options <ul><li>Trans-annular patch </li></ul><ul><li>VSD closure </li></ul><ul><li>Blalock-T...
Tetralogy of Fallot Post-operative Concerns <ul><ul><li>Post-pericardiotomy syndrome </li></ul></ul><ul><ul><ul><li>~ 4 we...
Tetralogy of Fallot Post-operative Concerns <ul><ul><li>Endocarditis </li></ul></ul><ul><ul><ul><li>Dx after >2 BCx or ech...
Tetralogy of Fallot Post-operative Concerns <ul><li>Arrhythmias </li></ul><ul><ul><li>TOF -  40%  increased incidence of l...
Hypoplastic Left Heart Syndrome
HLHS
HLHS <ul><li>Uncommon form of cyanotic heart disease </li></ul><ul><li>Most common cause of death in the first month of li...
HLHS <ul><li>Clinically: </li></ul><ul><ul><li>Progressive cyanosis and hypoxemia </li></ul></ul><ul><ul><li>Hx of poor fe...
Consequences and Complications <ul><li>Polycythemia (erythrocytosis) </li></ul><ul><li>Clubbing (>6 mos of age) </li></ul>...
HLHS Pre-operative Resuscitation <ul><li>Medical management: </li></ul><ul><ul><li>Intubation </li></ul></ul><ul><ul><li>V...
HLHS Norwood/  Blalock-Taussig Shunt <ul><li>Post-operative changes </li></ul><ul><ul><li>Uncontrolled PBF </li></ul></ul>...
HLHS Norwood/  Sano shunt <ul><li>Post-operative changes </li></ul><ul><ul><li>Direct PA communication with RV </li></ul><...
HLHS Post-Operative Resuscitation <ul><li>Limit oxygen (remember:  relative uncontrolled PBF ) </li></ul><ul><li>Hemoglobi...
Coarctation of Aorta
Coarctation of Aorta <ul><li>Common cause of left sided heart failure </li></ul><ul><li>95% located in juxtaductal region ...
Coarctation of Aorta <ul><li>Associations: </li></ul><ul><ul><li>HLHS </li></ul></ul><ul><ul><li>Aortic stenosis </li></ul...
Coarctation of Aorta <ul><li>Clinical </li></ul><ul><ul><li>Poor feeding, dyspnea & poor weight gain </li></ul></ul><ul><u...
Coarctation of Aorta <ul><li>Acute clinical presentation: </li></ul><ul><ul><li>Cardiovascular shock </li></ul></ul><ul><u...
Coarctation of Aorta <ul><li>Laboratory Evaluation: </li></ul><ul><ul><li>CBC & ABG/VBG </li></ul></ul><ul><ul><li>CMP, Ma...
Coarctation of Aorta <ul><li>Neonatal Coarctation </li></ul><ul><ul><li>rSR’ in the right precordial leads (V1 & V2) </li>...
Coarctation of Aorta <ul><li>Infant Coarctation </li></ul><ul><ul><li>LVH apparent (left lateral leads) </li></ul></ul><ul...
Coarctation of Aorta Surgical repairs
Coarctation of Aorta Post-operative State <ul><li>Re-coarctation </li></ul><ul><ul><li>Occurs most commonly within the fir...
Tachyarrhythmia: Sinus Tach vs. SVT
Clinical Signs of Tachyarrhythmia
Symptoms from History <ul><li>Neonate:   </li></ul><ul><ul><li>Sudden onset of irritability& sudden relief </li></ul></ul>...
ECG Findings Sinus Tach Sinus Tach
Rhythms SVT Sinus Tach <ul><li>Regular rhythm, narrow QRS, HR >200, p buried in T wave </li></ul><ul><li>Regular rhythm <2...
Sinus Tachycardia vs. SVT
SVT – Hemodynamically Stable
SVT – Hemodynamically  Unstable ** Cardioversion should be performed in a location which can provide for continuous monito...
Medications for SVT
Laboratory Evaluation <ul><li>Electrolytes </li></ul><ul><ul><li>Calcium, Magnesium & Phosphorus </li></ul></ul><ul><li>CB...
Shunt Dependent vs. Non-dependent What’s the big deal !!!
The Difference <ul><li>Shunt Dependent </li></ul><ul><ul><li>The only source of PBF =  SHUNT </li></ul></ul><ul><li>Non-De...
Shunt Dependent <ul><li>Oxygen therapy </li></ul><ul><ul><li>Limit O2 therapy for cyanosis </li></ul></ul><ul><ul><li>Main...
Non-Dependent <ul><li>Oxygen therapy </li></ul><ul><ul><li>Two sources of PBF: </li></ul></ul><ul><ul><ul><li>One with fix...
Summary <ul><li>CHD &/or arrhythmias should be suspected neonates with cardiovascular shock </li></ul><ul><li>Evaluation s...
Medical Management <ul><li>Airway, Breathing, Circulation </li></ul><ul><li>What disease and what was the repair? </li></u...
Miscellaneous <ul><li>What information do we  require ? </li></ul><ul><ul><li>4 extremity BP’s, weight %iles </li></ul></u...
Sources <ul><li>Internet websites : </li></ul><ul><ul><li>www.childrenshospital.org </li></ul></ul><ul><ul><li>www.cincina...
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  1. 1. Approach to Common Cardiac Emergencies Agustin E. Rubio, MD Sibley Heart Center Cardiology Children’s Healthcare of Atlanta Emory School of Medicine
  2. 2. Topics <ul><ul><li>Cyanosis & Ductal Dependent </li></ul></ul><ul><ul><li>Emergency Room Diagnoses: </li></ul></ul><ul><ul><ul><li>Tetralogy of Fallot </li></ul></ul></ul><ul><ul><ul><li>Hypoplastic Left Heart Syndrome </li></ul></ul></ul><ul><ul><ul><li>Coarctation of Aorta </li></ul></ul></ul><ul><ul><ul><li>SVT </li></ul></ul></ul><ul><ul><li>Shunt Dependent vs Non-shunt Dependent </li></ul></ul>
  3. 3. Epidemiology <ul><li>Cardiac malformations </li></ul><ul><ul><li>10% of infant mortality </li></ul></ul><ul><li>Incidence: </li></ul><ul><ul><li>4-6/1000 live births </li></ul></ul><ul><li>Most common lethal diagnosis: </li></ul><ul><ul><li>Left ventricular outflow tract obstruction </li></ul></ul><ul><ul><ul><li>Hypoplastic left heart syndrome </li></ul></ul></ul><ul><ul><ul><li>Coarctation of aorta </li></ul></ul></ul><ul><ul><ul><li>Aortic stenosis </li></ul></ul></ul>
  4. 4. Circulatory Transitions <ul><li>Conversion from right sided (placental oxygenation) to left sided circulation (pulmonary oxygenation) </li></ul><ul><li>Progression is secondary: </li></ul><ul><ul><li>Decreasing PVR </li></ul></ul><ul><ul><li>Closure of ductal shunts </li></ul></ul><ul><li>Clinical presentations: </li></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Respiratory failure </li></ul></ul><ul><ul><li>Shock </li></ul></ul>
  5. 5. Cyanosis <ul><li>Typically, 2 g/dL of reduced hemoglobin </li></ul><ul><ul><li>5g/dL of reduced Hb  clinical cyanosis </li></ul></ul><ul><li>Hb 15  cyanosis at 75-80% </li></ul><ul><li>Hb 20  cyanosis at 80-85% </li></ul><ul><li>Hb 6  cyanosis at 45-50% </li></ul>
  6. 6. Ductal Dependent Lesions Cyanosis CHF/Shock <ul><li>Rt to Lt shunting: </li></ul><ul><li>Tricuspid atresia </li></ul><ul><li>TOF/ Pulm atresia </li></ul><ul><li>Ebstein’s anomaly </li></ul><ul><li>Lt Ventricular Outflow Tract Obstruction: </li></ul><ul><li>HLHS </li></ul><ul><li>Coarctation of Aorta/ AS </li></ul><ul><li>Truncus arteriosus </li></ul><ul><li>TGA with VSD </li></ul><ul><li>TAPVR </li></ul>
  7. 7. Left Ventricular Outflow Tract Obstruction <ul><li>Major source of neonatal M&M from CHD </li></ul><ul><ul><li>Accounts for ~ 12% of congenital cardiac disease in infancy </li></ul></ul><ul><ul><li>~ 75% discharged from hospital w/o diagnosis </li></ul></ul><ul><ul><li>~ 65% - normal newborn screen examination </li></ul></ul><ul><ul><li>6% died before diagnosis </li></ul></ul><ul><ul><li>96% symptoms by 3 wks of life </li></ul></ul>
  8. 8. Symptoms Timeline of Clinical Diagnosis Week #1 HLHS Coarctation of aorta TAPVR - obstucted Week #2-6 Transposition of Great Arteries Total Anomalous Venous Return Truncus arteriosus
  9. 9. Tetralogy of Fallot
  10. 10. Tetralogy of Fallot <ul><li>Prevalence : </li></ul><ul><li>- 10% of CHD </li></ul><ul><li>Most common cyanotic heart defect beyond infancy </li></ul>
  11. 11. Tetralogy of Fallot <ul><li>+/- Cyanosis </li></ul><ul><li>Small to Nl cardiac silhouette </li></ul><ul><li>pulmonary vasculature </li></ul>
  12. 12. Tetralogy of Fallot <ul><li>“ Tet spell” </li></ul><ul><ul><li>Hyperpnea </li></ul></ul><ul><ul><li>Worsening cyanosis </li></ul></ul><ul><ul><li>Disappearance of murmur </li></ul></ul><ul><ul><li>RBBB pattern on ECG </li></ul></ul>
  13. 13. Tetralogy of Fallot <ul><li>“ Tet spell” </li></ul><ul><ul><li>Treatment objectives: </li></ul></ul><ul><ul><ul><li>Reverse the right-to-left shunt </li></ul></ul></ul><ul><ul><ul><li>systemic vascular resistance (SVR) </li></ul></ul></ul><ul><ul><ul><li>Correct potential acidosis with NaHCO3 & volume </li></ul></ul></ul><ul><ul><ul><li>Consider peripheral vasoconstriction (phenylephrine – 0.02 mg/kg IV) </li></ul></ul></ul><ul><ul><ul><li>Ketamine </li></ul></ul></ul><ul><ul><ul><ul><li>increase SVR and sedates 2 mg/kg over 1 min </li></ul></ul></ul></ul><ul><ul><ul><li>Morphine sulphate </li></ul></ul></ul><ul><ul><ul><li>Oxygen </li></ul></ul></ul>
  14. 14. Tetralogy of Fallot Surgical Options <ul><li>Trans-annular patch </li></ul><ul><li>VSD closure </li></ul><ul><li>Blalock-Taussig shunt </li></ul><ul><li>Delayed repair </li></ul>
  15. 15. Tetralogy of Fallot Post-operative Concerns <ul><ul><li>Post-pericardiotomy syndrome </li></ul></ul><ul><ul><ul><li>~ 4 weeks post-op (25-30% of open heart pts) </li></ul></ul></ul><ul><ul><ul><li>Fever, elevated ESR and CRP </li></ul></ul></ul><ul><ul><ul><li>Increased work of breathing (? pericardial effusion) </li></ul></ul></ul><ul><ul><ul><li>Cardiomegaly, pleural effusions </li></ul></ul></ul><ul><ul><ul><li>ECG – persistent ST segment elevation with flat or inverted T waves in limb & left lateral limb leads </li></ul></ul></ul><ul><ul><ul><li>Pericardiocentesis – performed when tamponade physiology present </li></ul></ul></ul>
  16. 16. Tetralogy of Fallot Post-operative Concerns <ul><ul><li>Endocarditis </li></ul></ul><ul><ul><ul><li>Dx after >2 BCx or echo evidence </li></ul></ul></ul><ul><ul><li>Residual VSD </li></ul></ul><ul><ul><li>Arrhythmias </li></ul></ul><ul><ul><ul><li>AV block, ventricular arrhythmias </li></ul></ul></ul><ul><ul><li>Remember: </li></ul></ul><ul><ul><ul><li>Any incision in the ventricle produces a RBBB pattern (rSR’ in V1; wide complex QRS) </li></ul></ul></ul>
  17. 17. Tetralogy of Fallot Post-operative Concerns <ul><li>Arrhythmias </li></ul><ul><ul><li>TOF - 40% increased incidence of lethal arrhythmias </li></ul></ul><ul><ul><li>Syncopal events - lethal ventricular arrhythmias ?? </li></ul></ul>
  18. 18. Hypoplastic Left Heart Syndrome
  19. 19. HLHS
  20. 20. HLHS <ul><li>Uncommon form of cyanotic heart disease </li></ul><ul><li>Most common cause of death in the first month of life </li></ul><ul><li>Critically ill infant within the first 7 days with low O 2 saturations </li></ul>
  21. 21. HLHS <ul><li>Clinically: </li></ul><ul><ul><li>Progressive cyanosis and hypoxemia </li></ul></ul><ul><ul><li>Hx of poor feeding, tachypnea and poor weight gain </li></ul></ul><ul><ul><li>Cardiovascular shock </li></ul></ul><ul><ul><li>Severe acidosis </li></ul></ul><ul><ul><li>Congestive heart failure </li></ul></ul>
  22. 22. Consequences and Complications <ul><li>Polycythemia (erythrocytosis) </li></ul><ul><li>Clubbing (>6 mos of age) </li></ul><ul><li>Hypoxic spells </li></ul><ul><li>CNS </li></ul><ul><ul><li>Cyanotic heart disease accounts for 5-10% of brain abscesses </li></ul></ul><ul><ul><li>Cerebral venous thrombosis - <2 yrs, cyanotic and microcytic anemia </li></ul></ul><ul><li>Dyscrasias </li></ul>
  23. 23. HLHS Pre-operative Resuscitation <ul><li>Medical management: </li></ul><ul><ul><li>Intubation </li></ul></ul><ul><ul><li>Ventilate and oxygen </li></ul></ul><ul><ul><li>Intravenous access </li></ul></ul><ul><ul><ul><li>Central/ umbilical/ intra-osseos </li></ul></ul></ul><ul><ul><li>Glucose </li></ul></ul><ul><ul><li>Na HCO3 </li></ul></ul><ul><ul><li>PGE 1 (get that PDA open!!) </li></ul></ul><ul><ul><ul><li>PGE 1 0.05 mcg/kg/min </li></ul></ul></ul><ul><ul><li>Volume – NS/ 5% Albumin/ PRBC’s </li></ul></ul><ul><ul><li>NIRS probe </li></ul></ul>
  24. 24. HLHS Norwood/ Blalock-Taussig Shunt <ul><li>Post-operative changes </li></ul><ul><ul><li>Uncontrolled PBF </li></ul></ul><ul><ul><li>Re-constructed aortic outflow tract </li></ul></ul><ul><ul><li>Fluid balance sensitive </li></ul></ul><ul><ul><li>Widened pulse pressures </li></ul></ul><ul><ul><li>Tenuous coronary circulation </li></ul></ul><ul><ul><li>Single ventricle for all circulation </li></ul></ul>
  25. 25. HLHS Norwood/ Sano shunt <ul><li>Post-operative changes </li></ul><ul><ul><li>Direct PA communication with RV </li></ul></ul><ul><ul><li>Uncontrolled PBF </li></ul></ul><ul><ul><li>Neo-aortic reconstruction </li></ul></ul><ul><ul><li>Higher diastolic pressures </li></ul></ul><ul><ul><li>Better coronary perfusion </li></ul></ul>
  26. 26. HLHS Post-Operative Resuscitation <ul><li>Limit oxygen (remember: relative uncontrolled PBF ) </li></ul><ul><li>Hemoglobin </li></ul><ul><li>Auscultate for murmur: </li></ul><ul><ul><li>Continuous murmur at RUSB (? BT shunt ) </li></ul></ul><ul><ul><li>Systolic murmur at RLSB/ LUSB ( Sano shunt ) </li></ul></ul><ul><li>Fluid balance: </li></ul><ul><ul><li>Palpate liver </li></ul></ul><ul><ul><li>+/- rales and CXR to evaluate for CHF </li></ul></ul><ul><ul><li>Reverse dehydration </li></ul></ul><ul><li>Reverse acidosis </li></ul>
  27. 27. Coarctation of Aorta
  28. 28. Coarctation of Aorta <ul><li>Common cause of left sided heart failure </li></ul><ul><li>95% located in juxtaductal region </li></ul><ul><li>Associated with other congenital anomalies </li></ul><ul><li>May be short segments or long segments </li></ul>
  29. 29. Coarctation of Aorta <ul><li>Associations: </li></ul><ul><ul><li>HLHS </li></ul></ul><ul><ul><li>Aortic stenosis </li></ul></ul><ul><ul><li>TOF </li></ul></ul><ul><ul><li>Truncus arteriosus </li></ul></ul><ul><ul><li>VSD </li></ul></ul><ul><ul><li>DORV </li></ul></ul><ul><ul><li>Turner’s syndrome </li></ul></ul>
  30. 30. Coarctation of Aorta <ul><li>Clinical </li></ul><ul><ul><li>Poor feeding, dyspnea & poor weight gain </li></ul></ul><ul><ul><li>Upper arm vs lower extremity BP discrepancy </li></ul></ul><ul><ul><ul><li>>10-20 mmHg systolic upper vs. lower </li></ul></ul></ul><ul><ul><ul><li>20-30% develop CHF by 2-3 months </li></ul></ul></ul><ul><ul><li>Hx of lower extremity weakness or pain after exercise </li></ul></ul><ul><ul><li>50% will have no murmur </li></ul></ul>
  31. 31. Coarctation of Aorta <ul><li>Acute clinical presentation: </li></ul><ul><ul><li>Cardiovascular shock </li></ul></ul><ul><ul><ul><li>Somnolent & lethargic </li></ul></ul></ul><ul><ul><ul><li>Poor po intake/ dehydrated, poor U/O </li></ul></ul></ul><ul><ul><ul><li>Cold, clammy & diaphoretic </li></ul></ul></ul><ul><ul><ul><li>Poor pulses </li></ul></ul></ul><ul><ul><ul><li>+/- organomegaly </li></ul></ul></ul><ul><ul><ul><li>Bradycardia/ tachycardia </li></ul></ul></ul>
  32. 32. Coarctation of Aorta <ul><li>Laboratory Evaluation: </li></ul><ul><ul><li>CBC & ABG/VBG </li></ul></ul><ul><ul><li>CMP, Magnesium & Phos </li></ul></ul><ul><ul><li>Lactate </li></ul></ul><ul><ul><li>BNP level </li></ul></ul><ul><ul><li>CXR & 12 lead ECG </li></ul></ul><ul><ul><li>Blood cultures </li></ul></ul><ul><ul><li>NIRS probe </li></ul></ul>
  33. 33. Coarctation of Aorta <ul><li>Neonatal Coarctation </li></ul><ul><ul><li>rSR’ in the right precordial leads (V1 & V2) </li></ul></ul><ul><ul><li>Deep S waves in the lateral leads </li></ul></ul><ul><ul><li>RAD </li></ul></ul>
  34. 34. Coarctation of Aorta <ul><li>Infant Coarctation </li></ul><ul><ul><li>LVH apparent (left lateral leads) </li></ul></ul><ul><ul><li>Deep S waves in the right chest </li></ul></ul><ul><ul><li>Large R waves in lateral leads </li></ul></ul>
  35. 35. Coarctation of Aorta Surgical repairs
  36. 36. Coarctation of Aorta Post-operative State <ul><li>Re-coarctation </li></ul><ul><ul><li>Occurs most commonly within the first 12 months </li></ul></ul><ul><ul><li>Evaluated by 4 extremity BP’s </li></ul></ul><ul><ul><li>Physical examination of upper & lower extremity pulses </li></ul></ul>
  37. 37. Tachyarrhythmia: Sinus Tach vs. SVT
  38. 38. Clinical Signs of Tachyarrhythmia
  39. 39. Symptoms from History <ul><li>Neonate: </li></ul><ul><ul><li>Sudden onset of irritability& sudden relief </li></ul></ul><ul><ul><li>Poor po intake & somnolence </li></ul></ul><ul><ul><li>Inconsolable </li></ul></ul><ul><ul><li>“ Rapid heart beat”– felt by parents </li></ul></ul><ul><li>Older Child: </li></ul><ul><ul><li>Stops activity abruptly </li></ul></ul><ul><ul><li>“ Palpitations”/ “feels funny” </li></ul></ul><ul><ul><li>Sudden relief with vasovagal manuever </li></ul></ul><ul><ul><li>Chest pain - rare </li></ul></ul>
  40. 40. ECG Findings Sinus Tach Sinus Tach
  41. 41. Rhythms SVT Sinus Tach <ul><li>Regular rhythm, narrow QRS, HR >200, p buried in T wave </li></ul><ul><li>Regular rhythm <200, distinct p waves, nl intervals </li></ul>
  42. 42. Sinus Tachycardia vs. SVT
  43. 43. SVT – Hemodynamically Stable
  44. 44. SVT – Hemodynamically Unstable ** Cardioversion should be performed in a location which can provide for continuous monitoring and potential complications of sedation.
  45. 45. Medications for SVT
  46. 46. Laboratory Evaluation <ul><li>Electrolytes </li></ul><ul><ul><li>Calcium, Magnesium & Phosphorus </li></ul></ul><ul><li>CBC with diff </li></ul><ul><li>CXR & 12 lead EKG </li></ul><ul><ul><li>looking for pre-excitation – WPW </li></ul></ul>
  47. 47. Shunt Dependent vs. Non-dependent What’s the big deal !!!
  48. 48. The Difference <ul><li>Shunt Dependent </li></ul><ul><ul><li>The only source of PBF = SHUNT </li></ul></ul><ul><li>Non-Dependent </li></ul><ul><ul><li>Two sources of PBF = Shunt + some antegrade flow through diminuitive PV </li></ul></ul>
  49. 49. Shunt Dependent <ul><li>Oxygen therapy </li></ul><ul><ul><li>Limit O2 therapy for cyanosis </li></ul></ul><ul><ul><li>Maintain sats 75-85% </li></ul></ul><ul><ul><li>Sats can drop significantly and quickly </li></ul></ul><ul><ul><li>If sats >85% : </li></ul></ul><ul><ul><ul><li>PVR  PBF  Pulmonary edema and circulatory shock </li></ul></ul></ul><ul><ul><li>Use blended O2 with range of up to FiO2 0.4 </li></ul></ul>
  50. 50. Non-Dependent <ul><li>Oxygen therapy </li></ul><ul><ul><li>Two sources of PBF: </li></ul></ul><ul><ul><ul><li>One with fixed obstruction and the other is uncontrolled </li></ul></ul></ul><ul><ul><li>If BT shunt present: </li></ul></ul><ul><ul><ul><li>Limit O2 </li></ul></ul></ul><ul><ul><ul><li>O2 saturations should not drop as far nor as quickly </li></ul></ul></ul>
  51. 51. Summary <ul><li>CHD &/or arrhythmias should be suspected neonates with cardiovascular shock </li></ul><ul><li>Evaluation should include: </li></ul><ul><ul><li>CBC, cultures, electrolytes, lactate levels, Blood gases </li></ul></ul><ul><ul><li>CXR, 12 Lead EKG </li></ul></ul><ul><li>H&P provide 90% of diagnoses </li></ul>
  52. 52. Medical Management <ul><li>Airway, Breathing, Circulation </li></ul><ul><li>What disease and what was the repair? </li></ul><ul><li>Prostaglandins </li></ul><ul><ul><li>0.03 to 0.1 mcg/kg/min </li></ul></ul><ul><ul><li>Side effects: </li></ul></ul><ul><ul><ul><li>Hyperpyrexia </li></ul></ul></ul><ul><ul><ul><li>Apnea </li></ul></ul></ul><ul><ul><ul><li>Flushing </li></ul></ul></ul>
  53. 53. Miscellaneous <ul><li>What information do we require ? </li></ul><ul><ul><li>4 extremity BP’s, weight %iles </li></ul></ul><ul><ul><li>H&P </li></ul></ul><ul><ul><ul><li>Murmurs </li></ul></ul></ul><ul><ul><ul><li>Organomegaly </li></ul></ul></ul><ul><ul><ul><li>Pulses </li></ul></ul></ul><ul><ul><ul><li>ECG </li></ul></ul></ul><ul><ul><ul><li>Labs, CXR findings, saturations </li></ul></ul></ul>
  54. 54. Sources <ul><li>Internet websites : </li></ul><ul><ul><li>www.childrenshospital.org </li></ul></ul><ul><ul><li>www.cincinattichildrens.org </li></ul></ul><ul><ul><li>www.ucsfhealth.org/childrens/ </li></ul></ul><ul><li>Pediatric Cardiology for the Practioners . MK Park 4 th ed. </li></ul><ul><li>Congenital Heart Disease - Moss and Adams </li></ul>
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