Cardiovascular System II
Objectives <ul><li>Present the clinical features and emergency management of cardiovascular disorders, including: </li></u...
Case Study 1: “Not Breathing” <ul><li>10-day-old boy brought to ED for not breathing and color change. </li></ul><ul><li>3...
Initial Assessment  (1 of 2) <ul><li>PAT: </li></ul><ul><ul><li>Abnormal appearance, abnormal breathing, abnormal circulat...
Initial Assessment  (2 of 2) <ul><li>A: Patent without evidence of obstruction </li></ul><ul><li>B: Nonlabored but diminis...
Detailed Physical Exam <ul><li>Head/Neck: No abnormalities </li></ul><ul><li>Heart: Tachycardia, no murmurs heard </li></u...
Question <ul><li>What is your general impression of this patient? </li></ul>
General Impression <ul><li>Cardiopulmonary failure </li></ul><ul><ul><li>Lethargic but responsive, inadequate respirations...
Management Priorities <ul><li>ABCs </li></ul><ul><li>Open airway.  </li></ul><ul><li>Give 100% O 2  by BMV, or perform end...
Case Discussion  (1 of 2) <ul><li>Tachyarrhythmias: </li></ul><ul><ul><li>Wide complex </li></ul></ul><ul><ul><ul><li>Vent...
Case Discussion  (2 of 2) <ul><li>Clinical features can be varied: </li></ul><ul><ul><li>Palpitations in verbal children <...
Background: Dysrhythmias <ul><li>3 basic types: </li></ul><ul><ul><li>Fast pulse (tachyarrhythmia) </li></ul></ul><ul><ul>...
Clinical Features: Your First Clue <ul><li>Intermittent, paroxysmal presence of symptoms </li></ul><ul><li>Sudden onset of...
Distinguishing SVT from ST SVT rate at or greater than 2x normal rate for age. Minimal or no rate change with activity. ST...
Supraventricular Tachycardia
Diagnostic Studies <ul><li>Radiology: </li></ul><ul><ul><li>CXR important to look for signs of: </li></ul></ul><ul><ul><ul...
Differential Diagnosis: What Else? <ul><li>Hypoglycemia </li></ul><ul><li>Sepsis </li></ul><ul><li>Hyperthyroidism </li></...
Management: Dysrhythmias <ul><li>ABCs </li></ul><ul><li>Get baseline ECG. </li></ul><ul><li>Obtain vascular access. </li><...
Tachycardia Management
The Bottom Line: Dysrhythmias <ul><li>Management is driven by presence or absence of poor perfusion. </li></ul><ul><li>Sin...
Other Considerations  (1 of 2) <ul><li>Interface with EMS/Transport: </li></ul><ul><ul><li>Transport issues: Case such as ...
Other Considerations  (2 of 2) <ul><li>Documentation: </li></ul><ul><ul><li>Always try to get baseline 12-lead ECG before ...
Reversible Non-Cardiac Causes of Dysrhythmias <ul><li>Four H’s: </li></ul><ul><ul><li>H ypoxemia </li></ul></ul><ul><ul><l...
Case Progression/Outcome <ul><li>ECG reveals SVT. </li></ul><ul><li>Infant receives BMV ventilation. </li></ul><ul><li>Pre...
Case Study 2: “Unresponsive Episodes” <ul><li>2-year-old girl passed out eating cereal; awoke after 5 min. </li></ul><ul><...
Initial Assessment and Focused History <ul><li>PAT: </li></ul><ul><ul><li>Normal appearance, normal breathing, normal circ...
Question <ul><li>What is your general impression of this patient? </li></ul>
General Impression <ul><li>Stable </li></ul><ul><ul><li>Patient with syncope  </li></ul></ul><ul><ul><li>In no distress; n...
Case Discussion <ul><li>Syncope in young children is a serious symptom. </li></ul><ul><li>Must attempt to exclude life-thr...
Clinical Features: Your First Clue <ul><li>Loss of consciousness </li></ul><ul><li>Lasted only a few minutes </li></ul><ul...
Diagnostic Studies <ul><li>Radiology: </li></ul><ul><ul><li>CXR offers little. </li></ul></ul><ul><ul><li>CT or MRI may be...
Markedly Prolonged QT Interval T-wave alternans
Prolonged QT <ul><li>10% present with seizures. </li></ul><ul><li>15% of patients with prolonged QTc die during their firs...
What Else? Cardiac Causes of Syncope <ul><li>Hypertrophic cardiomyopathy </li></ul><ul><ul><li>Syncope with exercise </li>...
Critical Concepts  (1 of 2) <ul><li>Consider cardiac arrhythmias in all patients presenting with brief, nonspecific change...
Critical Concepts  (2 of 2) <ul><li>Family history may be positive for sudden, unexplained deaths prior to 55, fainting ep...
Pulseless Arrest * VF/VT Not VF/VT Anti-arrhythmic Vasopressor (Drug - Shock) CPR x 3 min Shock x 3 Shock Vasopressor * CP...
Case Progression <ul><li>This patient has prolonged QT syndrome. </li></ul><ul><li>She is at risk for fatal dysrhythmia (v...
Case Outcome <ul><li>This child is hospitalized. </li></ul><ul><li>Monitored and confirmed to be at risk for dangerous dys...
Case Study 3: “Chicken Pox” <ul><li>6-month-old with chicken pox lesions that began 3 days ago. Lesions are spreading. Mor...
Initial Assessment  (1 of 2) <ul><li>PAT: </li></ul><ul><ul><li>Normal/abnormal appearance, normal breathing, normal circu...
Initial Assessment  (2 of 2) <ul><li>A: Patent without evidence of obstruction </li></ul><ul><li>B: Normal </li></ul><ul><...
Detailed Physical Exam <ul><li>Head/Neck: No abnormalities except for skin </li></ul><ul><li>Heart: Tachycardic, no murmur...
Question <ul><li>What is your general impression of this patient? </li></ul>
General Impression <ul><li>Compensated shock </li></ul><ul><ul><li>Tachycardia and mild change in appearance (fussy) </li>...
Management Priorities <ul><li>Provide supplemental oxygen. </li></ul><ul><li>Obtain vascular access. </li></ul><ul><li>Det...
Shock <ul><li>Inadequate tissue perfusion (delivery of oxygen and nutrients) to meet the metabolic demands of the body. </...
Background: Shock <ul><li>Compensated: </li></ul><ul><ul><li>Vital organs continue to be perfused by compensatory mechanis...
Clinical Features: Your First Clue <ul><li>Apnea, tachypnea, respiratory distress </li></ul><ul><li>Skin: Pale, cool, dela...
Hypovolemic Shock <ul><li>Fluid loss: </li></ul><ul><ul><li>Diarrhea, vomiting, anorexia, diuresis </li></ul></ul><ul><ul>...
Cardiogenic Shock <ul><li>Poor myocardial contractility or impaired ejection: </li></ul><ul><ul><li>Cardiomyopathy, congen...
Distributive Shock <ul><li>Inappropriate vasodilation with maldistribution of blood flow: </li></ul><ul><ul><li>Anaphylact...
Septic Shock <ul><li>Elements of distributive shock and cardiogenic shock: </li></ul><ul><ul><li>Inappropriate vasodilatio...
Case Progression/Outcome <ul><li>Labs drawn </li></ul><ul><li>IV fluids given with decrease in HR to 120 </li></ul><ul><li...
The Bottom Line: Shock <ul><li>Early recognition and treatment of compensated shock may prevent progression to decompensat...
EIF <ul><li>Available from ACEP, AAP </li></ul><ul><li>Updated by PCP and specialists </li></ul><ul><li>Very helpful </li>...
The Bottom Line <ul><li>Obtain rapid history and assess children in shock or respiratory distress for cardiac disease. </l...
 
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Cardiovascular System II

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  • Cardiovascular System II
  • Present the clinical features and emergency management of cardiovascular disorders, including: Diagnose and treat rhythm disturbances. Detect and treat cardiomyopathy. Treat shock. Create differential diagnosis and management plan for syncope.
  • A 10-day-old male infant is brought to ED for not breathing and color change. The child was 3 weeks premature, and was discharged from hospital 3 days ago with an apnea monitor. Decreased activity since discharge Poor feeding today
  • The PAT is as follows: A: Appearance: Abnormal B: Work of Breathing: Abnormal C: Circulation to the Skin: Abnormal Vital signs include: Heart rate: 220 bpm Respiratory rate: 14 breaths/min Blood pressure: 55/36 mm Hg Weight: 3.5 kg (birth weight 3.7 kg) Oxygen saturation: 88% on room air
  • A: Airway: Patent without evidence of obstruction B: Breathing: Nonlabored but diminished respiratory rate C: Circulation: Mottled, cool, distal cyanosis, tachycardic and weak pulse D: Disability: Weak cry, nonfocal exam E: Exposure: Normothermic, no evidence of trauma, fontanel flat
  • Head/Neck: No abnormalities Heart: Tachycardia, no murmurs heard Lungs: Decreased breath sounds Abdomen: Liver 2 finger breadths below RCM Neurologic: Weak cry, lethargic, poor interaction, responsive to pain and contact Extremities: Cyanotic, cool upper and lower extremities
  • Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
  • Cardiopulmonary failure because all arms of the PAT are abnormal. Patient appearance is lethargic but responsive, with inadequate respirations and tachycardia; mottling with distal cyanosis. What are your initial management priorities?
  • Check ABCs. Open airway. Give 100% O 2 by BMV, or perform endotracheal intubation. Check rhythm on cardiac monitor. Obtain vascular access. Obtain blood glucose prn. Check rectal temperature.
  • Tachyarrhythmias: Wide complex Ventricular tachycardia (rare rhythm in children but if wide need to consider of ventricular origin) SVT with aberrancy Narrow complex Sinus tachycardia (rates usually &lt; 220) SVT (Rates usually &gt; 220)
  • Clinical features can be varied: Palpitations in verbal children Shock in any age Generalized symptoms of malaise and weakness Diagnostic studies may include: Cardiac monitor, ECG, sepsis evaluation if young infant who has signs and symptoms suggestive of infection Chest radiograph, echocardiogram Management includes ABCs and stabilization.
  • The pediatric patient has 3 basic types of pathologic rhythm disturbances, which include fast pulse (tachyarrhythmia), slow pulse (bradyarrhythmia), and absent pulse (pulseless) (Table 4-3). These can be further divided into 7 classifications based on their anatomic function. Dysrhythmias may be the cause of impaired cardiac function leading to cardiac arrest. Occult dysrhythmias (e.g., prolonged QT syndrome, Wolf-Parkinson-White syndrome, etc.) may present with intermittent severe symptoms (e.g., palpitations or sudden death).
  • Consider the following symptoms: Intermittent, paroxysmal presence of symptoms Dramatic onset and change in condition Sudden onset of symptoms with little or no prodrome Presentation of dysrhythmias can range from stable to cardiopulmonary arrest. Infant or child may show subtle signs of major physiological derangement.
  • Supraventricular tachycardia (SVT) history is intermittent, paroxysmal, with sudden onset. Sinus tachycardia (ST) history suggests sepsis, dehydration, hemorrhage, hypovolemia. SVT ECG steady rate at or greater than 2x normal rate for age. ST rate is less than 2x normal rate for age. Minimal or no rate change with activity with SVT.
  • SVT characteristics (versus sinus tachycardia): Heart rate is &gt;2 times normal rate for age. Rhythm is steady. P waves are absent. History is not suggestive of volume depletion or sepsis.
  • Radiology studies include chest radiographs; it is important to look for signs of structural congenital heart disease, congestive heart failure (due to a prolonged dysrhythmia), or signs of infection (pneumonia). Laboratory tests should ALWAYS include a blood glucose check to exclude hypoglycemia in any child with abnormal mental status.
  • Differential diagnoses may include: Hypoglycemia Sepsis Hyperthyroidism Volume depletion Catastrophic illness, e.g., CNS, GI trauma (abuse) Metabolic disease
  • Manage ABCs. Get baseline ECG. Obtain vascular access. For SVT (see AHA algorithm): Vagal maneuvers for stable SVT Adenosine: 100 mcg/kg bolus, increase to 200 mcg/kg (maximum first dose is 6 mg, maximum second and subsequent doses 12 mg) – given for stable SVT if unresponsive to vagal maneuvers or for unstable SVT if IV access is immediately available. Cardioversion for unstable SVT (poor perfusion) Procainamide or amiodarone to be considered if possible of ventricular origin; that is QRS &gt;0.08 sec Digoxin to slow rate if cardioversion unsuccessful Cardiology consultation
  • This slide shows the PALS algorithm for tachycardia (sinus tachycardia, SVT, and ventricular tachycardia) with POOR PERFUSION.
  • Management is driven by presence or absence of poor perfusion. Sinus tachycardia is not an arrhythmia but its etiology must be determined. Provide ventilation and oxygenation for all patients in cardiopulmonary arrest, as the primary etiology is often respiratory failure.
  • Patients such as this should be transported to a pediatric referral center after stabilization. Transport issues include: ALS transport with monitoring and IV access Treatment plan for possible en route for recurrence – including potential for cardioversion Consult the accepting pediatric cardiologist
  • Documentation considerations include: Always try to get baseline 12-lead ECG before and after cardioversion. Treatment record from prehospital and ED care Emergency Medical Treatment and Active Labor Act (EMTALA) compliance Risk management considerations include: Always check blood glucose. Assure rapid triage of infants in distress. Do not hesitate to cardiovert when child is unstable.
  • Four H’s: Hypoxemia Hypovolemia Hypothermia Hyper/Hypokalemia and metabolic disorders Four T’s: Tamponade (cardiac) Tension pneumothorax Toxins/poisons/drugs Thromboembolism
  • ECG reveals SVT. Infant receives BMV ventilation. Preparations made to cardiovert but rapid IV access is obtained. Adenosine 100 mcg/kg IV push is given followed by normal saline bolus (flush). Return of sinus rhythm. BMV is discontinued as infant’s condition stabilized. 100% oxygen nonrebreather mask is placed. Return of sinus rhythm. ECG does not show early repolarization (e.g., WPW).
  • 2-year-old girl passed out eating cereal; awoke after 5 minutes. She was stiff with eyes rolled back for approximately 5 minutes. Minimal period of sleepiness, now awake and alert; no retractions; skin color is normal
  • The PAT is as follows: A: Appearance: Normal B: Work of Breathing: Normal C: Circulation to the Skin: Normal ABCDEs: Normal. Vital signs include: Heart rate: 120 bpm Respiratory rate: 24 breaths/min Blood pressure: 80/60 mm Hg Temperature: 37.7°C Weight: 12 kg Oxygen saturation: 99% Focused history: Three similar episodes; two associated with “temper tantrums.” PMH: Negative FH: Negative for sudden death
  • Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
  • The patient presents with syncope and normal appearance on exam. She is in no distress and the exam is normal. Her history, however, is concerning and ominous. What are your initial management priorities?
  • Syncope in young children is a serious symptom. Life-threatening causes must be eliminated. A differential diagnosis is critical: Seizure Cardiac Breath-holding spell
  • Clinical features include: Loss of consciousness Lasted only a few minutes Minimal or no postictal state No stigmata of seizure: Urinary incontinence, bitten tongue, witnessed tonic-clonic activity.
  • Radiology studies may include: Chest radiograph offers little. CT or MRI may be indicated if seizures are considered. Laboratory studies often are normal, but if patient has abnormal mental status or concerning history, may include: Electrolytes CBC with differential Ca++, Mg++, PO 4
  • Obtain an ECG as this will assist the physician in determining potential life threatening cardiac causes of syncope. In this case the ECG shows prolonged QT. This shows a markedly prolonged QT interval (corrected QTc interval is 0.75 seconds [750 ms]) with T-wave alternans. Courtesy of Dr. Bob Hickey.
  • Ten percent present with seizures.  Fifteen percent of patients with prolonged QTc die during their first episode of arrhythmia and 30% of these deaths occur during the first year of life.
  • Also consider in differential: Hypertrophic cardiomyopathy Formerly called IHSS (idiopathic hypertrophic subaortic stenosis) Syncope with exercise At risk for sudden death Positive family history Non-specific murmur ECG can show non-specific findings. CXR is non-diagnostic. Echocardiogram is diagnostic. Chronic cardiomyopathy Chronic CHF Dysrhythmias
  • Cardiac arrhythmias should be considered in all patients presenting with brief, nonspecific changes in level of consciousness: Fainting, syncope, seizures, breath-holding, apparent life-threatening events
  • Family history may be positive for sudden, unexplained deaths prior to 55, fainting episodes, or unexplained accidents. Episodes associated with exercise are particularly concerning. No further exercise until cleared by a cardiologist.
  • Review the above flowchart with the students. On this slide, “vasopressor” = epinephrine Epinephrine 0.01 mg/kg (0.1 mL/kg 1:10,000) IV or IO 0.1 mg/kg (0.1 mL/kg 1:1000) tracheal tube Anti-arrhythmic includes amiodarone, lidocaine and magnesium. Reversible causes include the 4 H’s (hypoxemia, hypovolemia, hypothermia, Hyper-/hypokalemia) and the 4 T’s (tamponade, tension pneumothorax, toxins, thromboembolism).
  • This patient has prolonged QT syndrome. She is at risk for fatal dysrhythmia (ventricular tachycardia or ventricular fibrillation). She needs to be admitted/transferred to a pediatric cardiology center for cardiology evaluation.
  • This child is hospitalized. She is monitored and confirmed to be at risk for dangerous dysrhythmia. She is discharged on medications shown to decrease her risk of ventricular tachycardia/ventricular fibrillation (e.g., ß blockers). She is a candidate to receive an AICD (automatic implantable cardiac defibrillator) when she gets older.
  • A 6-month-old boy present with chicken pox lesions that began 3 days ago. The lesions are spreading and there are more scabs today. Fever since yesterday, higher today. Today, his skin appears to be red. He is fussy and not feeding well.
  • The PAT is as follows: A: Appearance: Normal/Abnormal – he is fussy, which may be an early sign of shock or CNS condition. B: Work of Breathing: Normal. C: Circulation to the Skin: Normal. Vital signs include: Heart rate: 160 bpm – tachycardia is seen in many conditions, but there is concern in a patient with infection that it could be a sign of shock Respiratory rate: 40 breaths/min – without retractions, may indicate metabolic acidosis Blood pressure: 79/56 mm Hg – blood pressure is normal, so this is not decompensated shock Temperature: 39°C Weight: 8.1 kg Oxygen saturation: 98% on room air
  • A: Patent without evidence of obstruction B: Normal C: Generalized red erythroderma, warm, tachycardic (febrile) D: Nonfocal exam, irritable E: Many impetiginous scabs, pustules and vesicles; some with surrounding cellulitis
  • Head/Neck: No abnormalities except for skin Heart: Tachycardic, no murmurs heard Lungs: Clear breath sounds Abdomen: Normal except for skin Neuro: Alert, subdued, no meningismus Skin: Many vesicles, scabs, pustules; some with surrounding cellulitis. Generalized warm erythroderma. Capillary refill 2 seconds.
  • Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
  • Compensated shock Tachycardia and mild change in appearance (fussy) Possible septic shock as varicella lesions with signs of secondary infection ( Staph aureus , group A strep) Erythroderma: Scarlet fever versus toxic shock What are your initial management priorities?
  • Provide supplemental oxygen. Obtain vascular access. Determine rapid glucose. Begin fluid resuscitation at 20 mL/kg – 160 mL normal saline. CBC, blood culture, other optional labs IV antibiotics Repeated assessment for signs of shock Also important to continue assessment to determine if scarlet fever or toxic shock For toxic shock: IV fluid infusion Start infusion of dopamine. Consider dobutamine infusion.
  • Shock is inadequate tissue perfusion (delivery of oxygen and nutrients) to meet the metabolic demands of the body. Types of shock include: Hypovolemic Cardiogenic Distributive Septic
  • Compensated: Vital organs continue to be perfused by compensatory mechanisms. Blood pressure is normal. Decompensated: Compensatory mechanisms are overwhelmed and inadequate - hypotension, high mortality risk. Aggressive treatment of early shock: Halts progression to decompensated shock
  • Apnea, tachypnea, respiratory distress Skin: Pale, cool, delayed capillary refill. Warm shock will appear normal. Lethargic, weak, orthostatic weakness Tachycardia, hypotension Specific types of shock: Distributive shock: Neurologic deficits (spinal cord injury); anaphylaxis (urticaria, allergen trigger, wheezing) Septic shock: Petechiae, erythroderma
  • Fluid loss: Diarrhea, vomiting, anorexia, diuresis Hemorrhage Resuscitation: Fluid replacement Normal saline or lactated Ringer’s 20 mL/kg bolus infusions, reassess, repeat as needed Blood transfusion for excessive hemorrhage
  • Poor myocardial contractility or impaired ejection: Cardiomyopathy, congenital heart disease, myocarditis, tamponade, congestive heart failure, dysrhythmia, septic shock, drugs (e.g., thiopental) Resuscitation: Fluid bolus (10 mL/kg) and reassess Inotropes, pressors (e.g., dopamine, dobutamine, epinephrine)
  • Inappropriate vasodilation with a maldistribution of blood flow: Anaphylactic shock, spinal cord injury, septic shock “ Warm shock” Resuscitation: Vasoconstrictors (e.g., epinephrine) Anaphylaxis treatment Spinal cord injury treatment Sepsis treatment
  • Elements of distributive shock and cardiogenic shock: Inappropriate vasodilation with a maldistribution of blood flow Myocardial depression Resuscitation: Fluid bolus Pressors and inotropes Antibiotics (expect possible deterioration initially due to toxin release)
  • Labs drawn IV fluids given with decrease in heart rate to 120 bpm IV antibiotics given Patient admitted and discharged 4 days later Option for prolonged observation in ED monitoring for deterioration in vital signs and clinical status. Benign observation period suggests scarlet fever. Worsening suggests possible toxic shock. Toxic shock: Similar to septic shock requiring fluids, pressors, inotropes, ICU monitoring
  • Early recognition and treatment of compensated shock may prevent progression to decompensated shock. Identifying early compensated shock is difficult. Decompensated shock has a poor prognosis.
  • Overall, parents of patients with underlying cardiac disease should receive information about their child’s disease, treatment, and how to reach primary care (PCP) and specialty physicians. Ideally parents of children with cardiac disease should carry an updated emergency information form (EIF) when seeking emergency care. This form provides immediate pertinent medical information. A medical ID bracelet is also useful. Available from ACEP and AAP. The EIF should be updated by the patient’s primary care physician and specialists.
  • Obtain rapid history and assess children in shock or respiratory distress for cardiac disease including postsurgical complications. Utilize the EIF to gather information, contact specialists, and guide therapy. Echocardiography and cardiology consultation for definitive diagnosis and cardiac function determination.
  • Cardiovascular System II

    1. 1. Cardiovascular System II
    2. 2. Objectives <ul><li>Present the clinical features and emergency management of cardiovascular disorders, including: </li></ul><ul><ul><li>Diagnose and treat rhythm disturbances. </li></ul></ul><ul><ul><li>Detect and treat cardiomyopathy. </li></ul></ul><ul><ul><li>Treat shock. </li></ul></ul><ul><ul><li>Create differential diagnosis and management plan for syncope. </li></ul></ul>
    3. 3. Case Study 1: “Not Breathing” <ul><li>10-day-old boy brought to ED for not breathing and color change. </li></ul><ul><li>3 weeks premature, discharged from hospital 3 days ago with apnea monitor </li></ul><ul><li>Decreased activity since discharge </li></ul><ul><li>Poor feeding today </li></ul>
    4. 4. Initial Assessment (1 of 2) <ul><li>PAT: </li></ul><ul><ul><li>Abnormal appearance, abnormal breathing, abnormal circulation </li></ul></ul><ul><li>Vital signs: </li></ul><ul><ul><li>HR 220, RR 14, BP 55/36, Wt 3.5 kg (birth weight 3.7 kg), O 2 sat 88% on room air </li></ul></ul>
    5. 5. Initial Assessment (2 of 2) <ul><li>A: Patent without evidence of obstruction </li></ul><ul><li>B: Nonlabored but diminished respiratory rate </li></ul><ul><li>C: Mottled, cool, distal cyanosis, tachycardic and weak pulse </li></ul><ul><li>D: Weak cry, nonfocal exam </li></ul><ul><li>E: Normothermic, no evidence of trauma, fontanel flat </li></ul>
    6. 6. Detailed Physical Exam <ul><li>Head/Neck: No abnormalities </li></ul><ul><li>Heart: Tachycardia, no murmurs heard </li></ul><ul><li>Lungs: Decreased breath sounds </li></ul><ul><li>Abdomen: Liver 2 finger breadths below RCM </li></ul><ul><li>Neuro: Weak cry, lethargic, poor interaction, responsive to pain and contact </li></ul><ul><li>Extremities: Cyanotic, cool upper and lower extremities </li></ul>
    7. 7. Question <ul><li>What is your general impression of this patient? </li></ul>
    8. 8. General Impression <ul><li>Cardiopulmonary failure </li></ul><ul><ul><li>Lethargic but responsive, inadequate respirations and tachycardia; mottling with distal cyanosis </li></ul></ul><ul><li>What are your initial management priorities? </li></ul>
    9. 9. Management Priorities <ul><li>ABCs </li></ul><ul><li>Open airway. </li></ul><ul><li>Give 100% O 2 by BMV, or perform endotracheal intubation. </li></ul><ul><li>Check rhythm on cardiac monitor. </li></ul><ul><li>Obtain vascular access. </li></ul><ul><li>Obtain blood glucose prn. </li></ul><ul><li>Check rectal temperature. </li></ul>
    10. 10. Case Discussion (1 of 2) <ul><li>Tachyarrhythmias: </li></ul><ul><ul><li>Wide complex </li></ul></ul><ul><ul><ul><li>Ventricular tachycardia </li></ul></ul></ul><ul><ul><ul><li>Supraventricular tachycardia (SVT) with aberrancy </li></ul></ul></ul><ul><ul><li>Narrow complex </li></ul></ul><ul><ul><ul><li>Sinus tachycardia </li></ul></ul></ul><ul><ul><ul><li>SVT </li></ul></ul></ul>
    11. 11. Case Discussion (2 of 2) <ul><li>Clinical features can be varied: </li></ul><ul><ul><li>Palpitations in verbal children </li></ul></ul><ul><ul><li>Shock in any age </li></ul></ul><ul><ul><li>Generalized symptoms of malaise and weakness </li></ul></ul><ul><li>Diagnostic studies: </li></ul><ul><ul><li>Cardiac monitor, ECG, sepsis evaluation if young infant who has signs and symptoms suggestive of infection </li></ul></ul><ul><ul><li>CXR, echocardiogram </li></ul></ul><ul><li>Management: ABCs, stabilize </li></ul>
    12. 12. Background: Dysrhythmias <ul><li>3 basic types: </li></ul><ul><ul><li>Fast pulse (tachyarrhythmia) </li></ul></ul><ul><ul><li>Slow pulse (bradyarrhythmia) </li></ul></ul><ul><ul><li>Absent pulse (pulseless) </li></ul></ul><ul><li>Dysrhythmias may impair cardiac function , leading to cardiac arrest. </li></ul><ul><li>Occult dysrhythmias (e.g., prolonged QT syndrome, WPW syndrome) </li></ul>
    13. 13. Clinical Features: Your First Clue <ul><li>Intermittent, paroxysmal presence of symptoms </li></ul><ul><li>Sudden onset of symptoms with little or no prodrome </li></ul><ul><li>Presentation of dysrhythmias can range from stable to cardiopulmonary arrest. </li></ul>
    14. 14. Distinguishing SVT from ST SVT rate at or greater than 2x normal rate for age. Minimal or no rate change with activity. ST rate is less than 2x normal rate for age. Rate varies with activity. ECG Intermittent, paroxysmal in onset Fever, sepsis, dehydration, hemorrhage, hypovolemia, precedes History SVT ST
    15. 15. Supraventricular Tachycardia
    16. 16. Diagnostic Studies <ul><li>Radiology: </li></ul><ul><ul><li>CXR important to look for signs of: </li></ul></ul><ul><ul><ul><li>Structural congenital heart disease </li></ul></ul></ul><ul><ul><ul><li>Congestive heart failure (prolonged dysrhythmia) </li></ul></ul></ul><ul><ul><ul><li>Signs of infection (pneumonia) </li></ul></ul></ul><ul><li>Laboratory: </li></ul><ul><ul><li>ALWAYS check blood glucose to exclude hypoglycemia in any child with abnormal mental status. </li></ul></ul>
    17. 17. Differential Diagnosis: What Else? <ul><li>Hypoglycemia </li></ul><ul><li>Sepsis </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Volume depletion </li></ul><ul><li>Catastrophic illness: </li></ul><ul><ul><li>CNS, GI, trauma (abuse) </li></ul></ul><ul><li>Metabolic disease </li></ul>
    18. 18. Management: Dysrhythmias <ul><li>ABCs </li></ul><ul><li>Get baseline ECG. </li></ul><ul><li>Obtain vascular access. </li></ul><ul><li>For SVT (see AHA algorithm): </li></ul><ul><ul><li>Vagal maneuvers </li></ul></ul><ul><ul><li>Adenosine: 100 mcg/kg bolus, increase as necessary: 200 mcg/kg </li></ul></ul><ul><ul><li>Cardioversion for unstable SVT </li></ul></ul><ul><ul><li>Procainamide or amiodarone if QRS is wide </li></ul></ul><ul><ul><li>Digoxin to slow rate if cardioversion unsuccessful </li></ul></ul><ul><ul><li>Cardiology consultation </li></ul></ul>
    19. 19. Tachycardia Management
    20. 20. The Bottom Line: Dysrhythmias <ul><li>Management is driven by presence or absence of poor perfusion. </li></ul><ul><li>Sinus tachycardia is not an arrhythmia but its etiology must be determined. </li></ul><ul><li>Provide ventilation and oxygenation for all patients in cardiopulmonary arrest, as the primary etiology is often respiratory failure. </li></ul>
    21. 21. Other Considerations (1 of 2) <ul><li>Interface with EMS/Transport: </li></ul><ul><ul><li>Transport issues: Case such as this should be transported to pediatric referral center after stabilization. </li></ul></ul><ul><ul><ul><li>ALS transport with monitoring and IV access </li></ul></ul></ul><ul><ul><ul><li>Treatment plan for possible en route for recurrence – including potential for cardioversion </li></ul></ul></ul><ul><ul><ul><li>Consult accepting pediatric cardiologist </li></ul></ul></ul>
    22. 22. Other Considerations (2 of 2) <ul><li>Documentation: </li></ul><ul><ul><li>Always try to get baseline 12-lead ECG before and after cardioversion. </li></ul></ul><ul><ul><li>Treatment record from prehospital and ED care </li></ul></ul><ul><ul><li>EMTALA compliance </li></ul></ul><ul><li>Risk management: </li></ul><ul><ul><li>Always check blood glucose. </li></ul></ul><ul><ul><li>Assure rapid triage of infants in distress. </li></ul></ul><ul><ul><li>Do not hesitate to cardiovert when child is unstable. </li></ul></ul>
    23. 23. Reversible Non-Cardiac Causes of Dysrhythmias <ul><li>Four H’s: </li></ul><ul><ul><li>H ypoxemia </li></ul></ul><ul><ul><li>H ypovolemia </li></ul></ul><ul><ul><li>H ypothermia </li></ul></ul><ul><ul><li>H yper/Hypokalemia and metabolic disorders </li></ul></ul><ul><li>Four T’s: </li></ul><ul><ul><li>T amponade (cardiac) </li></ul></ul><ul><ul><li>T ension pneumothorax </li></ul></ul><ul><ul><li>T oxins/poisons/ drugs </li></ul></ul><ul><ul><li>T hromboembolism </li></ul></ul>
    24. 24. Case Progression/Outcome <ul><li>ECG reveals SVT. </li></ul><ul><li>Infant receives BMV ventilation. </li></ul><ul><li>Preparations are made to cardiovert as IV access is obtained. </li></ul><ul><li>Adenosine 100 mcg/kg IV push is given followed by NS bolus (flush). </li></ul><ul><li>ECG shows return of sinus rhythm. </li></ul><ul><li>BMV is discontinued as infant’s condition stabilized. 100% oxygen NRB mask is placed. </li></ul>
    25. 25. Case Study 2: “Unresponsive Episodes” <ul><li>2-year-old girl passed out eating cereal; awoke after 5 min. </li></ul><ul><li>She was stiff with eyes rolled back ~ approx. 5 min. </li></ul><ul><li>Minimal period of sleepiness, now awake and alert; no retractions; skin color is normal </li></ul>
    26. 26. Initial Assessment and Focused History <ul><li>PAT: </li></ul><ul><ul><li>Normal appearance, normal breathing, normal circulation </li></ul></ul><ul><li>ABCDEs: </li></ul><ul><ul><li>Normal </li></ul></ul><ul><ul><li>Vital signs: HR 120; RR 24; BP 80/60; T 37.7  C Wt 12 kg; O 2 sat 99% </li></ul></ul><ul><li>Focused History: </li></ul><ul><ul><li>Three similar episodes; two associated with “temper tantrums.” </li></ul></ul><ul><ul><li>PMH and FH: Negative </li></ul></ul>
    27. 27. Question <ul><li>What is your general impression of this patient? </li></ul>
    28. 28. General Impression <ul><li>Stable </li></ul><ul><ul><li>Patient with syncope </li></ul></ul><ul><ul><li>In no distress; normal exam </li></ul></ul><ul><ul><li>Concerning/ominous history </li></ul></ul><ul><li>What are your initial management priorities? </li></ul>
    29. 29. Case Discussion <ul><li>Syncope in young children is a serious symptom. </li></ul><ul><li>Must attempt to exclude life-threatening causes </li></ul><ul><li>Differential diagnosis is critical: </li></ul><ul><ul><li>Seizure </li></ul></ul><ul><ul><li>Cardiac </li></ul></ul><ul><ul><li>Breath-holding spell </li></ul></ul>
    30. 30. Clinical Features: Your First Clue <ul><li>Loss of consciousness </li></ul><ul><li>Lasted only a few minutes </li></ul><ul><li>Minimal or no postictal state </li></ul><ul><li>No stigmata of seizure: Urinary incontinence, bitten tongue, witnessed tonic-clonic activity </li></ul>
    31. 31. Diagnostic Studies <ul><li>Radiology: </li></ul><ul><ul><li>CXR offers little. </li></ul></ul><ul><ul><li>CT or MRI may be indicated if considering seizures. </li></ul></ul><ul><li>Laboratory is often normal but may include: </li></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><ul><li>CBC with differential </li></ul></ul><ul><ul><li>Ca ++ , Mg ++ , PO 4 </li></ul></ul>
    32. 32. Markedly Prolonged QT Interval T-wave alternans
    33. 33. Prolonged QT <ul><li>10% present with seizures. </li></ul><ul><li>15% of patients with prolonged QTc die during their first episode of arrhythmia. </li></ul><ul><ul><li>30% of these deaths occur during the first year of life. </li></ul></ul>
    34. 34. What Else? Cardiac Causes of Syncope <ul><li>Hypertrophic cardiomyopathy </li></ul><ul><ul><li>Syncope with exercise </li></ul></ul><ul><ul><li>At risk for sudden death; positive family history </li></ul></ul><ul><ul><li>Non-specific murmur; ECG can show non-specific findings. </li></ul></ul><ul><ul><li>CXR is non-diagnostic </li></ul></ul><ul><ul><li>Echocardiogram is diagnostic. </li></ul></ul><ul><li>Chronic cardiomyopathy </li></ul><ul><ul><li>Chronic CHF </li></ul></ul><ul><li>Dysrhythmias </li></ul>
    35. 35. Critical Concepts (1 of 2) <ul><li>Consider cardiac arrhythmias in all patients presenting with brief, nonspecific changes in level of consciousness: </li></ul><ul><ul><li>Fainting, syncope, seizures, breath-holding, apparent life-threatening events </li></ul></ul>
    36. 36. Critical Concepts (2 of 2) <ul><li>Family history may be positive for sudden, unexplained deaths prior to 55, fainting episodes, or unexplained accidents. </li></ul><ul><li>Episodes associated with exercise are particularly concerning. </li></ul><ul><ul><li>Patient instructed not to exercise until cleared by a cardiologist. </li></ul></ul>
    37. 37. Pulseless Arrest * VF/VT Not VF/VT Anti-arrhythmic Vasopressor (Drug - Shock) CPR x 3 min Shock x 3 Shock Vasopressor * CPR and seek reversible causes throughout
    38. 38. Case Progression <ul><li>This patient has prolonged QT syndrome. </li></ul><ul><li>She is at risk for fatal dysrhythmia (ventricular tachycardia or ventricular fibrillation). </li></ul><ul><li>She needs to be admitted/transferred to a pediatric cardiology center for cardiology evaluation. </li></ul>
    39. 39. Case Outcome <ul><li>This child is hospitalized. </li></ul><ul><li>Monitored and confirmed to be at risk for dangerous dysrhythmia </li></ul><ul><li>Discharged on medications shown to decrease her risk of VT/VF (e.g., ß blockers) </li></ul><ul><li>She is a candidate to receive an AICD when she gets older. </li></ul>
    40. 40. Case Study 3: “Chicken Pox” <ul><li>6-month-old with chicken pox lesions that began 3 days ago. Lesions are spreading. More scabs today. </li></ul><ul><li>Fever since yesterday, higher today. </li></ul><ul><li>Today, his skin appears to be red. </li></ul><ul><li>He is fussy and not feeding well. </li></ul>
    41. 41. Initial Assessment (1 of 2) <ul><li>PAT: </li></ul><ul><ul><li>Normal/abnormal appearance, normal breathing, normal circulation </li></ul></ul><ul><li>Vital signs: </li></ul><ul><ul><li>HR 160, RR 40, BP 79/56, T 39°C, Wt 8.1 kg, O 2 sat 98% on room air </li></ul></ul>
    42. 42. Initial Assessment (2 of 2) <ul><li>A: Patent without evidence of obstruction </li></ul><ul><li>B: Normal </li></ul><ul><li>C: Generalized red erythroderma, warm, tachycardic (febrile) </li></ul><ul><li>D: Nonfocal exam, irritable </li></ul><ul><li>E: Many impetiginous scabs, pustules and vesicles; some with surrounding cellulitis </li></ul>
    43. 43. Detailed Physical Exam <ul><li>Head/Neck: No abnormalities except for skin </li></ul><ul><li>Heart: Tachycardic, no murmurs heard </li></ul><ul><li>Lungs: Clear breath sounds </li></ul><ul><li>Abdomen: Normal except for skin </li></ul><ul><li>Neuro: Alert, subdued, no meningismus </li></ul><ul><li>Skin: Many vesicles, scabs, pustules; some with surrounding cellulitis. Generalized warm erythroderma. Capillary refill 2 seconds. </li></ul>
    44. 44. Question <ul><li>What is your general impression of this patient? </li></ul>
    45. 45. General Impression <ul><li>Compensated shock </li></ul><ul><ul><li>Tachycardia and mild change in appearance (fussy) </li></ul></ul><ul><ul><li>Possible septic shock as varicella lesions with signs of secondary infection ( Staph aureus , group A strep) </li></ul></ul><ul><ul><li>Erythroderma: Scarlet fever versus toxic shock </li></ul></ul><ul><li>What are your initial management priorities? </li></ul>
    46. 46. Management Priorities <ul><li>Provide supplemental oxygen. </li></ul><ul><li>Obtain vascular access. </li></ul><ul><li>Determine rapid glucose. </li></ul><ul><li>Begin fluid resuscitation at 20 mL/kg – 160 mL NS. </li></ul><ul><li>CBC, blood culture, other optional labs </li></ul><ul><li>IV antibiotics </li></ul><ul><li>Repeated assessment for signs of shock </li></ul>
    47. 47. Shock <ul><li>Inadequate tissue perfusion (delivery of oxygen and nutrients) to meet the metabolic demands of the body. </li></ul><ul><ul><li>Hypovolemic </li></ul></ul><ul><ul><li>Cardiogenic </li></ul></ul><ul><ul><li>Distributive </li></ul></ul><ul><ul><li>Septic </li></ul></ul>
    48. 48. Background: Shock <ul><li>Compensated: </li></ul><ul><ul><li>Vital organs continue to be perfused by compensatory mechanisms. </li></ul></ul><ul><ul><li>Blood pressure is normal. </li></ul></ul><ul><li>Decompensated: </li></ul><ul><ul><li>Compensatory mechanisms are overwhelmed and inadequate. </li></ul></ul><ul><ul><li>Hypotension, high mortality risk </li></ul></ul><ul><li>Aggressive treatment of early shock: </li></ul><ul><ul><li>Halts progression to decompensated shock </li></ul></ul>
    49. 49. Clinical Features: Your First Clue <ul><li>Apnea, tachypnea, respiratory distress </li></ul><ul><li>Skin: Pale, cool, delayed capillary refill. Warm shock will appear normal. </li></ul><ul><li>Lethargic, weak, orthostatic weakness </li></ul><ul><li>Tachycardia, hypotension </li></ul><ul><li>Specific types of shock: </li></ul><ul><ul><li>Neurologic deficits (spinal cord injury) </li></ul></ul><ul><ul><li>Urticaria, allergen trigger, wheezing </li></ul></ul><ul><ul><li>Petechiae, erythroderma </li></ul></ul>
    50. 50. Hypovolemic Shock <ul><li>Fluid loss: </li></ul><ul><ul><li>Diarrhea, vomiting, anorexia, diuresis </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><li>Resuscitation: </li></ul><ul><ul><li>Fluid replacement </li></ul></ul><ul><ul><li>NS or LR 20 mL/kg bolus infusions, reassess, repeat as needed </li></ul></ul><ul><ul><li>Blood transfusion for excessive hemorrhage </li></ul></ul>
    51. 51. Cardiogenic Shock <ul><li>Poor myocardial contractility or impaired ejection: </li></ul><ul><ul><li>Cardiomyopathy, congenital heart disease, myocarditis, tamponade, congestive heart failure, dysrhythmia, septic shock, drugs (e.g., thiopental) </li></ul></ul><ul><li>Resuscitation: </li></ul><ul><ul><li>Fluid bolus (10 mL/kg) and reassess </li></ul></ul><ul><ul><li>Inotropes, pressors (e.g., dopamine, dobutamine, epinephrine) </li></ul></ul>
    52. 52. Distributive Shock <ul><li>Inappropriate vasodilation with maldistribution of blood flow: </li></ul><ul><ul><li>Anaphylactic shock, spinal cord injury, septic shock </li></ul></ul><ul><ul><li>“ Warm shock” </li></ul></ul><ul><li>Resuscitation: </li></ul><ul><ul><li>Vasoconstrictors (e.g., epinephrine) </li></ul></ul><ul><ul><li>Anaphylaxis treatment </li></ul></ul><ul><ul><li>Spinal cord injury treatment </li></ul></ul><ul><ul><li>Sepsis treatment </li></ul></ul>
    53. 53. Septic Shock <ul><li>Elements of distributive shock and cardiogenic shock: </li></ul><ul><ul><li>Inappropriate vasodilation with a maldistribution of blood flow </li></ul></ul><ul><ul><li>Myocardial depression </li></ul></ul><ul><li>Resuscitation: </li></ul><ul><ul><li>Fluid bolus </li></ul></ul><ul><ul><li>Pressors and inotropes </li></ul></ul><ul><ul><li>Antibiotics (expect possible deterioration initially due to toxin release) </li></ul></ul>
    54. 54. Case Progression/Outcome <ul><li>Labs drawn </li></ul><ul><li>IV fluids given with decrease in HR to 120 </li></ul><ul><li>IV antibiotics given </li></ul><ul><li>Patient admitted and discharged 4 days later </li></ul>
    55. 55. The Bottom Line: Shock <ul><li>Early recognition and treatment of compensated shock may prevent progression to decompensated shock. </li></ul><ul><li>Decompensated shock has a poor prognosis. </li></ul>
    56. 56. EIF <ul><li>Available from ACEP, AAP </li></ul><ul><li>Updated by PCP and specialists </li></ul><ul><li>Very helpful </li></ul><ul><li>Medical ID bracelet </li></ul>
    57. 57. The Bottom Line <ul><li>Obtain rapid history and assess children in shock or respiratory distress for cardiac disease. </li></ul><ul><li>Utilize the EIF to gather information, contact specialists, and guide therapy. </li></ul><ul><li>Echocardiography and cardiology consultation for definitive diagnosis and cardiac function determination. </li></ul>
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