Cardiopulmonary resuscitation started with chest compression and bag mask ventilation. Inj adrenaline given. After 15 minutes spontaneous circulation restored. HR 120/min, BP 80/40. Baby shifted to PICU.

1. Presenter:
Dr. Anindita Bose
FCPS student
Neonatology, BSMMU.
Dr. Mostafa Kamal
Resident ( Year 2)
Paediatric Nephrology, BSMMU

2. Particulars of the patient
• Name : B/O Tania
• Age : 10 Days
• Sex : Male
• Address : West Dewbhog,
N Gonj
• Date of admission : 04/02/19
• Date of examination : 04/02/19
• Informant : Father

3. Chief complaints
H/O Delayed cry after birth
Multiple birth defects

4. History of present illness
Mother Tania, 31 years old, para: 4-1(IUD), having blood
group B(+) ve, fathers blood group B(+)ve, was on irregular
antenatal check up (total 3 visits) and was duly immunized
against tetanus. At 20 weeks of gestation, she was first
diagnosed as 20 weeks of alive pregnancy which was
unplanned. About 12 weeks before diagnosis of
pregnancy, she was diagnosed as coronary artery disease
(Double vessel disease) and hypertension. CABG was done
under GA on 30.05.2018 and treated with clopidogrel,

5. History of present illness cont.
aspirin, atorvastatin, frusemide, spironolactone,
metoprolol, riboflavin, ferrous sulphate, folic acid. She was
known case of DM for last 5 years and was being treated
irregularly with insulin, linagliptin, glicazide and continued
upto 20 weeks of pregnancy, her HbA1C was 7.4% . After
diagnosis of pregnancy she continued aspirin, bisoprolol,
insulin. She had no H/O of APH, PROM, Hypothyroidism,
fever with rash.

6. History of present illness cont.
At 38+4 weeks of gestation, she admitted at private
hospital, LUCS was done due to less fetal movement,
previous C/S & cardiac surgery. A male baby weighing
2300gm was delivered on 25/01/19. Baby was found
meconium stained & didn’t cry immediately after birth.
After laryngeal suction, bag mask ventilation was given,
then baby cried. APGAR score was 4/10 & 8/10 @ 1min &
5mins respectively.

7. History of present illness cont.
Soon after birth baby developed respiratory distress in the
form of tachypnea, chest retraction. Baby was shifted to
NICU of private hospital for delayed crying followed by
respiratory distress and multiple congenital anomalies. At
PNA day 10, baby referred to BSMMU for further evaluation
and management.

8. Antenatal History
At 20 weeks of gestation, she was diagnosed 20 weeks
of alive pregnancy. During this pregnancy mother
didn’t receive any ANC upto 20 weeks of gestation,
then was on regular ANC & was duly immunized
against tetanus.
At 8 weeks of pregnancy she was diagnosed as
coronary artery disease, CABG was done
She was diagnosed case of DM for last 5 years
She also diagnose case as hypertention.

9. Natal History
A male baby delivered by LUCS weighing
2300gm on 25/01/19, cried after giving bag
mask ventilation for 1 min, APGAR score
4/10, 8/10 at 1st and 5th min

10. Postnatal History
Soon after birth baby developed respiratory
distress in the form of tachypnea, chest indrawing

11. Immunization History
 Not started yet.

12. Feeding History
OG feeding with expressed breast milk

13. Drug History
 Antibiotic: Ceftazidime, Amikacin,
Meropenem, Vancomycin
 Frusemide injection

14. Family History
He is the 3rd issue of non-consanguineous
parents. Other sibs are good in health

15. Socio-economic History
He belongs to a middle socio-economic
background, father is a businessman, mother
is a homemaker and their monthly income is
around 35000 tk

16. General Examination

17. •Appearance: Alert
•Anicteric
•Pink on 2L/min O2
•SPO2: 93% in 2L/min O2
•Reflex-Activities: good
•CRT: 2 sec
•Pulse volume : good
•CBG: 4.5 mmol/L
•Temperature: 36.8C

18. R/R : 54/min
H/R : 290 beats/min
Fontanelle : Open, not bulged
 Back and spine : Normal
 Genitalia- Normal male pattern.
 Anus: Patent
 Congenital anomaly: Anotia (right),
Bilateral club foot

19. Anotia

20. Bilateral club foot

21. Anthropometry
Weight : At Birth 2300 g (between 25th & 50th
centile) At admission 2290 gm
Length : 44 cm (between 25th & 50th centile)
OFC : 32 cm (between 25th & 50th centile)

22. Systemic Examination

23. Cardiovascular System Examination
• Inspection:
• Visible apex beat -Absent
• Palpation
• Apex beat: left 4th intercostal space
• Left parasternal heave, thrill, palpable P2-Absent
• Auscultation:
• Heart Rate : 290 b/min
• Heart Sound: first and second heart sounds are
audible in all four areas of precordium.
• Murmur: Systolic, grade 3/6, left 2nd ICS with no
radiation

24. GIT System Examination
• Abdomen : Soft, not distended
• Liver – 4 cm from right costal Margin
along the mid-clavicular line, margin
sharp, smooth surface
• Bowel sound –present
• Umbilicus: Healthy

25. Respiratory System Examination
• RR-54 br/ min
• Chest is normal in size and shape
• No grunting, chest indrawing
• Bilateral equal good air entry
• Breath sound vesicular, no added
sound.

26. Nervous system
• Conscious, alert
• Posture normal
• Primitive reflexes were Good
• Tone normal
• Deep tendon reflexes normal.

27. Nervous system
Facial nerve examination:
 Loss of wrinkle in right side
 Eyelids on right side could
easily be opened
 Loss of nasolabial fold on
right side
 Mouth deviated to left side
during crying
Suggestive of right sided lower
motor type facial nerve palsy

28.  Other systemic examination reveals no
abnormality.

29. Salient feature
S/O Tania, outborn, 3rd issue of non-consanguineous parents, got
admitted in NICU at his 10 days of age due to delayed cry after
birth followed by respiratory distress, multiple congenital
anomalies. Mother Tania, 31 years old lady, Para: 4-1(IUD), having
blood group B(+)ve, was on irregular ANC upto 20 weeks when
she was diagnosed with 20weeks alive pregnancy. About 12
weeks before diagnosis of pregnancy, CABG was done under GA
due to coronary artery disease with hypertention. She was known
case of DM for last 5 years. She had no H/O of APH, PROM,
Hypothyroidism, fever with rash.

30. Salient feature
Regarding drug history of mother during this pregnancy, for
heart disease clopidogrel, aspirin, atorvastatin, frusemide,
spironolactone, metoprolol; for DM insulin, linagliptin,
glicazide. After diagnosis of pregnancy she continued aspirin,
bisoprolol, insulin. At 38+4 weeks of gestation, LUCS was
done due to less fetal movement, previous C/S & cardiac
surgery. A male baby weighing 2300gm was delivered.

31. Salient feature cont.
Baby was found meconium stained & didn’t cry
immediately after birth. After laryngeal suction and bag
mask ventilation baby cried. APGAR score was 4/10 &
8/10 @ 1 min & 5 mins respectively. Baby was admitted in
a private NICU for delayed crying followed by respiratory
distress and multiple congenital anomalies. There baby
was treated with O2 inhalation, injectable antibiotics,
frusemide. At PNA day 10, baby was referred to BSMMU
for further evaluation and management.

32. Salient feature cont.
On examination, baby was alert, anicteric, pink on 2L/M O2,
reflex activities were good, well perfused, euglycemic,
normothermic, SPO2 – 93% on 2L/min O2, RR- 54/m, HR –
290/min. Congenital anomaly- Anotia, Bilateral club foot.
Anthropometrically the baby was appropriate for gestational age.
CVS examination murmur present, Systolic, grade 3/6 left 2nd ICS
with no radiation. Nervous system examination revealed right
sided lower motor type facial nerve palsy. On abdominal
examination, liver is 4 cm. Other Systemic examination reveals
nothing significant.

33. Provisional Diagnosis
????

34. Provisional diagnosis
Term (38+4 wks), low birth weight (2300gm),
AGA, IDM, Perinatal asphyxia (HIE-1), Congenital
heart disease, tachyarrythmia, multiple
congenital anomalies (right sided anotia, right
sided lower motor type facial palsy, bilateral club
foot), suspected sepsis

35. Investigation ( Outside BSMMU)
Test 26/01/19 02.02.19
CBC Hb –20.1 g/dl
TC- 11320/cmm,
N= 47%, L= 40.6%
Platelet- 1,50,000/cmm
Hb –21.3 g/dl
TC- 10490/cmm,
N= 51%, L= 37.6%
Platelet- 81,000/cmm
Blood C/S No growth
Electrolyte Na 140 144
K 4.07 4.22
CL 95 100
T-CO2 24.5 24.8
S. Calcium 8.8
Mg 0.69mmol/L
TSH 0.5

36. Investigation (BSMMU)
Test 05/02/19 06.02.19
CBC Hb –19.8 g/dl
TC- 9000/cmm, N= 52%, L= 40%
Platelet- 1,50,000/cmm
Hct – 57.6%
PBF – Anisopoikilocytosis with target cell
IT Ratio- 0.09
CRP- 30.6
Blood CS No growth
Electrolyte Na 135 137
K 4.2 4.3
CL 95 100
T-CO2 31.5 24.8
S. Calcium 8.9mg/dl
S. Creatinine 0.79 0.6
Mg 1.6 mg/dL

37. Management after admission (8PM)
• O2 inhalation
• OG feeding 10ml/2hrly
• Infusion 10% DBS
• Inj Meropenem
• Inj Vancomycin
• Inj Frusemide
• Inj Digoxin
• Thermal care

38. Follow up at 10PM (04.02.2019)
 O/E:
 HR 280-290/min
 BP- 83/46(62)
 RR -56/min
 CRT – 2 sec
 Heart - S1+S2+ M
 Lungs – BL equal air entry, no added sound
 Assesssment: tachyarrythmia most probably SVT
 Plan: Continuous ECG monitoring
S- 72-82
D- 46-54
M- 55-63

39. ECG pic

40. Cont…
Vagal stimulation by
Ice cold compression on face
Persisting Tachycardia (HR-270-280)
Plan: Cardiology consultation
Inj Adenosine

41. Follow Up: 05.02.19 at 9AM
Subjective Objective Assessment Plan & Measures Taken
Tachycardia
persisting
Pink in 2L/min O2
Reflex activity- good
CRT -2 sec
R/R – 54 br/min
H/R- 280b/min
BP- 83/46(62)
SPO2- 98% in 2L/min O2
Lung- B/L equal air entry
Heart- S1+S2+ M
Abdomen- soft, not distended,
liver 2cm
Umbilicus- Healthy
CBG- 6 mmol/L
Temp- 98°F
Urine- 2.7 ml/kg/hr
Meconium- passed
Stable
S-72-82
D-46-54
M-55-63
• Cardiology consultation
• Inj Adenosine
• Echocardiography
Give Inj Adenosine
HR -150-156/M

42. Echocardiography
 Transposition of great artery (d-TGA), PA arising from LV,
Aorta arising from RV. Large inlet VSD (Size-6.8mm) with
bidirectional shunt. Large ostium secundum ASD (size-
7.5mm) with L-R shunt. Large PDA with bidirectional shunt.
Both dynamic and fixed obstruction of LVOT. Dilated
coronary sinus. Myxomatous change to septal leaflet ant
leaflet of tricuspid valve

43. Follow up on 06.02.2019
At 3.30AM
HR- 288/M
-Ensure Digoxin maintainance dose
At 9pm
HR- 250-260 b/m
MX- Inj Adenosine
HR-120-130b/min

44. Club foot Mx(Orthopedic consultation)
 Type: Flexible variety of Congenital Talepes Equino-
varus (Bilateral)
 Plan:
 Manipulation
 Follow up & Serial plaster after 1 month

45. Follow Up: 07.02.19 at 10AM
Subjective Objective Assessment Plan & Measures Taken
Unusual weight
gain (80gm)
Pink in air
SPO2- 90% in air
Reflex activity- good
Fontanelle- Open, normal
CRT -2 sec
R/R – 58 br/min
H/R- 120-130 b/min
BP- 92/53(63)
Lung- B/L equal air entry
Heart- S1+S2+ M
Abdomen- soft, not
distended, liver 2cm
Umbilicus- Healthy
CBG- 6 mmol/L
Temp- 98°F
Urine- 2.5 ml/kg/hr
Stool- 4 times
Static
S-72-82
D-46-54
M-55-63
-Decreased fluid
-Increased feed
-Inj MgSO2 (Mg -0.6)
• At 6PM, 10PM SVT
develop > Spontaneous
resolved

46. Follow Up: 09.02.19 at 10AM
Subjective Objective Assessment Plan & Measures Taken
Repeated
episode of SVT
Pink in air
Reflex activity- good
Fontanelle- Open, normal
CRT -2 sec
R/R – 42 br/min
H/R- 120 b/min
BP- 92/53(63)
SPO2- 84% in air
Lung- B/L equal air entry
Heart- S1+S2+ M
Abdomen- soft, not distended,
liver 2cm
Umbilicus- Healthy
CBG- 6 mmol/L
Temp- 98°F
Urine- 2.5 ml/kg/hr
Stool- 4 times
Static
S-72-82
D-46-54
M-55-63
• Cardiac Consultation
• Tab Amiodarone
(5mg/kg/day) started
from 5PM
• At 8.30PM & 10.30PM
Baby developed SVT
(spontaneously
resolved)

47. Follow Up: 10.02.19, 1AM
 Subjective- Sudden bradycardia (HR-70/min),
Desaturation (SPO2-74%)
 Objective-
 Pink in air
 Reflex activity-poor
 CRT - 4 sec
 R/R – Irregular
 H/R- gradually decreased to 50/m
 Pulse volume - weak
 Heart – S1+S2+M
 Assessment : Cardiac arrest

48.  Management :
Positioning, suction, stimulation and bag mask
ventilation , CPR started
2 shot of Inj Adrenaline was given (10unit/kg)
Baby having gasping respiration, heart rate 90b/min
Mechanical ventilation with SIMV mode in following
method - Rate-40, Pressure – 14/5, FiO2- 60%
- Dopamin, Dobutamine were added

49.  After that
 Pink in air
 Reflex activity-Improving than previous
 CRT - 2 sec
 R/R – 45/m
 H/R- 132/m
 Pulse volume – good
 Lungs – bilateral good air entry
 Heart – S1+S2+M
 Pupil – reacting to light
 Plan : Chest X-ray
ABG
ABG: pH-7.37
PCO2- 34
PO2- 45
HCO3- 19.4
BE- -5

51. Follow Up: 10.02.19 at 10AM
Subjective Objective Assessment Plan & Measures Taken
One episode of
SVT at 4.30AM
(Mx by Tab.
Amiodarone)
Pink in MV
F-40, P-14/5,Fio2-.60%
SPO2- 93%
Reflex activity- Moderate
Fontanelle- Open, normal
CRT -2 sec
R/R – 42 br/min
H/R- 140 b/min
BP- 97/63(75)
Lung- B/L equal air entry
Heart- S1+S2+ M
Abdomen- Distended, liver
3cm
Girth-29cm
CBG- 9 mmol/L
Temp- 98°F
Urine- 3.2 ml/kg/hr
Stool- 3 times
Static
S-72-82
D-46-54
M-55-63
• Decreased setup
FiO2 50%
PIP 12
• Weaning off Dopamin
• Decreased 10% to 7.5%
dextrose
• Send septic workup,
S. Electrolyte (Refused)
At 9PM wean from MV to
5L/M o2

52. Follow Up: 11.02.19 at 10AM
Subjective Objective Assessment Plan & Measures Taken
One episode of
SVT at 10.30PM
(Mx by Inj
Adenosine)
Pink in 3L O2
SPO2- 93%
Reflex activity- Moderate
Fontanelle- Open, normal
CRT -2 sec
Temp- 37°c
R/R – 52 br/min
H/R- 240 b/min
BP- 88/58(67)
Lung- B/L equal air entry
Heart- S1+S2+ M
Abdomen- Distended, liver 3cm
Girth-29cm
CBG-6.3
Urine- 3.2 ml/kg/hr
Stool- 3 times
Static
S-72-82
D-46-54
M-55-63
• Referred to NHF

53. Final diagnosis
Term (38+4 wks), low birth weight (2300gm), AGA,
IDM, Perinatal asphyxia (HIE-1), Congenital heart
disease (d-TGA, Large VSD, Large ASD, Large PDA),
Supraventricular tachycardia, multiple congenital
anomalies (right sided anotia, right sided lower
motor type facial palsy, bilateral club foot)

55. Our patient
S/O Tania
A baby with multiple congenital malformations
(unilateral anotia, facial nerve palsy, bilateral
club foot and congenital heart disease)
Presented with tachycardia
Heart failure
Sepsis
Excluded

56. ECG monitoring
Tachyarrhythmia
Most common cause of tachyarrhythmia in
newborn
Supraventricular tachycardia
(SVT)

57. Supraventricular Tachycardia
(SVT)

58. SVT
• An abnormal arrhythmia arising above or
within bundle of His.
• It includes essentially all forms of paroxysmal
or incessant tachycardia except ventricular
tachycardia.
• It is the most common abnormal tachycardia
in infancy and childhood.

59. TYPES
SITE RHYTHM
Sinus node Sinus tachycardia Always secondary; usually
non-cardiac cause e.g. sepsis,
fever, pain, hypovolaemia,
respiratory failure, anaemia,
fluid overload, ionotropes
Atrium Atrial flutter
Atrial fibrillation
Atrial tachycardia
Rare
Very rare
Uncommon
AV junction AV re-entry tachycardia
AV nodal re-entry
tachycardia
Commonest form in newborn
rare
Below AV node His bundle tachycardia
(junctional ectopic
tachycardia)
Associated with abnormal
hearts/cardiomyopathy;
Usually postoperative

60. RISK FACTORS
 Bimodal age distribution
• One peak at infancy
• Another peak is in between 8-12
years (Calabro ` MP, Cerrito M, Luzza F,
Oreto G (2008) Supraventricular tachycardia
in infants: Epidemiology and clinical
management. Curr Pharm Des 14(8):723–
728 )
 No significant gender differences
were present at younger ages
( Anand RG, Rosenthal GL, Van Hare GF,
Snyder CS (2009) Is the mechanism of
supraventricular tachycardia in pediatrics
influenced by age, gender or ethnicity?
Congenit Heart Dis 4(6):464–468)
Our patient:
 presented in
neonatal period
 Male baby

61. PRESENTATION
Antenatal:
• Fetal SVT (fetal tachycardia, less fetal
movement)
• Non- immune hydrops fetalis, if started early
in pregnancy

62. Post natal:
Asymptomatic
Tachycardia (HR: 180-300/min)
• Abrupt onset and cessation
• May occur during rest
• May be precipitated by acute infection
• Attacks may persist from seconds to hours
Heart failure
If tachycardia goes unrecognized for a long time
Shock
Our patient:
Tachycardia
with
Sudden onset &
spontaneous
remission;
Some episodes
occurred during
sleep; persisted
for minutes to
hours

63. Causes of SVT
• Any form of structural heart disease
• Myocardial tumors
• Myocarditis
• Electrolyte disturbances
• Indwelling right arterial lines
In our patient:
Congenital heart
defect
(murmur+)

64. ASSOCIATED CARDIAC
DEFECTS/SYNDROME
According to Tripathy A, Black GB (2014) Factors associated with
the occurrence and treatment of supraventricular tachycardia in a
pediatric congenital heart diseaes cohort. Pediatr cardiol 35:368-
373
• 6–7 % of children with CHD have SVT
• ASD secundum (14.3 %)
• VSD (6 %)
• Pulmonary stenosis (5.4 %)
• PDA (5.3 %)
• Pulmonary hypertension (2.4 %)

65. Continued….
• Two or more concomitant CHDs were present in
8.6 % of SVT patients.
• A smaller percentage (7.2 %) of patients were
diagnosed with severe/complex (cyanotic) CHDs,
i.e., tetralogy of Fallot, transposition of the great
arteries, double-outlet right ventricle (DORV),
common ventricle, truncus arteriosus,
atrioventricular canal/endocardial cushion defect
(AV/ ECD), Ebstein’s anomaly, hypoplastic left
heart syndrome (HLHS), or total anomalous
pulmonary venous return

66. Our patient had associated CHD
• TGA
• A Large inlet VSD (6.8 mm)
• A Large ostium secundum ASD (7.5 mm)
• A Large PDA
• Posterior deviation of conal septum producing
dynamic Left Ventricular Outflow Tract
Obstruction

67. This patient also had some other
congenital anomalies
• Unilateral anotia
• Facial nerve palsy
• Bilateral club foot
There was no
reported case of
SVT found to be
associated with
these congenital
malformations

68. DIAGNOSIS
• Clinical
• ECG
• Echocardiogram

69. ECG
Our Patient
SVT

70. Echocardiography
Congenital heart disease

72. PRINCIPLES OF MANAGEMENT
Conversion of rhythm:
Vagal maneuvers: Ice pack to the face until
conversion or max. 10 seconds
Adenosine, if vagal maneuver fails
Control of rate:
Propranolol (if there are no signs of heart failure)
Digoxin
Amiodarone

73. Management of emergency/complication:
Digoxin (if there are signs of heart failure or
propranolol has failed) after ensuring not
hypokalaemic and no WPW syndrome
Electrical cardioversion by synchronous DC
cardioversion: if the baby is in shock

74. Maintenance therapy:
Once sinus rhythm is restored, maintenance
therapy with whatever agent restored, is
usually given for 3- 6 months
Surgical correction
Artificial pacing
Radiofrequency catheter ablation

75. Our patient was treated with
Vagal maneuver:
• Ice pack to the face
Inj. Adenosine
Inj. Digoxin
Tab. Amiodarone

76. How Adenosine was given
 Dose: 0.1 mg/kg/dose
 Prerequisite for giving Inj.
Adenosine:
• A large fresh cannula as close to
heart as possible
• 3-way channel
 Procedure: rapid IV bolus
followed by saline flush with
continuous ECG recording

78. COMPLICATION
• Heart failure
• Shock
• Cardiac arrest
• Myocardial dysfunction
• Mitral regurgitation
• Dilated cardiomyopathy Our patient:
Cardiac arrest

79. PROGNOSIS
• Usually excellent, in absence of structural cardiac
disease or cardiomyopathy
• WPW syndrome has small risk of sudden cardiac
death
• One fifth will recur after treatment
• When SVT starts in first months of life, it resolves
in 80% cases within the first year; If SVT starts
later in life, spontaneous remission may occur in
only 15-20% cases
(Vignati G, Annoni G (2008) Characterization of supraventricular tachycardia in
infants: Clinical and instrumental diagnosis. Curr Pharm Des 14(8):729–735)
Our patient:
Prognosis is
guarded

80. FOLLOW UP
Clinical
Investigations:
• Digoxin level
• CBC
• Electrolytes
• ECG