Basics of pediatrics cardiology

1. Paediatric Cardiology
Dr Ratna Merugumalla
Consultant in Emergency Medicine
Peterborough City Hospital

2. Cardiovascular presentations
• Collapse
• The blue baby
• Syncope
• Palpitations
• Chest pain

3. The normal Heart Rate

4. THE ECG

5. ECG in a 2 year old

6. ECGs in children
• Heart rate >100 beats/min
• Rightward QRS axis > +90°
• T wave inversions in V1-3 (“juvenile T-wave pattern”)
• Dominant R wave in V1
• RSR’ pattern in V1
• Marked sinus arrhythmia
• Short PR interval (< 120ms) and QRS duration
(<80ms)
• Slightly peaked P waves
• Q waves in the inferior and left precordial leads.

7. The normal ECG
• QRS variable with age - Newborn 50-80ms, at 16
years 75-115ms
• cQTC under 6/12: 490ms, 440ms otherwise
• Notched t waves; may be normal in V2&3
• Transient Wenckebach during sleep

8. The normal ECG
• Parameters vary through age
• Right ventricular dominance owing to high
pulmonary pressures, normalise at ~6/12
• T waves; usually upright in most leads for first 7/7,
then downwards in most leads until adolescence.
•Upright t waves in childhood may reflect RVH.

9. CHEST PAIN

10. Chest pain
Common but usually benign presentation
4436 presentations age < 19 yrs over 3 1/2 year period
in a tertiary PED in USA
•0.6% deemed cardiac
•37% arrhythmia
•29% pericardial
•17% myocarditis
•13% AMI
•4% PE
American Journal of Emergency Medicine Volume 29, Issue 6 , Pages 632-638, July 2011)

11. Non cardiac chest pain
• 56% musculoskeletal
• 12% asthma/ wheeze
• 8% infection
• 6% GI – gastritis and GORD
• 4% sickle cell disease

12. Texidor’s twinge
• Precordial catch syndrome:
• acute, non-radiating left sided chest pain in an
adolescent
• occurs suddenly, exacerbated during inspiration and
resolves in a few minutes

13. SYNCOPE

14. Syncope
• 15-20% all children will have an episode
Neurally mediated
Vasovagal
Reflex anoxic seizures
Orthostatic
Cardiac
Structural
Cardiomyopathy
Arrythmias
Non CVS
Psychogenic
Factitious
Neurological non syncope e.g. Seizure

15. Syncope Red Flags
• History of cardiac disease
• Family history of SCD
• Recurrent episodes
• Exertional
• Prolonged LoC
• Associated chest pain / palpitations
• Medications that can alter cardiac conduction

16. Sudden Cardiac Death
• Myocarditis
• HOCM
• Cyanotic / Acyanotic congenital heart disease
• Valvular heart disease
• Complete heart block
• WPW, long QT syndrome
• Marfan’s syndrome
• CAD
• Anomalous coronary arteries

17. PALPITATIONS

18. Cardiac arrhythmias in children
• Likely to be the result rather than the cause of
acute illness
• Often preceded by hypoxia, acidosis and / or
hypotension
• Primary cardiac arrhythmias are uncommon

19. Heart rate
Age Bradycardia Tachycardia
< 1 y < 80 min-1 > 180 min-1
> 1 y < 60 min-1 > 160 min-1

20. Bradycardia

21. Bradycardia - causes
• Bradyarrythmias rare in structurally normal
hearts
• Usually pre-terminal following hypoxia and
ischaemia
• Vagal stimulation
• Raised ICP
• Poisoning with digoxin/ beta-blockers
• Congenital CHB seen in infants of mothers
with anti ro and la antibodies

22. Bradycardia Treatment
• Oxygenation
• Adrenaline – 10mcg/kg
• Atropine - Consider when vagal stimulation e.g.
airway instrumentation – 20mcg/kg
• Pacing (rarely required)

23. Tachycardia
rdia
Narrow QRS complex Broad QRS complex
ST VT or SVT
SVT Treat as VT

24. Sinus Tachycardia

25. ST – Treat the cause
• Physiological response:
Crying
Exercise
Anxiety/fear
Pain
• Compensatory
mechanism for:
Respiratory failure
Hypovolaemia
Sepsis
Anaemia

26. Supraventricular tachycardia

27. Supraventricular Tachycardia
• Most common primary cardiac arrhythmia in
children
• Paroxysmal, regular, narrow QRS complexes
• Caused by re-entry mechanism through an accessory
pathway or AV conduction system
• HR > 220 bpm in infants or > 180 bpm in children

28. ST or SVT

29. SVT - Management
• Valsalva manoeuvre
• IV Adenosine
100 mcg/kg
200 mcg/kg
maximum 1st dose 6mg, 2nd dose 12mg
• Amiodarone in refractory SVT
• DC cardioversion – for decompensated children

30. Ventricular Tachycardia

31. Ventricular Tachycardia Causes
• Congenital HD & surgery
• Poisoning (TCAs, Quinidine)
• Brugada syndrome / Long QT interval
• Renal Disease / Hyperkalaemia

32. VT - management

33. Long QT - congenital
Normal QTc < 400ms, > 460 ms abnormal
Easiest to reproducibly measure in II & V5
Channelopathy
Genetic mutations identifies in 90% familial cases
Subtypes 1-14
Risk of torsades and VF
May present with syncope (VT), risk greatest with QT > 500ms
Ask about family history of syncope, sudden death and epilepsy
European registry 1993; 8% 5 yr mortality
Treatment with BB

34. Atrial Flutter

35. Atrial Fibrillation

36. Atrial Flutter and Fibrillation
• Rare
• Underlying CHD, status post-open heart surgery
• Cardioversion in decompensated
• In haemodynamically stable children,
amiodarone or elective cardioversion

37. Pre-excitation syndromes
• Commonest WPW
• Ventricular Pre-excitation in SR,
short PR and delta wave
• Commonest arrhythmia is
orthodromic AV re-entry
tachycardia
• Antidromic less common

38. COLLAPSE

39. The collapsed infant
• Wide differential
• Always cover for sepsis
Congenital heart disease
• May present as lethargy, poor feeding, "not right",
cyanosis to complete cardiovascular collapse

40. Congenital heart disease
Foetal PVR>SVR; blood
bypasses lungs through
ductus arteriosus and
foramen ovale
DA usually closes 24-36hrs
post birth – may be much
longer
FO closes when left atrium
volume increases

41. Congenital heart disease
• Failure of normal development or
• Persistence of foetal circulation
• 7-9% live births
• Acyanotic or Cyanotic heart disease

42. Acyanotic Heart Disease
VSD (25%)
ASD
PDA
PV stenosis
CoA
AS
Hypoplastic left heart
HOCM
Dextrocardia
Cyanotic Heart Disease
Tetralogy
Transposition
Tricuspid atresia
TAPVD

43. Congenital heart disease
Common presentations:
• Cyanosis
• Heart failure
• Heart murmur

44. Cyanosis
• Cyanosis – ~4-5g/dL of deoxygenated blood
• Cardiac cause – ‘comfortably blue’, worse with crying,
minimal improvement with O2
• Primary pulmonary disease; no R-L sats diff
• Primary cardiac; 5-10 % R-L sats diff
• Sepsis; no diff

45. Failure
• Sweating
• Poor feeding
• Hepatomegaly
• SOB
• Creps
• Tachycardia

46. Innocent murmurs
• Common in children
• Never diastolic
• Soft, Short, midsystolic,
low intensity
• Localised
• Often vibratory or
musical
• Increase with output,
(fever)
• No thrill/ heave or
radiation
• Asymptomatic
• May resolve in few
months
• Commonest at lower left
sternal edge
• Venous hum

47. Evaluation
• Pre-natal (USS)
• Family history
• Birth history (birth state, trauma, risk infection)
• Is this cardiac? (murmur + cyanosis + absent pulses)
Pre- and post ductal oxygen saturations
ABG
4 limb BP (>10mmHg difference suggests coarctation)
ECG
CXR
Echo

48. ED management
• ABC – sats 75-85%
• Correct metabolic acidosis and shock with fluid and
bicarb
• 2 lines/ UVC if possible
• Antibiotics anyway!
• Gentle handling
• Keep warm
• Prostoglandin – ductal patency
• Inotropes
• Ventilate – in air if possible, PEEP 4-6cmH2O

49. Prostaglandin
• PGE2 infusion (dinoprostone)
• In duct dependent lesion
• Hyperoxia test suggestive, femoral pulses
diminished, metabolic acidosis persistent after
volume and inotropes
• Ensure antibiotics given!
• Beware of apnoea. May cause hypotension,
jitteriness and jerks
• No absolute contraindications

50. Prostaglandin
Possible Adverse Effects
• Apnoea
• Hypotension
• Hyperthermia (transient)
• Tachycardia
• Bradycardia
• Seizures
• Diarrhoea
• Skin flush
Administration
• Intravenous infusion
• Consider intubation
• Dose
• 0.01 – 0.1 mcg/kg/min

51. Hyperoxia test
• 10 mins on 100% O2
PaO2 <20 KPa, cyanotic heart disease likely
Pao2 <27KPa but >20, equivocal
PaO2 >27 KPa, respiratory disease
Caution, severe pulmonary disease
Care duct dependent lesions

52. ACQUIRED HEART DISEASE

53. • 18 month old girl
6 days of high fever
Miserable
Swollen hands and feet with pain and redness
Immediate action?
Investigations?
Working diagnosis?
Further management?

54. Diagnosis?

55. Kawasaki Disease
• Commonest cause of acquired heart disease in
children in the UK
• Febrile, exanthematous, multi-system vasculitis in
children <5y
• Coronary arteritis with aneurysm formation in 20-
30% in untreated patients

56. Diagnosing Kawasaki disease
• Fever of 5 days plus any 4 physical exam findings:
Rash
Cervical lymphadenopathy (at least 1.5 cm in
diameter)
Bilateral conjunctival injection
Oral mucosal changes
Peripheral extremity changes

57. Kawasaki disease
• Admission as in-patient
• ECG, ECHO
• IV immunoglobulins
• Aspirin high dose
• Paediatric/Cardiology F/U (repeat ECHO at 6
weeks)

58. Any Questions?