Pediatric Cardiology Emergencies

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Pediatric Cardiology Emergencies

  1. 1. Pediatric Cardiology Emergencies Jeffrey D. Schuster, M.D. Texas Tech University-El Paso
  2. 2. Newborn Problems <ul><li>Cyanosis </li></ul><ul><li>Low Cardiac Output </li></ul>
  3. 3. Newborn Problems - Cyanosis <ul><li>Cardiac Cyanosis </li></ul><ul><ul><li>Does not respond to oxygen </li></ul></ul><ul><ul><li>Does not respond to ventilation </li></ul></ul><ul><ul><li>Usually no respiratory distress </li></ul></ul>
  4. 4. Newborn Problems - Cyanosis <ul><li>Evaluation </li></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>Arterial blood gasses </li></ul></ul><ul><ul><li>Echocardiogram </li></ul></ul>
  5. 5. Newborn Problems - Cyanosis <ul><li>Right sided obstructive lesions </li></ul><ul><ul><li>Pulmonary atresia </li></ul></ul><ul><ul><li>Tricuspid atresia </li></ul></ul><ul><ul><li>Tetralogy of Fallot </li></ul></ul>
  6. 6. Tricuspid Atresia
  7. 7. Newborn Problems - Cyanosis <ul><li>Abnormal Circulations </li></ul><ul><ul><li>Transposition of the great arteries </li></ul></ul><ul><ul><li>Total anomalous pulmonary venous return </li></ul></ul>
  8. 8. Transposition of the Great Arteries
  9. 9. TAPVR
  10. 10. Newborn Problems - Cyanosis <ul><li>Treatment </li></ul><ul><ul><li>PGE1 </li></ul></ul><ul><ul><li>Restoration of acid/base balance </li></ul></ul><ul><ul><li>Surgical Evaluation </li></ul></ul>
  11. 11. Newborn Problems - Cyanosis <ul><li>PGE1 </li></ul><ul><ul><li>0.1 mcg/kg/min </li></ul></ul><ul><ul><li>Any intravenous site </li></ul></ul><ul><ul><ul><li>UAC </li></ul></ul></ul><ul><ul><ul><li>UVC </li></ul></ul></ul><ul><ul><ul><li>Peripheral </li></ul></ul></ul><ul><ul><li>Interosseous </li></ul></ul>
  12. 12. Newborn Problems Low Cardiac Output <ul><ul><li>Shock </li></ul></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Circulatory shutdown </li></ul></ul>
  13. 13. Newborn Problems Low Cardiac Output <ul><li>Evaluation </li></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>Arterial blood gasses </li></ul></ul><ul><ul><li>Echocardiogram </li></ul></ul><ul><ul><li>Electrocardiogram </li></ul></ul>
  14. 14. Newborn Problems Low Cardiac Output <ul><li>Left Sided Obstructive lesions </li></ul><ul><ul><li>Hypoplastic left heart </li></ul></ul><ul><ul><li>Critical aortic stenosis </li></ul></ul><ul><ul><li>Critical coarctation of the aorta </li></ul></ul>
  15. 15. Hypoplastic Left Heart
  16. 16. Severe Coarctation
  17. 17. Newborn Problems Low Cardiac Output <ul><li>Muscle diseases </li></ul><ul><ul><li>Myocarditis </li></ul></ul><ul><ul><li>Cardiomyopathies </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Asphyxia </li></ul></ul>
  18. 18. Newborn Problems Low Cardiac Output <ul><li>Heart Rate Problems </li></ul><ul><ul><li>Supraventricular tachycardias </li></ul></ul><ul><ul><li>Complete heart block </li></ul></ul>
  19. 19. Newborn Problems Low Cardiac Output <ul><li>Supraventricular Tachycardia </li></ul><ul><ul><li>Narrow Complex </li></ul></ul><ul><ul><li>Heart Rate > 220 bpm </li></ul></ul><ul><ul><li>Usually > 240 bpm </li></ul></ul>
  20. 20. Narrow Complex Tachycardia
  21. 21. Newborn Problems Low Cardiac Output <ul><li>Complete Heart Block </li></ul><ul><ul><li>Heart rate below 60 bpm </li></ul></ul><ul><ul><li>No relationship between P waves and QRS’s </li></ul></ul>
  22. 22. Complete Heart Block
  23. 23. Newborn Problems <ul><li>Treatment </li></ul><ul><ul><li>Left heart obstructive lesions </li></ul></ul><ul><ul><li>Muscle diseases </li></ul></ul><ul><ul><li>Heart rate problems </li></ul></ul><ul><ul><li>PGE1 </li></ul></ul><ul><ul><li>Inotropic support and afterload reduction </li></ul></ul><ul><ul><li>Slow down or speed up </li></ul></ul>
  24. 24. Infant and Childhood Problems <ul><li>Hypercyanotic spells </li></ul><ul><li>Congestive heart failure </li></ul><ul><li>Arrhythmias </li></ul>
  25. 25. Infant and Childhood Problems <ul><li>Hypercyanotic Spells </li></ul><ul><ul><li>Tetralogy of Fallot </li></ul></ul><ul><ul><li>Pulmonary Atresia </li></ul></ul>
  26. 26. Tetralogy of Fallot
  27. 27. Infant and Childhood Problems <ul><li>Hypercyanotic Spells </li></ul><ul><ul><li>Sudden decrease in pulmonary blood flow, usually in the morning </li></ul></ul><ul><ul><li>Provocation </li></ul></ul>
  28. 28. Hypercyanotic Spells <ul><li>Treatment </li></ul><ul><ul><li>Calming </li></ul></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Morphine </li></ul></ul><ul><ul><li>Beta Blocker </li></ul></ul><ul><ul><li>Phenylepherine </li></ul></ul>
  29. 29. Hypercyanotic Spells <ul><li>Phenylepherine </li></ul><ul><ul><li>Increase systemic vascular resistance which leads to less R - > L shunting and improved saturation </li></ul></ul>
  30. 30. Hypercyanotic Spells <ul><li>Long Term Treatment with Propranolol </li></ul><ul><ul><li>Indication for surgery, either palliative shunt or total repair </li></ul></ul>
  31. 31. Congestive Heart Failure <ul><li>Differing etiology at different ages </li></ul>
  32. 32. Congestive Heart Failure <ul><li>Presentation in Infancy </li></ul><ul><ul><li>Structural Diseases: Left Heart Obstructions </li></ul></ul><ul><ul><ul><li>First days: Hypoplastic Left Heart Syndrome </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Critical aortic stenosis </li></ul></ul></ul></ul></ul><ul><ul><ul><li>First month: Coarctation of the aorta </li></ul></ul></ul><ul><ul><ul><li>First 2 months: Left-to-right Shunts </li></ul></ul></ul><ul><ul><ul><ul><li>VSD, PDA, Truncus Arteriosus </li></ul></ul></ul></ul>
  33. 33. Congestive Heart Failure <ul><li>Presentation after infancy </li></ul><ul><ul><li>Progression of structural heart disease </li></ul></ul><ul><ul><li>Arrhythmias </li></ul></ul><ul><ul><li>Infectious diseases </li></ul></ul><ul><ul><li>Later onset myopathies </li></ul></ul><ul><ul><li>Toxins: </li></ul></ul><ul><ul><ul><li>Anthracyclines </li></ul></ul></ul><ul><ul><ul><li>Diphtheria </li></ul></ul></ul>
  34. 34. Congestive Heart Failure Pre-load Afterload Contractility Heart Rate Determinants of Cardiac Output
  35. 35. Congestive Heart Failure <ul><li>Preload reduction </li></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Fluid Restriction </li></ul></ul><ul><ul><li>High caloric density </li></ul></ul>
  36. 36. Congestive Heart Failure <ul><li>Afterload reduction </li></ul><ul><ul><li>ACE inhibitors </li></ul></ul><ul><ul><li>Nitroprusside </li></ul></ul>
  37. 37. Congestive Heart Failure <ul><li>Heart Rate modification </li></ul><ul><ul><li>Beta Blockers </li></ul></ul><ul><ul><ul><li>Also treats diastolic dysfunction </li></ul></ul></ul>
  38. 38. Contractility <ul><li>Acute Treatment </li></ul><ul><ul><li>Beta Agonists </li></ul></ul><ul><ul><ul><li>Dobutamine </li></ul></ul></ul><ul><ul><ul><ul><li>Afterload reduction also </li></ul></ul></ul></ul><ul><ul><ul><li>Epinepherine </li></ul></ul></ul><ul><ul><li>Dopamine </li></ul></ul><ul><ul><li>Increased myocardial demands </li></ul></ul><ul><ul><li>Milrinone </li></ul></ul>
  39. 39. Contractility <ul><li>Milrinone increases contractility and reduces afterload without increasing myocardial oxygen demand </li></ul>
  40. 40. Contractility <ul><li>Chronic Treatment </li></ul><ul><ul><li>Digoxin </li></ul></ul><ul><ul><li>New Treatments </li></ul></ul>
  41. 41. Arrhythmias <ul><li>Narrow Complex Tachycardias </li></ul>
  42. 42. Arrhythmias <ul><li>Supraventricular Tachycardia </li></ul>
  43. 43. Arrhythmias <ul><li>Re-entrant Tachycardias </li></ul><ul><ul><li>AV node re-entry </li></ul></ul><ul><ul><li>Wolfe-Parkinson-White </li></ul></ul>
  44. 44. Wolfe-Parkinson White
  45. 45. Arrhythmias <ul><li>Treatment </li></ul><ul><ul><li>Pre-hospitalization </li></ul></ul><ul><ul><ul><li>Diving reflex </li></ul></ul></ul><ul><ul><ul><ul><li>Ice Bag to the face </li></ul></ul></ul></ul><ul><ul><ul><li>Valsalva </li></ul></ul></ul><ul><ul><ul><li>Carotid Massage </li></ul></ul></ul>
  46. 46. Arrhythmias <ul><li>Hospitalization </li></ul><ul><ul><li>Adenosine </li></ul></ul><ul><ul><ul><li>Diagnostic and therapeutic </li></ul></ul></ul>
  47. 47. Arrhythmias <ul><li>Adenosine </li></ul><ul><ul><li>100 mcg/kg IV rapid push </li></ul></ul><ul><ul><li>Repeat every 5 minutes with increasing doses </li></ul></ul>
  48. 48. Arrhythmias <ul><li>Shock requires Shock </li></ul><ul><ul><li>Synchronized cardioversion </li></ul></ul><ul><ul><li>1 joule/kg </li></ul></ul>
  49. 49. Arrhythmias <ul><li>If adenosine fails: </li></ul><ul><ul><li>Calcium Channel blockers </li></ul></ul><ul><ul><ul><li>Not in infants! </li></ul></ul></ul>
  50. 50. Arrhythmias <ul><li>Digoxin Loading </li></ul><ul><li>Procainamide loading </li></ul><ul><li>Repeat adenosine </li></ul>
  51. 51. Ventricular Tachycardia Image 3
  52. 52. Wide Complex Tachycardias <ul><li>Treat all as if Ventricular Tachycardia </li></ul>
  53. 53. Wide Complex Tachycardias <ul><li>Unstable rhythm requires Cardioversion 2 joules/kg </li></ul>
  54. 54. Ventricular Fibrillation Image 4
  55. 55. Wide Complex Tachycardias <ul><li>Medical therapy </li></ul><ul><ul><li>Lidocaine </li></ul></ul><ul><ul><li>Amiodarone </li></ul></ul>
  56. 56. Wide Complex Tachycardias <ul><li>Surgical Therapy </li></ul><ul><ul><li>Automatic Implantable Cardioverter-Defibrillator </li></ul></ul>

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