approch to cyanotic neonate and infant

1. STEP WISE APPROACH TO
CCHD
Prof Dr Jai Prakash Soni
Division of pediatric cardiology
Dr S N Medical college
Jodhpur

3. Under standing the CHD’s just like like a magic.
It Require little practice to understand how to approach a baby with
CHD’S in stepwise manner. Require little practice

4. 7 days old baby born to 18 year old primi gavida female, admitted to pediatric cardiology ward
with complaints of -
Feeding difficulty – while feeding baby remove his mouth from breast for a while then again
starts feeding. This happen frequently.
Baby color turn to dusky or blue while crying, passing motion & feeding.
Increased rate if respiration with little chest retraction.
Baby is not having any cough and fever
No other obvious congenital anomalies.

5. DIAGNOSTIC APPROACH
STEP 1
7
3
2
6
5
4
History
taking

6. History taking ? First step

7. DIFFICULTY IN BREAST FEEDING
DIFFICULTY IN BREATHING
CYANOSIS
CYANOTIC SPELL
ABNORMAL SHAPE OF CHEST
ABNORMAL HEART BEAT
Step I History - when to have Suspicion of CHD’s ?

8. DIAGNOSTIC APPROACH
STEP 1
7
3
2
6
5
4
History
taking
Examination

9. step II
✓ Watch what happens to the baby while feeding
✓ Cyanosis – clinically as well as by pulse oxy meter
✓ Count respiratory rate - One minute
✓ Watch for chest retraction
✓ Examination of CVS - pulse, BP, Neck vein, pericardium, Auscultation
✓ Weight gain - Baby with complex CHD’s will not gain weight

10. •Cyanosis = Greek word “Kuaneos” meaning Dark blue color
• Blue discoloration of skin and mucous membranes is caused by reduced
• oxygen content. Christen Lundagaard (1923) quantified amount of deoxy Hb
required to produce bluish discolorarion of skin and mucosa.
• It depend upon oxygen content of blood and determined by :
Hgb level
oxygen saturation
blood flow
•cyanosis usually noted when Sat’s <86%
•cyanosis is more easily seen if it is associated with polycythemia
•cyanosis is more difficult to see in anemia

11. •All babies are blue at birth.
•By 10 minutes, baby should have pink because spo2 increases by 5 very
minute after birth as lungs start functioning, but hands and feet still blue
•Crying may cause cyanosis because of patent foramen ovale and pul.
hypertesion

12. 4 8 12 16 20 24 gm%
Severe anaemia 62.5
Anaemia 75
Normal 81
Normal 85
Polycythaemia 87.5
It depend upon oxygen content of blood and
determined by : Hgb level and % oxygen saturation
of Hb

13. Pulmonary Cardiac Others
Airway disease
Intrapulmonary
shunting
Intracardiac
shunting
Cyanosis

14. Central cyanosis
•noted in the trunk, tongue, mucous membranes
•due to reduced oxygen saturation
Peripheral cyanosis
•noted in the hands and feet, around mouth due to reduced local blood flow
The cyanosis usually correspond to oxygen saturation of 70-80%.
Therefore mild desaturation may clinically be missed.

15. Right => Left shunt
Pulmonary to System Flow Ratio Qp: Qs
SpO2 =
V.Caval SpO2 x Qs – Pv SpO2 x Qp
________________________
Qp + Qs
=
60 x3 + 96 x 1
____________________
3+1
= 87%

16. Mechanisms of Cardiac Cyanosis
Right to left
shunt
Mixing Recirculation
TOF physiology Single ventricle TGA
Blood is returning to the heart from the
body is recirculated directly back to the
body without going to the lungs to be
oxygenated.

17. Differential cyanosis
1. pink upper,
blue lower
CoA, IAA, Pulm Htn
Blue lower
Pink Upper Pink Upper

18. blue upper and pink lower limb
d-TGA with pulm Htn
*indicates serious underlying cardiac
Deep Blue upper
Less blue

19. THE A,B,C, OF CYANOSIS
AIR WAY BREATHING CIRCULATION
Choanal atresia pneumonia Polycythaemia, Anaemia,
methemoglobinemia
micrognathia Congenital Dia hernia Cyanotic C H D
Decrease Pul flow – TOF like
Increased Pul flow – without PS
Severe Pul venous congestion - TAPVC
Normal pul arterial pressure – Pul aretrio-
venous malformation
Pierre Robin syn Pul sequestration PPHN
laryngomalacia Congenital lobar emphysema
Tracheal stenosis Pul hypoplasia
Cystic hygroma
Oyher necl tumors

20. Approach
Confirm
cyanosis
By SpO2
Pre and post
ductal SpO2
D/d differential
cyanosis
Clinical
assessment A B G

21. Pulse Oximetry
•Easy to use, harmless when done correctly
•Accuracy of 2% in the range of 70 to 100%
•Consider for CHD’s when Sat <94% at 24 hours of age
•Should be obtained prior to discharge from nursery
= Policy for newborn’s - Measure sat in foot
If <95%, gets evaluation

22. Approach
Confirm
cyanosis
By Pulse
oximetery
SpO2
Pre and post
ductal SpO2
D/d
differential
cyanosis
Clinical
assessment A B G

24. Approach
Clinical
assessment
A B G

25. NADA’S CRITERIA
MAJOR
• systolic murmur Gr III or more
• diastolic murmur
• cyanosis
• CHF
MINOR
systolic murmur less than Gr
III
• abnormal S2
• abnormal ECG
• abnormal X-ray
• abnormal BP
One major & two minor criteria
Two major & three minor criteria Nada’s - TOF physiology

26. CLINICAL ASSESSMENT
Tachypnoea with RDS
Crepitation
H/O meconium aspiration
Cyanosis Mild and uniform
Responsive to Oxygen therapy
Improve with crying
NONCARDIAC
Distress absent except with PVH
Cyanosis Uniform or differential
No or minimal response to oxygen
therapy
Worsen with cry
Develop usually after 24 hours of birth
Baby is usually Pale with shock
Poor pulse
Tachypnoea But less RDS

28. Repeat
radial
artery
ABG
Give 100%
oxygen by
hood for 10-
15 min
Radial artery
A B G
Pulse
oximetery
SpO2 <85% at
room air
Hyperoxia test

29. Low Ph
Elevated PCO2
PaO2 > 150 mm Hg
Respiratory acidosis
Passed Hyperoxia test
• NONCARDIAC
Low Ph
Low or normal PCO2
PaO2 < 100 mm Hg
PaO2 increase by < 10-
30mmHg
Metabolic acidosis
Failed Hyperoxia test
• NONCARDIAC
How to Differentiate CCHD from PPHN
Perform Hyperoxia test after endotracheal intubation or Look for response to NO inhalation

30. Hyperoxia test
Administration of 100% O2 for 15 minutes
By - Mask or ETT
Measure arterial PO2
PO2 <150 PO2 >250PO2 150-250
Cardiac PulmonaryGray zone
Increase in SpO2 post ductal by > 25 mm Hg

31. DANGERS: Pulmonary over circulation
Closing the PDA
Death
With the availability of Neonatal Echo machine in ICU yperoxia test is rarely performed

32. Liver span is normal
Liver is pushed down because of Respiratory distress
It suggest – No evidence of CHF

33. Pulse : good volume, regular
Blood pressure Normal
Neck nein Normal
Precordium : normal shape
apex beat normal, in 3rd ICS
No thrill and para-sternal heave
S1 normal
S2 single
Ejection systolic or systolic murmur in pulmonary area

34. Cyanotic Heart Disease
Tetralogy of
Fallot
Transposition
Of Great Arteries
Truncus
Arteriosus
Tricuspid
Atresia
Total Anomalous
Pulmonary venous Return

35. DIAGNOSTIC APPROACH
STEP 1
7
3
2
6
5
4
History
taking
Examination
X ray chest
AP view

36. For detailed understanding of the X ray chest one must know Aorta position,
size and shape
STEP III

37. For detailed understanding of the X ray chest one must
know Aorta position, size and shape
X – ray chest

38. For detailed understanding of the X ray chest one must
know Range of norm’s for pulmonary vasculature marking.

39. For detailed understanding of the X ray chest one must
know Cardiac size and shape
Step III

43. The X ray chest reveals - normal contours
X – ray chest

44. - STENOSIS
Our patient revealed Absent pulmonary conus
Decreased pulmonary vasculature
Oligaemia of the pulmonary vasculature represents decreased blood flow through the
pulmonary circulation, Tetralogy physiology

45. 1、Upturned apex - RV hypertrophy
2、The absence of main PA segment gives it the
shape described as (Cor-en Sabot)
3、Pul. Fields are oligemic.
(decrease pulmonary vasculature, clear lung
fields)

46. CXR : EGG ON SIDE
NARROW MEDIASTINUM

47. TAPVR WITH OBSTRUCTION

48. TAPVR SUPRACARDIAC TYPE, NO OBSTRUCTION
‘Snowman’
or
‘Figure of 8’
Cardiomegaly (+)
Pulmonary congestion

49. CHEST X-RAY
IN EBSTEIN’S ANOMALY
‘Squared shape’
‘Balloon shape’
Cardimegaly
→ or ↓ PVM

50. ↓ PBF – TOF physiology
•Tetralogy of Fallot
•Tricuspid atresia
•Ebstein’s anomaly
• “Blue blood bypasses the lungs”
• Degree of cyanosis varies
• Classification is based on pulmonary blood flow (PBF)

51. blue newborn +
no airway or breathing problem +
quiet heart =
decreased PBF lesion (TOF)
TOF physiology

52. DIAGNOSTIC APPROACH
STEP 1
7
3
2
6
5
4
History
taking
Examination
X ray chest
AP view
E C G

53. Step 4

54. AT GLANCE ONE MAY FEEL ALL E.C.G. LOOK ALIKE.
LOOK CLOSELY AND ONE WILL SEE THE
DIFFERENCES!

55. • ECG is a simple .and useful bedside investigation which helps in the diagnosis
and management of patients with CHDs.
• In specific setting ECG can give specific diagnostic informations.
E. C. G.

56. E. C. G.
• ECG reflects the underlying structural and hemodynamic changes that occur in
the disease state. Hence a number of conditions with similar profiles may have
similar ECG patterns.

57. HOW TO DIAGNOSE CHDS
BY ECG ?

58. RAD WITH RVH - TOF physiology
Cyanotic CHD

59. Abnormal quadrant QRS axis - Double outlet right ventricle with PS
Cyanotic CHD

60. Left axis deviation with left ventricular hypertrophy - tricuspid Atresia with PS atresia
Cyanotic CHD

61. DIAGNOSTIC APPROACH
STEP 1
7
3
2
6
5
4
History
taking
Examination
X ray chest
ECG
ECHO

62. Identify the large overriding aorta
RV hpertrophy and outflow obstruction
Shunt between ventricles

63. DIAGNOSTIC APPROACH
STEP 1
7
3
2
6
5
4
History
taking
Examination
X ray chest
ECG
ECHO
CT ,Angio

64. Cardiac catheterization