This document summarizes the diagnosis and management of common cardiac emergencies in children. It presents several case studies and uses them to discuss key considerations like differentiating various causes of cyanosis, shock, or arrhythmias in infants and children. For each case, it analyzes presenting signs and test results to identify the underlying condition. It then outlines the initial emergency management principles, focusing on stabilization, organ support, and addressing specific issues like restoring blood flow or minimizing pulmonary pressures. The document emphasizes the importance of early diagnosis and intervention for high mortality cardiac conditions in children.

1. CARDIACEMERGENCIESINCHILDREN–
DIAGNOSIS&MANAGEMENT
Dr Manish Chokhandre
Consultant Pediatric Cardiologist
Swasthyam Superspeciality Hospital, Nagpur

2. Introduction
• Cardiac emergencies-most stressful emergencies in ER
• Infancy and early childhood
• Acquired or congenital heart disease
• Often complex
• Coexisting pathology-heart lung interaction
• High mortality
• Early diagnosis and management –Key

3. Case 1
• FTAGA male neonate born to a 35yo G3P3. Home birth. Limited PNC. Normal
prenatal labs per report.
• APGARS 4 and 7. Remained cyanotic
• Vitals: HR 185, RR 50, BP 64/30
• Sats: 62% on 100% O2
• Exam:
• Mild tachypnea w/o increased WOB. Lungs clear bilaterally.
• Tachycardia, no murmurs.
• Pulses 2+ equal. Extremities warm. Cap refill 3 seconds.

4. Case 1 –additional data
• Pre- and post-ductal Oxygen saturations on 100% NRB: Right arm: 64%
• Right leg: 82%
• Arterial blood gas (right radial artery, FiO2 = 1.0):
7.45/32/26
• Four-extremity blood pressures equal
• ECG normal for age

5. CXR

6. DD-Cyanosis, tachypnoe
• Neonatal Sepsis
• Neonatal RDS
• Persistent Pulmonary Hypertension of Newborn (PPHN)
• Cyanotic Congenital Heart Disease

7. DD-cyanosis,tachypnoea
• Cyanotic Congenital Heart Disease
• Reverse differential saturations– D-TGA
• Right arm: 64%
• Right leg: 82%
• Hypoxia with respiratory alkalosis
• Arterial blood gas (right radial artery, FiO2 = 1.0): 7.45/32/26

8. •Reverse Differential Saturations in a
neonate indicates:
•TGA + High PVR
•TGA + Ao Arch obstruction
•TGA/PPHN results in severe cyanosis
•May progress to shock
•May require ECMO support pre-op

9. Cyanotic CHD with increased pulmonary
blood flow- TGA
• Assist "Mixing”
• Prostaglandin E1
• Atrial Septostomy – usually not urgent
• Manage pulmonary edema
• Diuresis
• Optimize lung recruitment and gas exchange
• Avoid excess FiO2 and hyperventilation
• Optimize systemic output
• Optimize preload/inotropic support
• Optimize hemoglobin

10. Case-2
• 10 day old infant brought to ED for poor feeding and lethargy.
• FT/AGA infant, uncomplicated pregnancy, home on DOL #2
• Vital signs: HR 180, RR 70, BP 95/70(RUE), SaO2 92% (RA).
• Exam: Tachypnea with retractions, fine crackles bilaterally. Mottled, poor
perfusion, Cap refill 5-6 seconds.
• He undergoes a septic workup.
• What data will be most helpful?
• Differential Diagnosis?

11. Labs
WBC 21, Hct 41
AST 360, ALT 350
BUN 65, Cr 1.2
Pre/Post-ductal Sats (100% NRB)
RUE 99%
LLE 99%
ABG (Rt radial artery, FiO2 1.0)
6.92/24/170/Lactate 9.5
Case 2 Additional Data

12. DD-Shock, metabolic acidosis
• Sepsis
• Sepsis
• Sepsis
• Inborn Error of metabolism
• Congenital Heart Disease
• Ductal-dependent systemic blood flow
• Critical Coarctation of the aorta
• Interrupted aortic arch
• Critical Aortic Stenosis
• Hypoplastic Left Heart Syndrome

13. Differential Diagnosis – Shock/Metabolic acidosis Less than 2 months old
• Congenital Heart Disease
• Ductal-dependent systemic blood flow
• Critical Coarctation of the aorta
• Interrupted aortic arch
• Critical Aortic Stenosis
• Hypoplastic Left Heart Syndrome
• Sepsis
• Inborn Error of metabolism

14. • Hallmark presentation: acute shock with severe
progressive metabolic acidosis
• End-organ injury common
• Fetal diagnosis has decreased incidence
• 4-Ext BP discrepancy – essential part of workup for
HTN in children
• Cannot rule out CoA in setting of open PDA on
ECHO
Left sided obstructive lesions

15. Duct dependent systemic circulation:
Initial management
• Early diagnosis / rapid intervention
• Restore systemic blood flow
• Prostaglandin E1
• Inotropic support
• Afterload reduction contraindicated - reduce coronary perfusion
• Mechanical ventilation/respiratory support
• Eliminate work of breathing
• Lung recruitment
• After restoration of systemic blood flow
• Diuresis
• If L-R shunt, manipulate SVR/PVR to limit pulmonary flow

16. Duct dependent lesion
Shock, acidosis Central caynosis
History/Exam
oligemia Plethora
Plethora
Systemic pulmonary
• Coarctation
• HLHS
• Critical AS
• Arch interruption
CXR
• TOF
• Tri Atresia
• PA/IVS
• DORV/PA/PS
• Critical PS
• Ebstein’s PA
• TGA
• Truncus
• TAPVC

19. Case-3
• 4mo infant k/c/o TOF brought to the ED with 3 days of vomiting and
diarrhea.
• Normothermic HR 140, BP 70/40, Sats 90% on 2L O2. Initial Exam:.
• Fussy, but consolable
• Mild tachypnea, clear lung fields
• 3/6 harsh systolic murmur at LSB.
• Abdomen mildly distended, soft, no HSM.
• Pulses 2 centrally, extremities cool, Cap refill 3 seconds

20. Case-3
• Diagnosis: dehydration from viral GE.
• 20mL/kg bolus and labs are ordered. The nurse goes in to place IV – a few
minutes later, calls urgently for help
• Patient is crying, inconsolable and severely cyanotic. Saturations
progressively fall, which is associated with progressive tachypnea and
tachycardia.

21. Diagnosis
• TET spell

22. • Presentation depends on age
• Younger kids - poor feeding, intermittent cyanosis. May “pass out” or sleep
for prolonged periods after crying
• Infants and older kids - often squat during episodes.
• Physiology— Hyperdynamic contraction of the infundibular septum (RVOT)
which causes worsening R to L shunt.
• Causes of Tet Spell—Dehydration, acidosis, stress, infection, exercise,
b-agonist therapy

23. Management
• Minimize RVOTO
• Knees to chest (especially while awaiting IV or if no IV)
• Sedation
• Preload
• b-blockade/avoid catecholamines
• Increase SVR
• Phenylephrine, Vasopressin, Ketamine
• Minimize PVR
• O2, Sedation, Alkalinize - pH 7.50 - 7.55
• lung recruitment to FRC
• ECMO – if all else fails

24. Case 4
• A 3year/6Kg
• fever, cough and breathing difficulty-4 days
• recurrent respiratory infections and poor weight gain
• O/e, cachectic, no dysmorphic features.
• respiratory distress, bounding pulses, bilateral crepitations
• laterally displaced apical impulse, grade 2/6 systolic murmur in the left infra-clavicular area and
hepatomegaly

25. CXR-cardiomegaly and right upper zone
consolidation`

26. • Echocardiogram: large patent ductus arteriosus (PDA) with severe
pulmonary hypertension

27. Classical Left to right shunt with HF
• PDA
• VSD
• AP window

28. Management in ED
• If needs bolus, give 5-10 mL/kg and titrate. Continuous reassessment.
Never wrong to think sepsis and treat as such – but ALWAYS reassess
therapy if patient doesn’t respond appropriately.
• Avoid cardiac depressant drugs—Benzo’s, Propofol.
• EKG, continuous monitoring for arrhythmias
QTc, ST changes, Ventricular or atrial enlargement. Ectopy worrisome.
• CAREFUL WITH INTUBATION!! Once intubated usually more stable but
arrest can/does occur peri-intubation.

29. Adjust oral therapy
Volume,Ionotropes
Diuretics
Vasodilators
Ultrafiltration
Ionotropes
Diuretics
Vasodilators
Vasopressors
Ventilation

30. Acute heart failure (LR)-Management
decisions
The child is given furosemide and oxygen.
How would you manage fluid balance in this patient?
A: Diurese patient as much as possible
B: Diurese patient by monitoring fluid input/output and clinical exam
C: Diurese patient by monitoring serial BNP
D: Diurese patient by monitoring BUN/Cr ratio
E: Diurese patient by monitoring daily weights
F: Diurese patient by central venous pressure assessment

31. What inotropic agents would you initiate?
A: Epinephrine
B: Milrinone
C: Dobutamine
D: Dopamine
E: Nitroprusside
F: Other
Acute heart failure-Management decisions
Hypertension

32. AHF
•How would you determine the need to increase or decrease inotropic support in this
patient?
• Clinical assessment of end-organ function (UOP, BUN/Cr ratio, LFTs,
physical exam)
• Echo assessment of ventricular function
• Serial lactate measurements
• Serial BNP measurements
• Goal oriented therapy with SVC oximetry (surrogate mixed-venous
Sat)

33. Case: 4
• Clinical pitfalls:
• Absence of a loud murmur may mask the underlying large PDA/VSD/ASD.
• Each respiratory tract infection may get treated in isolation.
• The failure to thrive may be falsely attributed to prevalent malnourishment in the community.
• Diagnostic Clues: history of repeated lower respiratory tract infections, failure to thrive, signs
of heart failure (mild tachypnea, baseline tachycardia, murmur, congestive hepatomegaly).

34. Case 5
• 10yr/26Kg, boy
• 10 day history of high fever and a rash.
• Ecchymotic spots all over the body and a swollen and painful left knee joint.
• Mild splenomegaly.
• ECG shows a 2nd degree heart block type 1.

36. Case -5 Diagnosis
• A diagnosis of infective endocarditis (IE) is entertained and
appropriate antibiotics are started after obtaining blood culture.

37. • An echocardiogram shows a perivalvar vegetation of the aortic valve.
Over the course of next 48hours, the patient condition deteriorates;
complete heart block and moderate aortic regurgitation develop. The
patient is taken to the operating room for high risk aortic valve surgery.

38. Infective endocarditis, Rheumatic fever, Myocarditis
• Clinical pitfalls: The initial presentation of fever and rash may get mistaken for collagen
vascular disease , viral fever etc.
-absence of history of a congenital heart disease or a murmur.
• Diagnostic clues: ECG
• Emergency management principles: supportive care by use of inotropes, ventilator,
appropriate antibiotics, early review for surgical intervention; temporary transvenous
pacemaker

39. Case - 6
• 10Yrs/19Kg/boy (HIV)
• Fever, cough and chest pain on and off for four months.
• Bilateral leg swelling for the last month
• Emaciated, anasarca, pulses - weak and thread, heart rate is 130/minute
• Cold peripheries, BP- 80/60mm Hg.
• Raised JVP, muffled heart sounds, tender hepatomegaly.

40. CXR
ECG: low voltage/PR segment depression

41. ECHO

42. Case-6:
Large pericardial effusion with tamponade
• Cardiac tamponade has to be an important differential diagnosis in any situation with catecholamine
resistant shock
• Hydration if hypovolemic, inotropes and antibiotics (these are temporizing measures and should not
be allowed to substitute for or to delay pericardiocentesis)
• Pericardiocentesis

43. ARRHYTHMIA

44. Arrhythmia
Tachyarrhythmia
Narrow complex
QRS<90ms
Unstable
Cardioversion
Stable
Adenosine
Amiodarone
Wide complex
QRS>90ms
Unstable
Cardioversion
Stable
Amiodarone
Bradyarrhythmia
CHB
pacemaker
Pulseless
PALS/NALS

45. Summary
• Pediatric cardiac emergencies: life-threatening
• Systematic approach for diagnosis (Schem)
• Timely intervention is the key
• Sick newborns with shock and acidosis- consider CHD

46. Queries: 9975636092, drmanish2310md@gmail.com
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