1. The document contains 8 cases presented as "Toacs" or topics to discuss management of pediatric cardiology patients. 2. The cases involve patients of various ages from newborns to 10 years old presenting with conditions such as congenital heart disease, arrhythmias, heart failure and more. 3. For each case, questions are provided about interpreting ECGs, assessing the patient, making a differential diagnosis, and deciding on management according to pediatric advanced life support protocols. Detailed answers addressing each question are also provided.

1. Toacs for IMM
Dr. Abdul Ahad
Trainee fellow Paeds cardiology
LNH

2. Toacs 1
• You got called from Gynae resident that they
are delivering a baby, gestational age 35
weeks. Mother had some rheumatological
problem. ECG was done.

3. Questions
• 1. interpret ECG
• 2. What is management plan?
• 3. What advice would you give for next
pregnancy?

5. ANSWERS
• 1. Complete heart block
• 2. Counsel for PPM
• 3. Fetal Echo and monitor heart rate on fetal
Echo

7. Toacs 2
• 2 months old male baby came with history of
SVT at 15 days of life. SVT corrected at that
time. Now ECG was advised.

8. Questions
• 1. Interpret ECG
• 2. What will you advice?
• 3. What are treatment options?

10. Answers
• 1. WPW syndrome, Delta wave on ECG, LBBB?
• 2. Avoid precipitating factors, Fever, caffeine,
anxiety, Drugs causing tachycardia
• Advice Echo
• 3. Propranolol, catheter ablation of accessory
pathway

11. Toacs 3
• 2 years old male baby presented in OPD with
complaint of fever for 3 days, flue and nasal
discharge of for 3 days.
• On examination: baby is conscious, Colour is
Pink with normal respiration

12. Questions
• 1. What is initial assessment according to
PALS?
• Do primary assessment according to PALS?
• Give 2 treatment options?

14. Answers
• 1. Non-Acute life threatening event
• Call for help, O2, IV line, attach monitor
• 2. Primary assessment: Airway, breathing,
circulation, Disability, Exposure
• 3. Adenosine stat, if not aborted then can
repeat twice. If refractory, then add
amiodarone bolus in 1 hour then infusion

15. Toacs 4
• In er you call from some peripheral hospital
that there is 4 years old male baby had history
of fever for 5 days, cough and and difficulty in
breathing for 2 days. In morning mother
noticed, child had abnormal breathing
pattern.
• When baby arrived, you noticed, child is
lethargic, pale and tachypneic. They had ECG
done in peripheral hospital.

16. Questions
• 1. Do initial assessment according to PALS?
• 2. Do primary assessment according to PALS?
• 3. What is management according to PALS?

18. Answers
• 1. Acute life threatening event
• 2. Primary assessment: A B C D E
• 3. VT with pulse or with out pulse
• Synchronized cardioversion in VT with pulse
• Un synchronized shock in VT with out pulse

19. Toacs 5
• 5 years old male baby with history of
developmental delay, ophthalmoplegia,
pigmentary retinopathy, cerebellar ataxia,
proximal myopathy, deafness, delayed puberty
and endocrine dysfunction.
• CSF shows increase CSF protein.
• He had history of Syncope
• ECG, fundoscopy and MRI advised.

20. Questions
• 1. What is diagnosis?
• 2. interpret ECG?
• 3. What does fundoscopy shows and give 3
differential diagnosis?
• 4. Describe important MRI finding?

24. • 1. Kearns sayre syndrome
• 2. Sinus Rhythm, normal PR, Left axis
deviation, RBBB
• 3. Retinitis pigmentosa. D/D Bardet-Biedl
syndrome, Abetalipoproteinemia, Refsum
Disease, toxoplasmosis
• 4. Hyperintense signal at Basal ganglia, Brain
atrophy?

25. Toacs 6
• 10 years old male patient came with chief
complaint of 2 syncopal episodes while
playing.
• He had family history of sudden cardiac death.

26. • 1. What is your approach for this child?
• 2. Interpret ECG?
• 3. Describe management of syncope?

28. Answer
• 1. take history about syncopal episodes, rule out
non-cardiac causes, fits or other
neuropsychiatric problem. Metabolic workup,
EEG, baseline ECG, ambulatory ECG, Holter,
HUTT, Exercise stress
• 2. Sinus rhythm, prolong PR interval, LBBB,
Atrial hypertrophy, Strain pattern
• 2. Treat according to cause. If Heart block or
arrhythmia, refer to p-cardiology, in case of
autonomic causes maintain volume, salt or
florinef. Treat metabolic cause

29. Toacs 7
• 9 months old male baby known case cyanotic
CHD, presented with complaint of severe
cyanosis and lethargy. He had history of loose
stools and vomiting 2 days ago.
• ECG was done in some periphery hospital

30. Questions
• 1. Interpret ECG?
• 2. What is your approach for this child?
• 3. What is your differential diagnosis?

32. • 1. RAD, RVH
• 2. Admit, vital, Knee chest position , calm baby
oxygen, i/m or i/v morphine, iv bolus 10-20
mg/kg, iv soda bicarb 1-2 meq/kg, iv
propranolol or iv phenylephrine, mechanical
ventilation
• 3. BT shunt

33. Toacs 8
• 7 years old male child presented with chief
complaint of difficulty in breathing since last 6
months, functional class 3. He also had history of
cough and difficulty in breathing.
• On examination: Heart rate 125/minute,
Saturation 96%, Blood pressure 123/75 mm Hg.
• On CVS: Normal volume pulses, S1 and S2
normal with ESM grade 2-3/6 at left sternal
border

34. Questions
• 1. Interpret ECG?
• 2. 3 D/D,s?
• 3. Describe management?

36. Answer
• 1. LAD, BVH
• 2. Myocarditis, DCMP, CAVSD
• 3. Get detailed history, examination, baseline
workup, Echo
• If reduce function, start anti failure medication