This document discusses several pediatric cardiac emergencies seen in the emergency department, including duct-dependent congenital heart disease, supraventricular tachycardia, and hypercyanotic spells in infants with Tetralogy of Fallot. It presents four case studies, with echocardiogram findings and management outlined for each case. Key teaching points are emphasized regarding early diagnosis and treatment of critical congenital heart disease.
When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?
Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may require more than an advanced life support (ALS) algorithm to effectively treat and suppress.
The mainstay of therapy for our patients in ICU is pharmacotherapy, usually with amiodarone or diltiazem, however specific circumstances may dictate the use of other antiarrhythmic drugs. Ablation therapies may offer effective treatment for ICU patients, however have risks specific to ICU patients, associated with transport, procedural risk, delay of ongoing therapies, requirement for personnel, and isolated location.
This session will outline a practical approach to diagnosis and management of common and important arrhythmias in the ICU, and will include case and ECG discussions.
Saludos! de parte del Ceipem (Centro de Entrenamiento e instrucción para profesionales en Emergencias Médicas), nuestra misión es brindar al profesional de la salud en un ambiente de simulación( Laboratorio de Simulación ), la oportunidad de adquirir habilidades y destrezas, desarrollar competencias individuales y/o grupales ante emergencias médicas, en los ámbitos pre e intra hospitalarios, contamos con el mejor Staff de profesionales para facilitar su aprendizaje. Cualquier información no dude en consultarnos, 0212 7314967/4063 /info@ceipem.org/ www.ceipem.org y si quieres ver fotos, videos y nuestras actividades ingresa por FACEBOOK en ceipem fundación y estarás en línea directa con nuestra comunidad de alumnos y docentes.
A teaching session I gave in 2012 to Cardiology / Acute Medicine trainees when I was working as a Staff Specialist / Professor of Cardiology in Darwin, Australia.
Interactive Cases in Clinical Medicine (SPHMMC production) Episode 01ahmedx20
An interactive case where we discuss the diagnosis and management of Acute Rheumatic Fever, Rheumatic Heart Disease and Heart Failure in general.
Presented at Saint Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?
Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may require more than an advanced life support (ALS) algorithm to effectively treat and suppress.
The mainstay of therapy for our patients in ICU is pharmacotherapy, usually with amiodarone or diltiazem, however specific circumstances may dictate the use of other antiarrhythmic drugs. Ablation therapies may offer effective treatment for ICU patients, however have risks specific to ICU patients, associated with transport, procedural risk, delay of ongoing therapies, requirement for personnel, and isolated location.
This session will outline a practical approach to diagnosis and management of common and important arrhythmias in the ICU, and will include case and ECG discussions.
Saludos! de parte del Ceipem (Centro de Entrenamiento e instrucción para profesionales en Emergencias Médicas), nuestra misión es brindar al profesional de la salud en un ambiente de simulación( Laboratorio de Simulación ), la oportunidad de adquirir habilidades y destrezas, desarrollar competencias individuales y/o grupales ante emergencias médicas, en los ámbitos pre e intra hospitalarios, contamos con el mejor Staff de profesionales para facilitar su aprendizaje. Cualquier información no dude en consultarnos, 0212 7314967/4063 /info@ceipem.org/ www.ceipem.org y si quieres ver fotos, videos y nuestras actividades ingresa por FACEBOOK en ceipem fundación y estarás en línea directa con nuestra comunidad de alumnos y docentes.
A teaching session I gave in 2012 to Cardiology / Acute Medicine trainees when I was working as a Staff Specialist / Professor of Cardiology in Darwin, Australia.
Interactive Cases in Clinical Medicine (SPHMMC production) Episode 01ahmedx20
An interactive case where we discuss the diagnosis and management of Acute Rheumatic Fever, Rheumatic Heart Disease and Heart Failure in general.
Presented at Saint Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
3. Paediatric Cardiac Emergencies in ED
• Neonatal
• Duct-dependent congenital heart disease
• Infants & older children
• Hypercyanotic spells
• Supraventricular tachycardia
• Pericardial tamponade
4. Case 1
• Term baby, delivered in a specialist hospital
• Birth weight 3.2 kg, good Apgar
• Uneventful postnatal period
• Discharged home at 24 hours of life
• Came to ED on day 3 of life because mother noted child to be
“blue”
5. Case 1
• Alert, good cry
• SpO2 65 – 70%
• No respiratory distress
• Heart: S1 S2, no heart murmur
• Lungs: clear
• SpO2 improved to 80% after giving 2L/min oxygen via nasal cannula
6.
7. Quiz
Could he has cyanotic heart disease?
• Yes
• Unlikely; his SpO2 improved with oxygen supplementation suggestive of lung
pathology
• Unlikely; there was no heart murmur
• Unlikely; there was no respiratory distress
• Unlikely; he should have presented much earlier during postnatal period
before home discharge
12. Why Missed During Newborn Check?
• Cyanosis is easily missed during early
postnatal period
• Haemoglobin-oxygen dissociation
curve
• Fetal haemoglobin
• Presence of PDA
• Absence of heart murmur
• Absence of respiratory distress
13. Cyanosis: Heart vs Lungs
Heart Lungs
History None
Fever, cough, rapid breathing, poor
feeding
Clinical signs Cyanosis
Chest recession, tachypnoea,
abnormal auscultatory findings
Chest X-ray
Normal; sometimes
oligaemic lung fields
Abnormal lung fields
Arterial blood gas
↓ PaO2
Normal PaCO2
↓ PaO2
Variable PaCO2
Response to O2
supplementation
Poor response Good response
14. Management
• Airway, breathing, circulation
• IV Prostaglandin E2 infusion
• Emergency balloon atrial septostomy for
transposition of great arteries
• Definitive surgery or catheter intervention after
stabilization
• Early diagnosis is the key!
15. Case 2
• Term baby, delivered in a district hospital
• Birth weight 3.5 kg, good Apgar
• Uneventful postnatal period
• Discharged home at 24 hours of life
• Came to ED on day 3 of life as mother noticed poor feeding
17. Quiz
What is your immediate management?
• Intubate and start ambu-bagging with 100% oxygen
• Obtain venous access and administer 20 ml/kg of fluid bolus
• Start IV Dopamine infusion
• Given IV NaCO3 to correct metabolic acidosis
• Do septic workout and start IV antibiotics
• Perform bedside echocardiogram
22. Management
• High index of suspicion
• Early diagnosis by echocardiogram is the key!
• Start IV Prostaglandin E2 infusion
• Intubation, mechanical ventilation
• Fluid resuscitation
• Inotropic support
• Correction of hypoglycaemia, acidosis, electrolytes
• Empirical IV antibiotics
24. Critical Congenital Heart Disease
• Only 45% of all CHD had abnormal finding
on routine neonatal examination
• Heart murmur is not a reliable sign
• Sensitivity rate = 44% (CI 31 – 51%)
• Positive predictive value = 54% (CI 39
– 69%)
1. Wren C et al. Presentationof congenital heart disease in infancy: implications for routine examination. Arch Dis Child Fetal Neonatal Ed 1999;80:F49–53
2. Ainsworth SB et al. Prevalence and clinical significance of cardiac murmurs in neonates. Arch Dis Child Fetal Neonatal Ed 1999;80:F43-F45
25. Case 3
• 5 years old girl
• History of fever & cough for 3 days
• Given cough mixture by GP
• Complains of chest discomfort this morning
• No past history of heart problem
• Heart rate 200/min on cardiac monitor
• BP stable, good perfusion
26.
27. Quiz
What is your diagnosis?
• Sinus tachycardia
• Atrioventricular re-entrant tachycardia
• Atrial flutter
• Junctional tachycardia
• Ventricular tachycardia
28. Case 3
• Carotid massage → no response
• IV Adenosine 0.2 mg/kg rapid bolus → no response also !!
29. Quiz
What is your diagnosis now?
• Sinus tachycardia
• Atrioventricular re-entrant tachycardia
• Atrial flutter
• Junctional tachycardia
• Ventricular tachycardia
30.
31. Atrioventricular Reentry Tachycardia
• Most common supraventricular tachycardia
in paediatric
• Substrate: accessory pathway connecting
atrium with adjacent ventricular myocardium
• Reentry circuit formed by
• Atrium
• AV node
• Ventricle
• Accessory pathway
33. Clinical Presentation
• Older children & adults
• Paroxysmal, abrupt onset and termination
• Palpitation, chest discomfort, pre-syncope
• Usually well tolerated
• Infants
• Inability to express
• Non-specific symptoms of irritability, poor feeding, diaphoresis
• SVT may persists for days leading to heart failure
34. ECG
• Rate depends on age
• 300/min in neonates, 250/min in infancy, 200/min in older children
• Narrow QRS complex
• Except in pre-existing bundle branch block or rate-related aberrant
conduction
• P wave difficult to visualize
• Constant rate, no beat-to-beat variation
• Abrupt onset, abrupt termination (all or none phenomenon)
36. ECG
• Sometimes P wave can be seen immediately after QRS (best seen
on lead V1)
• Short RP tachycardia
37. IV Adenosine
• IV Adenosine terminate the tachycardia
• Results in non-conducted P wave, transient junctional escape
rhythm followed by restoration of sinus rhythm
38. Case 3
When tachycardia is “not responding” to IV Adenosine
• Inadequate dose
• Suboptimal administration (not fast enough, small peripheral vein)
• Wrong diagnosis of AVRT
• AVRT stopped by IV Adenosine but restarted soon after
39.
40. IV Adenosine as Diagnostic Tool
Important to have continuous ECG recording when administering IV
Adenosine
4 patterns of response
• Tachycardia terminated
• Tachycardia stopped but restart shortly
• Tachycardia slowed down transiently then speed up
• Tachycardia continues in the presence of AV block
41. IV Adenosine as Diagnostic Tool
• Tachycardia terminated
→ AVRT, AVNRT
• Tachycardia stops transiently, then restart
→ AVRT, PJRT
42. IV Adenosine as Diagnostic Tool
• Tachycardia slows transiently and then speed up
→ sinus tachycardia, atrial ectopic tachycardia
• Tachycardia continues in the presence of AV block
→ atrial flutter, atrial ectopic tachycardia
43. Management
• In haemodynamically stable patients
• Vagal maneuvers
• Diving reflex (ice bag/cold clothe on forehead)
• Valsalva maneuvers
• Carotid massage
• IV Adenosine
• 0.1 mg/kg rapid IV bolus, double the dosage until termination or maximal
dose 0.6 mg/kg 1
1. Dixon J et al. Guidelines and adenosine dosing in supraventricular tachycardia. Arch Dis Child (2005) 90:1190-1
44. Management
• Initial dose of 0.2 mg/kg was found to be more effective 1
• Important technical issues
• As fast as possible
• Saline flush
• Large cannula
• As close to central vein
1. Dixon J et al. Guidelines and adenosine dosing in supraventricular tachycardia. Arch Dis Child (2005) 90:1190-1
45. AVRT Management
If haemodynamically unstable/decompensated heart failure
• IV Adenosine (up to 1 mg/kg) if venous access available
• DC cardioversion (0.5 – 1 J/kg)
• Avoid IV Verapamil, especially in infants (cardiovascular collapse) 1, 2
1. Epstein ML et al. Cardiac decompensation following verapamil therapy in infants with supraventricular tachycardia. Pediatrics (1985) 75:737-40
2. Kirk CR et al. Cardiovascular collapse after verapamil in supraventricular tachycardia. Arch Dis Child (1987) 62:1265-85
46. AVRT Management
If recurrence soon after acute termination
• IV Digoxin; loading dose of 15 mcg/kg followed by 5 mcg/kg 6 hours later
• IV Propranolol: 0.02 mg/kg test dose, then 0.1 mg/kg over 10 mins
• IV Amiodarone 25 mcg/kg/min for 4 hour followed by 5 to 15 mcg/kg/min until
conversion
Repeat IV Adenosine dosing may work after initial “priming” with
another anti-arrhythmics
47. Case 4
• 3 months old boy
• Known case of Tetralogy of Fallot, planned for elective surgical
repair at 1 year old
• Sudden onset of bluish discoloration of lips and finger tips this
morning after defaecation
• Associated with ↓ conscious level & breathing difficulty
• No fever
• Was still active and feeding well last nigh
48. Case 4
• SpO2 40 – 50%
• Drowsy
• Tachypnoea, hyperventilating
• Grade 2 systolic murmur upper left sternal border
• Lungs: clear
• No clubbing
49.
50. Quiz
What is the diagnosis?
• Status epilepticus
• Breath holding attack
• Sepsis
• Hypercyanotic spell
51. Tetralogy of Fallot
• Commonest cyanotic heart disease
• Constellation of
• RV outflow tract obstruction
• Large VSD
• Overriding of aorta
• RV hypertrophy
54. Management
• Oxygen
• Nasal cannula/non-rebreather mask
• Calm the child
• Knee-chest position
• Morphine
• Intramuscular/intravenous
• 0.1 mg/kg
• May be repeated but monitor for
respiratory depression
55. Management
• 20 ml/kg IV normal saline bolus
• IV NaHCO3 1 to 2 mmol/kg if severe metabolic acidosis (pH < 7.1)
• IV Ketamine 1 mg/kg
• Beta blockers
• IV Propranolol 0.1 mg/kg slow bolus
• IV Esmolol 0.5 mg/kg bolus, followed by infusion 50 - 1000 mcg/kg/min
• Systemic vasoconstrictors
• IV Phenylephrine 0.1 mg/kg slow bolus, followed by infusion
• IV Noradrenaline infusion 0.01 – 1 mcg/kg/min
56. Management
• Intubation & general anaesthesia
if fail all the above measures
• Emergency surgical BT shunt
57. Case 5
7 years old girl
• Known case of large ASD
• Underwent surgical ASD closure at IJN 3 weeks ago
• Uneventful postoperative recovery
• Postop echocardiogram: no residual ASD
• Discharged home on POD5
58. Case 5
• Abdominal pain x 2 days
• Afebrile, normal vital signs
• Sternotomy wound clean & healed
• S1, S2, no murmur
• Lungs clear
• Abdomen soft, non tender
• Prescribed some antacids, discharged home
59. Case 5
3 days later
• Shortness of breath
• Came to ED again
• Collapsed while doing CXR
• Immediate CPR, return of circulation
64. Pericardial Effusion
• Common after any open heart
surgery
• 1 to 6 weeks after surgery
• Majority are small and self-limiting
• Occasionally can cause cardiac
tamponade
65. Pericardial Effusion
Causes
• Post open heart surgery
• Infective – pyogenic, tuberculous
• Connective tissue disease – SLE
• Malignancy
• Central line extravasation
• Post-traumatic