Cvs in a and e

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  • Cardiovascular System II
  • Present the clinical features and emergency management of cardiovascular disorders, including: Diagnose and treat rhythm disturbances. Detect and treat cardiomyopathy. Treat shock. Create differential diagnosis and management plan for syncope.
  • A 10-day-old male infant is brought to ED for not breathing and color change. The child was 3 weeks premature, and was discharged from hospital 3 days ago with an apnea monitor. Decreased activity since discharge Poor feeding today
  • The PAT is as follows: A: Appearance: Abnormal B: Work of Breathing: Abnormal C: Circulation to the Skin: Abnormal Vital signs include: Heart rate: 220 bpm Respiratory rate: 14 breaths/min Blood pressure: 55/36 mm Hg Weight: 3.5 kg (birth weight 3.7 kg) Oxygen saturation: 88% on room air
  • A: Airway: Patent without evidence of obstruction B: Breathing: Nonlabored but diminished respiratory rate C: Circulation: Mottled, cool, distal cyanosis, tachycardic and weak pulse D: Disability: Weak cry, nonfocal exam E: Exposure: Normothermic, no evidence of trauma, fontanel flat
  • Head/Neck: No abnormalities Heart: Tachycardia, no murmurs heard Lungs: Decreased breath sounds Abdomen: Liver 2 finger breadths below RCM Neurologic: Weak cry, lethargic, poor interaction, responsive to pain and contact Extremities: Cyanotic, cool upper and lower extremities
  • Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
  • Cardiopulmonary failure because all arms of the PAT are abnormal. Patient appearance is lethargic but responsive, with inadequate respirations and tachycardia; mottling with distal cyanosis. What are your initial management priorities?
  • Check ABCs. Open airway. Give 100% O 2 by BMV, or perform endotracheal intubation. Check rhythm on cardiac monitor. Obtain vascular access. Obtain blood glucose prn. Check rectal temperature.
  • Tachyarrhythmias: Wide complex Ventricular tachycardia (rare rhythm in children but if wide need to consider of ventricular origin) SVT with aberrancy Narrow complex Sinus tachycardia (rates usually < 220) SVT (Rates usually > 220)
  • Clinical features can be varied: Palpitations in verbal children Shock in any age Generalized symptoms of malaise and weakness Diagnostic studies may include: Cardiac monitor, ECG, sepsis evaluation if young infant who has signs and symptoms suggestive of infection Chest radiograph, echocardiogram Management includes ABCs and stabilization.
  • The pediatric patient has 3 basic types of pathologic rhythm disturbances, which include fast pulse (tachyarrhythmia), slow pulse (bradyarrhythmia), and absent pulse (pulseless) (Table 4-3). These can be further divided into 7 classifications based on their anatomic function. Dysrhythmias may be the cause of impaired cardiac function leading to cardiac arrest. Occult dysrhythmias (e.g., prolonged QT syndrome, Wolf-Parkinson-White syndrome, etc.) may present with intermittent severe symptoms (e.g., palpitations or sudden death).
  • Consider the following symptoms: Intermittent, paroxysmal presence of symptoms Dramatic onset and change in condition Sudden onset of symptoms with little or no prodrome Presentation of dysrhythmias can range from stable to cardiopulmonary arrest. Infant or child may show subtle signs of major physiological derangement.
  • Supraventricular tachycardia (SVT) history is intermittent, paroxysmal, with sudden onset. Sinus tachycardia (ST) history suggests sepsis, dehydration, hemorrhage, hypovolemia. SVT ECG steady rate at or greater than 2x normal rate for age. ST rate is less than 2x normal rate for age. Minimal or no rate change with activity with SVT.
  • SVT characteristics (versus sinus tachycardia): Heart rate is >2 times normal rate for age. Rhythm is steady. P waves are absent. History is not suggestive of volume depletion or sepsis.
  • Radiology studies include chest radiographs; it is important to look for signs of structural congenital heart disease, congestive heart failure (due to a prolonged dysrhythmia), or signs of infection (pneumonia). Laboratory tests should ALWAYS include a blood glucose check to exclude hypoglycemia in any child with abnormal mental status.
  • Differential diagnoses may include: Hypoglycemia Sepsis Hyperthyroidism Volume depletion Catastrophic illness, e.g., CNS, GI trauma (abuse) Metabolic disease
  • Manage ABCs. Get baseline ECG. Obtain vascular access. For SVT (see AHA algorithm): Vagal maneuvers for stable SVT Adenosine: 100 mcg/kg bolus, increase to 200 mcg/kg (maximum first dose is 6 mg, maximum second and subsequent doses 12 mg) – given for stable SVT if unresponsive to vagal maneuvers or for unstable SVT if IV access is immediately available. Cardioversion for unstable SVT (poor perfusion) Procainamide or amiodarone to be considered if possible of ventricular origin; that is QRS >0.08 sec Digoxin to slow rate if cardioversion unsuccessful Cardiology consultation
  • This slide shows the PALS algorithm for tachycardia (sinus tachycardia, SVT, and ventricular tachycardia) with POOR PERFUSION.
  • Management is driven by presence or absence of poor perfusion. Sinus tachycardia is not an arrhythmia but its etiology must be determined. Provide ventilation and oxygenation for all patients in cardiopulmonary arrest, as the primary etiology is often respiratory failure.
  • Patients such as this should be transported to a pediatric referral center after stabilization. Transport issues include: ALS transport with monitoring and IV access Treatment plan for possible en route for recurrence – including potential for cardioversion Consult the accepting pediatric cardiologist
  • Documentation considerations include: Always try to get baseline 12-lead ECG before and after cardioversion. Treatment record from prehospital and ED care Emergency Medical Treatment and Active Labor Act (EMTALA) compliance Risk management considerations include: Always check blood glucose. Assure rapid triage of infants in distress. Do not hesitate to cardiovert when child is unstable.
  • Four H’s: Hypoxemia Hypovolemia Hypothermia Hyper/Hypokalemia and metabolic disorders Four T’s: Tamponade (cardiac) Tension pneumothorax Toxins/poisons/drugs Thromboembolism
  • ECG reveals SVT. Infant receives BMV ventilation. Preparations made to cardiovert but rapid IV access is obtained. Adenosine 100 mcg/kg IV push is given followed by normal saline bolus (flush). Return of sinus rhythm. BMV is discontinued as infant’s condition stabilized. 100% oxygen nonrebreather mask is placed. Return of sinus rhythm. ECG does not show early repolarization (e.g., WPW).
  • 2-year-old girl passed out eating cereal; awoke after 5 minutes. She was stiff with eyes rolled back for approximately 5 minutes. Minimal period of sleepiness, now awake and alert; no retractions; skin color is normal
  • The PAT is as follows: A: Appearance: Normal B: Work of Breathing: Normal C: Circulation to the Skin: Normal ABCDEs: Normal. Vital signs include: Heart rate: 120 bpm Respiratory rate: 24 breaths/min Blood pressure: 80/60 mm Hg Temperature: 37.7°C Weight: 12 kg Oxygen saturation: 99% Focused history: Three similar episodes; two associated with “temper tantrums.” PMH: Negative FH: Negative for sudden death
  • Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
  • The patient presents with syncope and normal appearance on exam. She is in no distress and the exam is normal. Her history, however, is concerning and ominous. What are your initial management priorities?
  • Syncope in young children is a serious symptom. Life-threatening causes must be eliminated. A differential diagnosis is critical: Seizure Cardiac Breath-holding spell
  • Clinical features include: Loss of consciousness Lasted only a few minutes Minimal or no postictal state No stigmata of seizure: Urinary incontinence, bitten tongue, witnessed tonic-clonic activity.
  • Radiology studies may include: Chest radiograph offers little. CT or MRI may be indicated if seizures are considered. Laboratory studies often are normal, but if patient has abnormal mental status or concerning history, may include: Electrolytes CBC with differential Ca++, Mg++, PO 4
  • Obtain an ECG as this will assist the physician in determining potential life threatening cardiac causes of syncope. In this case the ECG shows prolonged QT. This shows a markedly prolonged QT interval (corrected QTc interval is 0.75 seconds [750 ms]) with T-wave alternans. Courtesy of Dr. Bob Hickey.
  • Ten percent present with seizures.  Fifteen percent of patients with prolonged QTc die during their first episode of arrhythmia and 30% of these deaths occur during the first year of life.
  • Also consider in differential: Hypertrophic cardiomyopathy Formerly called IHSS (idiopathic hypertrophic subaortic stenosis) Syncope with exercise At risk for sudden death Positive family history Non-specific murmur ECG can show non-specific findings. CXR is non-diagnostic. Echocardiogram is diagnostic. Chronic cardiomyopathy Chronic CHF Dysrhythmias
  • Cardiac arrhythmias should be considered in all patients presenting with brief, nonspecific changes in level of consciousness: Fainting, syncope, seizures, breath-holding, apparent life-threatening events
  • Family history may be positive for sudden, unexplained deaths prior to 55, fainting episodes, or unexplained accidents. Episodes associated with exercise are particularly concerning. No further exercise until cleared by a cardiologist.
  • Review the above flowchart with the students. On this slide, “vasopressor” = epinephrine Epinephrine 0.01 mg/kg (0.1 mL/kg 1:10,000) IV or IO 0.1 mg/kg (0.1 mL/kg 1:1000) tracheal tube Anti-arrhythmic includes amiodarone, lidocaine and magnesium. Reversible causes include the 4 H’s (hypoxemia, hypovolemia, hypothermia, Hyper-/hypokalemia) and the 4 T’s (tamponade, tension pneumothorax, toxins, thromboembolism).
  • This patient has prolonged QT syndrome. She is at risk for fatal dysrhythmia (ventricular tachycardia or ventricular fibrillation). She needs to be admitted/transferred to a pediatric cardiology center for cardiology evaluation.
  • This child is hospitalized. She is monitored and confirmed to be at risk for dangerous dysrhythmia. She is discharged on medications shown to decrease her risk of ventricular tachycardia/ventricular fibrillation (e.g., ß blockers). She is a candidate to receive an AICD (automatic implantable cardiac defibrillator) when she gets older.
  • A 6-month-old boy present with chicken pox lesions that began 3 days ago. The lesions are spreading and there are more scabs today. Fever since yesterday, higher today. Today, his skin appears to be red. He is fussy and not feeding well.
  • The PAT is as follows: A: Appearance: Normal/Abnormal – he is fussy, which may be an early sign of shock or CNS condition. B: Work of Breathing: Normal. C: Circulation to the Skin: Normal. Vital signs include: Heart rate: 160 bpm – tachycardia is seen in many conditions, but there is concern in a patient with infection that it could be a sign of shock Respiratory rate: 40 breaths/min – without retractions, may indicate metabolic acidosis Blood pressure: 79/56 mm Hg – blood pressure is normal, so this is not decompensated shock Temperature: 39°C Weight: 8.1 kg Oxygen saturation: 98% on room air
  • A: Patent without evidence of obstruction B: Normal C: Generalized red erythroderma, warm, tachycardic (febrile) D: Nonfocal exam, irritable E: Many impetiginous scabs, pustules and vesicles; some with surrounding cellulitis
  • Head/Neck: No abnormalities except for skin Heart: Tachycardic, no murmurs heard Lungs: Clear breath sounds Abdomen: Normal except for skin Neuro: Alert, subdued, no meningismus Skin: Many vesicles, scabs, pustules; some with surrounding cellulitis. Generalized warm erythroderma. Capillary refill 2 seconds.
  • Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
  • Compensated shock Tachycardia and mild change in appearance (fussy) Possible septic shock as varicella lesions with signs of secondary infection ( Staph aureus , group A strep) Erythroderma: Scarlet fever versus toxic shock What are your initial management priorities?
  • Provide supplemental oxygen. Obtain vascular access. Determine rapid glucose. Begin fluid resuscitation at 20 mL/kg – 160 mL normal saline. CBC, blood culture, other optional labs IV antibiotics Repeated assessment for signs of shock Also important to continue assessment to determine if scarlet fever or toxic shock For toxic shock: IV fluid infusion Start infusion of dopamine. Consider dobutamine infusion.
  • Shock is inadequate tissue perfusion (delivery of oxygen and nutrients) to meet the metabolic demands of the body. Types of shock include: Hypovolemic Cardiogenic Distributive Septic
  • Compensated: Vital organs continue to be perfused by compensatory mechanisms. Blood pressure is normal. Decompensated: Compensatory mechanisms are overwhelmed and inadequate - hypotension, high mortality risk. Aggressive treatment of early shock: Halts progression to decompensated shock
  • Apnea, tachypnea, respiratory distress Skin: Pale, cool, delayed capillary refill. Warm shock will appear normal. Lethargic, weak, orthostatic weakness Tachycardia, hypotension Specific types of shock: Distributive shock: Neurologic deficits (spinal cord injury); anaphylaxis (urticaria, allergen trigger, wheezing) Septic shock: Petechiae, erythroderma
  • Fluid loss: Diarrhea, vomiting, anorexia, diuresis Hemorrhage Resuscitation: Fluid replacement Normal saline or lactated Ringer’s 20 mL/kg bolus infusions, reassess, repeat as needed Blood transfusion for excessive hemorrhage
  • Poor myocardial contractility or impaired ejection: Cardiomyopathy, congenital heart disease, myocarditis, tamponade, congestive heart failure, dysrhythmia, septic shock, drugs (e.g., thiopental) Resuscitation: Fluid bolus (10 mL/kg) and reassess Inotropes, pressors (e.g., dopamine, dobutamine, epinephrine)
  • Inappropriate vasodilation with a maldistribution of blood flow: Anaphylactic shock, spinal cord injury, septic shock “ Warm shock” Resuscitation: Vasoconstrictors (e.g., epinephrine) Anaphylaxis treatment Spinal cord injury treatment Sepsis treatment
  • Elements of distributive shock and cardiogenic shock: Inappropriate vasodilation with a maldistribution of blood flow Myocardial depression Resuscitation: Fluid bolus Pressors and inotropes Antibiotics (expect possible deterioration initially due to toxin release)
  • Labs drawn IV fluids given with decrease in heart rate to 120 bpm IV antibiotics given Patient admitted and discharged 4 days later Option for prolonged observation in ED monitoring for deterioration in vital signs and clinical status. Benign observation period suggests scarlet fever. Worsening suggests possible toxic shock. Toxic shock: Similar to septic shock requiring fluids, pressors, inotropes, ICU monitoring
  • Early recognition and treatment of compensated shock may prevent progression to decompensated shock. Identifying early compensated shock is difficult. Decompensated shock has a poor prognosis.
  • Overall, parents of patients with underlying cardiac disease should receive information about their child’s disease, treatment, and how to reach primary care (PCP) and specialty physicians. Ideally parents of children with cardiac disease should carry an updated emergency information form (EIF) when seeking emergency care. This form provides immediate pertinent medical information. A medical ID bracelet is also useful. Available from ACEP and AAP. The EIF should be updated by the patient’s primary care physician and specialists.
  • Obtain rapid history and assess children in shock or respiratory distress for cardiac disease including postsurgical complications. Utilize the EIF to gather information, contact specialists, and guide therapy. Echocardiography and cardiology consultation for definitive diagnosis and cardiac function determination.
  • Cvs in a and e

    1. 1. Cardiovascular System II Continuing Education Modules 1
    2. 2. Objectives Present the clinical features and emergency management of cardiovascular disorders, including: – Diagnose and treat rhythm disturbances. – Detect and treat cardiomyopathy. – Treat shock. – Create differential diagnosis and management plan for syncope. Continuing Education Modules 2
    3. 3. Case Study 1: “Not Breathing” 10-day-old boy brought to ED for not breathing and color change. 3 weeks premature, discharged from hospital 3 days ago with apnea monitor Decreased activity since discharge Poor feeding today Continuing Education Modules 3
    4. 4. Initial Assessment (1 of 2)PAT: – Abnormal appearance, abnormal breathing, abnormal circulationVital signs: – HR 220, RR 14, BP 55/36, Wt 3.5 kg (birth weight 3.7 kg), O2 sat 88% on room air Continuing Education Modules 4
    5. 5. Initial Assessment (2 of 2)A: Patent without evidence of obstructionB: Nonlabored but diminished respiratory rateC: Mottled, cool, distal cyanosis, tachycardic and weak pulseD: Weak cry, nonfocal examE: Normothermic, no evidence of trauma, fontanel flat Continuing Education Modules 5
    6. 6. Detailed Physical Exam Head/Neck: No abnormalities Heart: Tachycardia, no murmurs heard Lungs: Decreased breath sounds Abdomen: Liver 2 finger breadths below RCM Neuro: Weak cry, lethargic, poor interaction, responsive to pain and contact Extremities: Cyanotic, cool upper and lower extremities Continuing Education Modules 6
    7. 7. QuestionWhat is your general impression of this patient? Continuing Education Modules 7
    8. 8. General Impression Cardiopulmonary failure – Lethargic but responsive, inadequate respirations and tachycardia; mottling with distal cyanosisWhat are your initial management priorities? Continuing Education Modules 8
    9. 9. Management Priorities ABCs Open airway. Give 100% O2 by BMV, or perform endotracheal intubation. Check rhythm on cardiac monitor. Obtain vascular access. Obtain blood glucose prn. Check rectal temperature. Continuing Education Modules 9
    10. 10. Case Discussion (1 of 2) Tachyarrhythmias: – Wide complex  Ventricular tachycardia  Supraventricular tachycardia (SVT) with aberrancy – Narrow complex  Sinus tachycardia  SVT Continuing Education Modules 10
    11. 11. Case Discussion (2 of 2) Clinical features can be varied: – Palpitations in verbal children – Shock in any age – Generalized symptoms of malaise and weakness Diagnostic studies: – Cardiac monitor, ECG, sepsis evaluation if young infant who has signs and symptoms suggestive of infection – CXR, echocardiogram Management: ABCs, stabilize Continuing Education Modules 11
    12. 12. Background: Dysrhythmias 3 basic types: – Fast pulse (tachyarrhythmia) – Slow pulse (bradyarrhythmia) – Absent pulse (pulseless) Dysrhythmias may impair cardiac function, leading to cardiac arrest. Occult dysrhythmias (e.g., prolonged QT syndrome, WPW syndrome) Continuing Education Modules 12
    13. 13. Clinical Features: Your First Clue Intermittent, paroxysmal presence of symptoms Sudden onset of symptoms with little or no prodrome Presentation of dysrhythmias can range from stable to cardiopulmonary arrest. Continuing Education Modules 13
    14. 14. Distinguishing SVT from ST ST SVTHistory Fever, sepsis, Intermittent, dehydration, paroxysmal in onset hemorrhage, hypovolemia, precedesECG ST rate is less than 2x SVT rate at or normal rate for age. greater than 2x Rate varies with normal rate for age. activity. Minimal or no rate change with activity. Continuing Education Modules 14
    15. 15. Supraventricular Tachycardia Continuing Education Modules 15
    16. 16. Diagnostic Studies Radiology: – CXR important to look for signs of:  Structural congenital heart disease  Congestive heart failure (prolonged dysrhythmia)  Signs of infection (pneumonia) Laboratory: – ALWAYS check blood glucose to exclude hypoglycemia in any child with abnormal mental status. Continuing Education Modules 16
    17. 17. Differential Diagnosis: What Else? Hypoglycemia Sepsis Hyperthyroidism Volume depletion Catastrophic illness: – CNS, GI, trauma (abuse) Metabolic disease Continuing Education Modules 17
    18. 18. Management: Dysrhythmias ABCs Get baseline ECG. Obtain vascular access. For SVT (see AHA algorithm): – Vagal maneuvers – Adenosine: 100 mcg/kg bolus, increase as necessary: 200 mcg/kg – Cardioversion for unstable SVT – Procainamide or amiodarone if QRS is wide – Digoxin to slow rate if cardioversion unsuccessful – Cardiology consultation Continuing Education Modules 18
    19. 19. Tachycardia ManagementContinuing Education Modules 19
    20. 20. The Bottom Line: Dysrhythmias Management is driven by presence or absence of poor perfusion. Sinus tachycardia is not an arrhythmia but its etiology must be determined. Provide ventilation and oxygenation for all patients in cardiopulmonary arrest, as the primary etiology is often respiratory failure. Continuing Education Modules 20
    21. 21. Other Considerations (1 of 2) Interface with EMS/Transport: – Transport issues: Case such as this should be transported to pediatric referral center after stabilization.  ALS transport with monitoring and IV access  Treatment plan for possible en route for recurrence – including potential for cardioversion  Consult accepting pediatric cardiologist Continuing Education Modules 21
    22. 22. Other Considerations (2 of 2) Documentation: – Always try to get baseline 12-lead ECG before and after cardioversion. – Treatment record from prehospital and ED care – EMTALA compliance Risk management: – Always check blood glucose. – Assure rapid triage of infants in distress. – Do not hesitate to cardiovert when child is unstable. Continuing Education Modules 22
    23. 23. Reversible Non-Cardiac Causes of Dysrhythmias Four H’s: • Four T’s: – Hypoxemia – Tamponade – Hypovolemia (cardiac) – Hypothermia – Tension pneumothorax – Hyper/Hypokalemia and metabolic – Toxins/poisons/ disorders drugs – Thromboembolism Continuing Education Modules 23
    24. 24. Case Progression/Outcome ECG reveals SVT. Infant receives BMV ventilation. Preparations are made to cardiovert as IV access is obtained. Adenosine 100 mcg/kg IV push is given followed by NS bolus (flush). ECG shows return of sinus rhythm. BMV is discontinued as infant’s condition stabilized. 100% oxygen NRB mask is placed. Continuing Education Modules 24
    25. 25. Case Study 2: “Unresponsive Episodes” 2-year-old girl passed out eating cereal; awoke after 5 min. She was stiff with eyes rolled back ~ approx. 5 min. Minimal period of sleepiness, now awake and alert; no retractions; skin color is normal Continuing Education Modules 25
    26. 26. Initial Assessment and Focused HistoryPAT: – Normal appearance, normal breathing, normal circulationABCDEs: – Normal – Vital signs: HR 120; RR 24; BP 80/60; T 37.7° C Wt 12 kg; O2 sat 99%Focused History: – Three similar episodes; two associated with “temper tantrums.” – PMH and FH: Negative Continuing Education Modules 26
    27. 27. QuestionWhat is your general impression of this patient? Continuing Education Modules 27
    28. 28. General Impression Stable – Patient with syncope – In no distress; normal exam – Concerning/ominous historyWhat are your initial management priorities? Continuing Education Modules 28
    29. 29. Case Discussion Syncope in young children is a serious symptom. Must attempt to exclude life-threatening causes Differential diagnosis is critical: – Seizure – Cardiac – Breath-holding spell Continuing Education Modules 29
    30. 30. Clinical Features: Your First Clue Loss of consciousness Lasted only a few minutes Minimal or no postictal state No stigmata of seizure: Urinary incontinence, bitten tongue, witnessed tonic-clonic activity Continuing Education Modules 30
    31. 31. Diagnostic Studies Radiology: – CXR offers little. – CT or MRI may be indicated if considering seizures. Laboratory is often normal but may include: – Electrolytes – CBC with differential – Ca++, Mg++, PO4 Continuing Education Modules 31
    32. 32. Markedly Prolonged QT Interval T-wave alternans Continuing Education Modules 32
    33. 33. Prolonged QT 10% present with seizures. 15% of patients with prolonged QTc die during their first episode of arrhythmia. – 30% of these deaths occur during the first year of life. Continuing Education Modules 33
    34. 34. What Else? Cardiac Causes of Syncope Hypertrophic cardiomyopathy – Syncope with exercise – At risk for sudden death; positive family history – Non-specific murmur; ECG can show non-specific findings. – CXR is non-diagnostic – Echocardiogram is diagnostic. Chronic cardiomyopathy – Chronic CHF Dysrhythmias Continuing Education Modules 34
    35. 35. Critical Concepts (1 of 2) Consider cardiac arrhythmias in all patients presenting with brief, nonspecific changes in level of consciousness: – Fainting, syncope, seizures, breath-holding, apparent life-threatening events Continuing Education Modules 35
    36. 36. Critical Concepts (2 of 2) Family history may be positive for sudden, unexplained deaths prior to 55, fainting episodes, or unexplained accidents. Episodes associated with exercise are particularly concerning. – Patient instructed not to exercise until cleared by a cardiologist. Continuing Education Modules 36
    37. 37. Pulseless Arrest* VF/VT Not VF/VT Shock x 3 Vasopressor Vasopressor CPR x 3 min(Drug - Shock) Shock *CPR and seek reversible causes throughoutAnti-arrhythmic Continuing Education Modules 37
    38. 38. Case Progression This patient has prolonged QT syndrome. She is at risk for fatal dysrhythmia (ventricular tachycardia or ventricular fibrillation). She needs to be admitted/transferred to a pediatric cardiology center for cardiology evaluation. Continuing Education Modules 38
    39. 39. Case Outcome This child is hospitalized. Monitored and confirmed to be at risk for dangerous dysrhythmia Discharged on medications shown to decrease her risk of VT/VF (e.g., ß blockers) She is a candidate to receive an AICD when she gets older. Continuing Education Modules 39
    40. 40. Case Study 3: “Chicken Pox” 6-month-old with chicken pox lesions that began 3 days ago. Lesions are spreading. More scabs today. Fever since yesterday, higher today. Today, his skin appears to be red. He is fussy and not feeding well. Continuing Education Modules 40
    41. 41. Initial Assessment (1 of 2)PAT: – Normal/abnormal appearance, normal breathing, normal circulationVital signs: – HR 160, RR 40, BP 79/56, T 39°C, Wt 8.1 kg, O2 sat 98% on room air Continuing Education Modules 41
    42. 42. Initial Assessment (2 of 2)A: Patent without evidence of obstructionB: NormalC: Generalized red erythroderma, warm, tachycardic (febrile)D: Nonfocal exam, irritableE: Many impetiginous scabs, pustules and vesicles; some with surrounding cellulitis Continuing Education Modules 42
    43. 43. Detailed Physical Exam Head/Neck: No abnormalities except for skin Heart: Tachycardic, no murmurs heard Lungs: Clear breath sounds Abdomen: Normal except for skin Neuro: Alert, subdued, no meningismus Skin: Many vesicles, scabs, pustules; some with surrounding cellulitis. Generalized warm erythroderma. Capillary refill 2 seconds. Continuing Education Modules 43
    44. 44. QuestionWhat is your general impression of this patient? Continuing Education Modules 44
    45. 45. General Impression Compensated shock – Tachycardia and mild change in appearance (fussy) – Possible septic shock as varicella lesions with signs of secondary infection (Staph aureus, group A strep) – Erythroderma: Scarlet fever versus toxic shockWhat are your initial management priorities? Continuing Education Modules 45
    46. 46. Management Priorities Provide supplemental oxygen. Obtain vascular access. Determine rapid glucose. Begin fluid resuscitation at 20 mL/kg – 160 mL NS. CBC, blood culture, other optional labs IV antibiotics Repeated assessment for signs of shock Continuing Education Modules 46
    47. 47. Shock Inadequate tissue perfusion (delivery of oxygen and nutrients) to meet the metabolic demands of the body. – Hypovolemic – Cardiogenic – Distributive – Septic Continuing Education Modules 47
    48. 48. Background: Shock Compensated: – Vital organs continue to be perfused by compensatory mechanisms. – Blood pressure is normal. Decompensated: – Compensatory mechanisms are overwhelmed and inadequate. – Hypotension, high mortality risk Aggressive treatment of early shock: – Halts progression to decompensated shock Continuing Education Modules 48
    49. 49. Clinical Features: Your First Clue Apnea, tachypnea, respiratory distress Skin: Pale, cool, delayed capillary refill. Warm shock will appear normal. Lethargic, weak, orthostatic weakness Tachycardia, hypotension Specific types of shock: – Neurologic deficits (spinal cord injury) – Urticaria, allergen trigger, wheezing – Petechiae, erythroderma Continuing Education Modules 49
    50. 50. Hypovolemic Shock Fluid loss: – Diarrhea, vomiting, anorexia, diuresis – Hemorrhage Resuscitation: – Fluid replacement – NS or LR 20 mL/kg bolus infusions, reassess, repeat as needed – Blood transfusion for excessive hemorrhage Continuing Education Modules 50
    51. 51. Cardiogenic Shock Poor myocardial contractility or impaired ejection: – Cardiomyopathy, congenital heart disease, myocarditis, tamponade, congestive heart failure, dysrhythmia, septic shock, drugs (e.g., thiopental) Resuscitation: – Fluid bolus (10 mL/kg) and reassess – Inotropes, pressors (e.g., dopamine, dobutamine, epinephrine) Continuing Education Modules 51
    52. 52. Distributive Shock Inappropriate vasodilation with maldistribution of blood flow: – Anaphylactic shock, spinal cord injury, septic shock – “Warm shock” Resuscitation: – Vasoconstrictors (e.g., epinephrine) – Anaphylaxis treatment – Spinal cord injury treatment – Sepsis treatment Continuing Education Modules 52
    53. 53. Septic Shock Elements of distributive shock and cardiogenic shock: – Inappropriate vasodilation with a maldistribution of blood flow – Myocardial depression Resuscitation: – Fluid bolus – Pressors and inotropes – Antibiotics (expect possible deterioration initially due to toxin release) Continuing Education Modules 53
    54. 54. Case Progression/Outcome Labs drawn IV fluids given with decrease in HR to 120 IV antibiotics given Patient admitted and discharged 4 days later Continuing Education Modules 54
    55. 55. The Bottom Line: Shock Early recognition and treatment of compensated shock may prevent progression to decompensated shock. Decompensated shock has a poor prognosis. Continuing Education Modules 55
    56. 56. EIF  Available from ACEP, AAP  Updated by PCP and specialists  Very helpful  Medical ID braceletContinuing Education Modules 56
    57. 57. The Bottom Line Obtain rapid history and assess children in shock or respiratory distress for cardiac disease. Utilize the EIF to gather information, contact specialists, and guide therapy. Echocardiography and cardiology consultation for definitive diagnosis and cardiac function determination. Continuing Education Modules 57
    58. 58. Continuing Education Modules 58

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