Approach to pediatric cardiovascular emergency ; The most common presentation of Cardiovascular disease in pediatric emergency department

1. Pediatric Cardiovascular
Emergency
Approach and initial management of PCE for pediatrician
Dr Hamid Mohammadi
Pediatric Cardiologist
Shiraz University of Medical sciences – Pediatric Ward
Nov 2016
Thanks for Dr Shahraban Abdulla ;Consultant Pediatric Cardiologist; Latifa Hospital, DHA for sharing his presentation in this field

2. What we earn with this presentation
Lecture structure
Cardiovascular
emergency
among
pediatric
emergency
department
Introduction
What we
should done
Management
Guide to
correct
diagnosis
Clue for DDX
Sign and
Symptom
Common Cause
What is the
presenting
scenario
Presentation

3. Introduction
• Cardiac emergencies are among the most
stressful ED presentations.
• Cardiac Problem in infancy & childhood are
not rare, often are complex.
• Cardiac disease in infancy & childhood can be
congenital or acquired.
• 2nd or 3rd cause of emergency mortality
department

4. PCE - Common Causes
Ductal Dependent:
Pulmonary circulation Dependent Cyanosis
Systemic Circulation Dependent  Circulatory collapse
Decompensated HF
Myocardium / Shunt / CHD / Arrhythmia
Arrhythmia
Sudden event / gradual presentation
Tamponed
PH crisis

5. DUCTAL DEPENDENT
CHD with PDA dependency

6. Scenario one
• A 5 days old neonate with cyanosis and irritability since
last night
– She is product of NVD with no significant prenatal and delivery
time history
– Now she is tachypnic and has respiratory distress

7. Ductal dependent lesion- Causes
Systemic Circulation dependent
• Presented with Cardiogenic shock and circulatory collapse
• The major causes:
• Hypoplastic Left Heart Syndrome
• Pre-ductal Coarcotation
• Interrupted Aortic Arch
• Critical Aortic Stenosis
Pulmonary circulation dependent
• Presented with cyanosis and irritability
• The major causes:
• Tricuspid Atresia
• Pulmonary Atresia
• Critical pulmonary stenosis
• Ebstein anomaly Functional PA
• TGA ?

8. Ductal dependent lesion- Presentation
Shock (systemic circ.)
• Pale an cold
• Absent Lower pulse (Femoral pulse detection is
critical to Dx)
• Wet lung
• Hepatomegaly
Cyanosis (pulmonic circ.)
• Clear lung
• No hepatomegaly
• Profound cyanosis –Hyperoxia test

9. Ductal dependent lesion- Management
Critical Neonate
PGE1
Cyanotic
+++
Collapse
+++
O2 therapy
Cyanotic
++
Collapse
+/-
IV fluid
Cyanotic
Free
Hydrate
Collapse
+/-
(Restrict)
Inotrope
support
Cyanotic
-
Collapse
+
Anti-PH Rx
Cyanotic
+
Collapse
-

10. Hyper cyanotic Attack
• TOF physiology is the major cause of this attack
– May be result of non cardiac source
• Presentation:
– Period of uncontrollable crying / panic
– Rapid and deep breathing (hyperpnoea)- Clear lung
– Deepening of cyanosis
– ↓heart murmur
– Limpness, convulsions
– Rarely, death.
– Common in Early morning

11. Spell Physiology
and Tx
Pain or
anxiety
Increase
catecholamine
stat
- Decrease SVR
- +/- Increase
PVR
- Tachycardia
- Increase shunt
Rt  Left
- Decrease Rt
preload
Increase
cyanosis
Treatment strategy:
• ↑ SVR
• Knee chest position
• Phenylephrine
• Decrease anxiety:
• Hugging Baby
• Morphine
• O2 therapy
• Hydration
• Treatment of Acidosis
• Inderal (0.01mg/kg Iv
slowly)
• Sedation and Intubation
• Ketamine (↑ SVR)

12. DECOMPENSATED HEART
The end stage of Cardiac disease

13. Scenario Two
• A 6 month old infant with nausea,
vomiting and malaise since 2 weeks ago.
Since 2 days ago patient had sporadic
cough and also poor feeding
– Negative family history of any cardiac
disease in childhood
– Patient has grunting and R/D
– Abdominal exam reveled Hepatomegaly

14. Decompensated Heart - Causes
• Shunt
Pulmonary overflow CHF
• Myocarditis
• Musculopathy
• Metabolic cause
• Ischemic cardiomyopathy
CHF due to Impaired myocardium
• Lt side obstructive (AS- COA …) – usually in early presentation
CHF due to obstructive lesion
• Any neglected arrhythmia may lead to CHF
Tachyarrhythmia induced CHF

15. Decompensated Heart – Common
Presentation
• Different causes lead to similar sign and
symptom in the end stage  Typical CHF
presentation
– Diagnostic Clue for HF:
• Gallop Rhythm
• Hepatomegaly (Rt side failure)
• Poor filling pressure (More with Lt side failure)
• Cold extremity (More with Lt side failure)
• Rales (Lt side Failure)

16. Decompensated Heart – Specific Presentation
Load P2
• Shunt
• Lt side obstructive lesion
Different Lower and Upper
extremity pulse or HTN
• COA
PMHx of common cold
• Myocarditis
Systemic disease (Muscle-
Metabolic)
• Myopathy
• Metabolic
Constant rapid pulse or
abnormal ECG
• Arrhythmia
Obstructive Murmur( AS )
• Lt side Obstructive lesion

17. Decompensated Heart failure- Management
• Usually the most effective Rx +++
• Caution regard obstructive lesion
Diuretic
Lasix - Spironolactone
• Restricted +++
• No Restriction in Obstructive Lesion
IV fluid management
• Most case recommended ++
• Caution in Obstructive Lesion
Inotrope support
• Effective ,specially in Lt side failure++
• Contraindicate in Obstructive lesion
Captopril
• Not essential Rx in Acute Phase
• May hold in Arrhythmia
• Caution in Myocarditis
Digoxin
• May be benefit in some case (+/-)
• Caution in Shunt and obstructive lesion
Anti-PH
Rx

18. ARRYHTMIA
When your art and knowledge are everythings

19. Scenario Three
A 8 years olds girl with palpitation since 2
days ago
Patient had Some similar events with
spontaneous relief in last year.
No relation to exercise
A 14 years olds boy with faint during
football.
Patient is unconscious and no pulse
detected

20. Emergency Dysrhythmia
Causes and Presentation
Sudden Death-
Tachyarrhythmia
• Ventricular origin
• VF – VT - Torsade
point
Gradual course-
Tachyarrhythmia
•SVT
•Slow VT
•Atrial Fibrillation /Flutter
Brady arrhythmia
• Rarely present as
sudden event
• Fainting and HF is the
most common
presentation

21. Emergency Dysrhythmia - Management
Emergency dysrhythmia
Pulse present
Wide
Complex
Unstable
S.
Cardioversion
for VT
Stable
Monomorphic
Rhythm (? SVT
aberrancy)
Adenosine
Amiodarone
Narrow
Complex
Unstable
S.
Cardioversion
for SVT
Stable
Adenosine
Amiodarone
No Pulse
CPR
Defibrillation
Epinephrine

22. TAMPONAD
Diagnosis is critical for early intervention

23. Scenario Four
A 4 years olds girl with shortness of breath and
chest discomfort since 3 days ago
He had a history of common cold in two weeks ago
that with some OTC drugs improved.
The patient is lethargic and heart sound is muffled
A 10 years old boy with history of prolonged fever ,
chest pain and mild tachypnea since one month ago
He ecived multiple Antibiotic treatment without
significant efficacy
Since last night his condition worsen and now he is
agitated and can not lying down for examination.

24. Tamponade- Causes
Viral Pericarditis The most common cause of Pericardial effusion
Heart failure
Nephrologic
cause
Renal Failure
Nephrotic Syndrome
Post cardiac
Surgery
Tuberculosis Rarely lead to tamponade
Malignancy
Hypothyroidism
Lupus
Trauma

25. Tamponade - Presentation
• Beckes triad is not usual in pediatric
and is late finding ( Muffled Heart
sound, Engorge Neck vein ,
Hypotension)
• Pulsus paradoxus
• Kussmaul's sign
• Non specific symptom
• Need high index of suspicion to
detect
• Need Echocardiographic assessment
for early intervention

26. Tamponade - Presentation

27. Decompensated Heart failure- Management
• Indicated in all case of Tamponade or near tamponade
Pericadiocentsis or surgical
intervention
• Contraindicate
• Only may be use in HF and Renal failure with caution
Diuretic
Lasix - Spironolactone
• Maintainace or 1.5 time of maintenance
• Restriction with repeated evaluation in HF and Renal failure
IV fluid management
• Not indicated in most case except Heart failureInotrope support
• Not indicatedCaptopril - Digoxin
• Maintence therapy (after Pericardiocentesis or before it in
non symptomatic effusion)
Aspirin - NSAID

28. Points
• History and Physical exam is the most
informative data to select the best management
in pediatric Cardiovascular emergency (PCE)
• Most of Cardiovascular emergency could be
managed without echocardiography in initial
visit
• Iv fluid handling, Diuretic and inotrope
support are the 3 basis of treatment in the PCE

29. Research proposal
What is the
position of
cardiovascula
r emergency
in our
Emergency
department
visits,
morbidity and
mortality.
What are the
most common
pitfall &
mismanagem
ent in
approach to
PCE in our
emergency
department
Role of
Simulation
based
education in
preparing
pediatrician
for PCE
Is it possible
to publish a
guideline for
some
common PCE
management
in our center
I’m working
on a PCE
case book and
any
cooperation
in this field is
welcome

30. Dr Hamid Mohammadi
Thank you