Most people think it is easy to spot the paediatric emergency – and this usually holds true. However, this is not so in undiagnosed paediatric emergency cardiac disease, as Michele Domico explains. She delves into the practical points on recognising children over one month of age with life threatening cardiac disease. No child comes in and says, “I have chest pain” or in any way alerts the Emergency Department providers to include some type of paediatric heart disease in the differential diagnosis. This talk will review the most commonly missed cardiac “zebras”. Cardiac emergencies can masquerade as anything – fatigue, emesis, tachypnoea, septic shock, failure to thrive and abdominal pain could all point to a cardiac aetiology! Recognition is the key Recognition is the key Michele present five cases of paediatric cardiac emergencies to highlight the subtleties that can exist. Each case provides its own lesion and clinical pearl. A 7-year-old with abdominal pain and fatigue teaches us that a persistently tired child is not normal. A 5-month-old with respiratory symptoms highlights that when things do not add up, keep looking! A 4-month-old with tachypnoea since birth couple with peri-oral cyanosis teaches us that if something is abnormal, it is abnormal. Do not be falsely reassured by parents or other health care providers. A 3-month-old with tachypnoea and poor oral intake is a lesson in being aware of the quiet tachypneic! Finally, a 7-week-old with feeding problems shows us that failure to thrive is not always a gut problem – do not wear blinders when working these patients up. This presentation is meant to provide you with some helpful hints for when it is time to stray from the straight path and start entertaining a cardiac diagnosis in a sea of children complaining of respiratory, gastrointestinal, and other symptoms.

2. Needle in the Haystack
Pediatric Cardiac Disease

3. Disclaimer
When you’re a hammer everything looks like a nail

4. Managing Expectations

6. Recognition
over 1 month of age

8. something you will never see
• epos

9. 90,000 ED visits per year

11. hard to find and easy to miss

14. Abdominal Pain
Metabolic
Septic Shock
Emesis
Respiratory Distress
Failure to Thrive
Fatigue
Tachypnea

15. 30
Chang R. Arch Ped Adolesc Med 2008;162 (10): 969-74

16. cases

17. 7 year old with
abdominal pain and distention

19. Exam
mild ascites
occasional PVC’s
Labs
Slightly low serum bicarbonate
Mild increase BUN
Impression
Mild dehydration
Abdominal Sono
Ascites and small bilateral pleural effusions

20. B type Natriuretic Peptide
1400 pg/ml
(normal < 100)

21. ECHO: EF 10%

22. Idiopathic dilated cardiomyopathy

23. Healthy kids don’t fatigue easily

24. 5 month old with
respiratory symptoms

25. pH 6.8, pCO2 97 mmHg (13 Kpa), lactate 10 (normal < 2)
parainfluenza positive

26. Troponin I
1.56 ng/ml
(normal < 0.04)
B type Natriuretic Peptide
3400 pg/ml
(normal < 100)

27. EF 10%
Severe Aortic Stenosis

28. Something pushes them over the edge

29. things don't add up
pH 6.8
pCO2 97
Lactate 10

30. Don’t get locked into one diagnosis

31. 4 month old tachypnea since birth
and peri-oral cyanosis

32. that tachypnea
is not normal

33. BNP > 5000 pg/mL
ECHO:
Supracardiac TAPVR

34. Intercurrent viral infection
unmasked
Supracardiac TAPVR

35. This is abnormal

36. 3 month old
tachypnea and
poor po intake

38. BNP > 5000 pg/ml

39. Dilated LV
EF 10%

40. Viral Myocarditis

41. Anomalous
Left
Coronary
Artery
from the
Pulmonary
Artery

42. Beware of
“quiet tachypnea”
can be a sign of
poor systemic perfusion

43. 7 week old with feeding problems

44. Ranitidine
Omeperazole
Breast Milk
Gentlease
Alimentum
Rice Cereal
Elecare

46. EF 10%
Severe Coarctation of the Aorta

47. the problem was not the gut
DO2 was impaired

48. beware of cognitive bias

49. Physical exam can be misleading

50. MAP = CO x SVR
Normal HR or BP
does not necessarily
equal good cardiac output

51. Multiple doctors visits
+
child is not getting better
= consider the heart

52. B Type Natriuretic Peptide

53. ALCAPA
Coarctation of the Aorta
Aortic Stenosis
Cardiomyopathy
Myocarditis
TAPVR

54. Index of Suspicion