Cardiac 101 for School Nurses Dr. Mark Martindale

Outline: Normal vs. abnormal cardiac standards School cardiac emergencies What physicians need school nurses to know

Normal vs. abnormal cardiac standards

Heart rate Heart rate 70-120 <50 always abnormal Regular or regularly irregular rhythm Respiratory sinus arrythmia ***Always confirm manually if abnormal

Blood pressure ***Always confirm manually if abnormal Normal Blood Pressure by Age (mm Hg) Reference: PALS Guidelines, 2015 Age Systolic Pressure Diastolic Pressure Systolic Hypotension Birth (12 h, <1000 g) 39-59 16-36 <40-50 Birth (12 h, 3 kg) 60-76 31-45 <50 Neonate (96 h) 67-84 35-53 <60 Infant (1-12 mo) 72-104 37-56 <70 Toddler (1-2 y) 86-106 42-63 <70 + (age in years x 2) Preschooler (3-5 y) 89-112 46-72 School-age (6-9 y) 97-115 57-76 Preadolescent (10-11 y) 102-120 61-80 <90 Adolescent (12-15 y) 110-131 64-83 ***Always confirm manually if abnormal

Capillary refill Less than or equal to 3 seconds Longer can indicate shock, dehydration and decreased peripheral perfusion

O2 sat >90% Usually is closer to 100% in children ***If cyanotic should include the nails and lips

Auscultation Normal: separate S1, S2 (“lub dub”) Still’s (innocent) murmur 7 key features of an innocent murmur: Sensitive (changes with child’s position or with respiration) Short duration (not holosystolic) Single (no associated clicks or gallops_ Small (limited to a small area and nonradiating) Soft Sweet (not harsh sounding) Systolic Reference: Bronzetti G, Corzani A. The seven “S” murmurs: an alliteration about innocent murmurs in cardiac auscultation. Clin Pediatr (Phila). 2010;49(7):713.

Auscultation continued- murmurs

School cardiac emergencies

Sudden Cardiac Arrest Incidence/survival rate 3 to 13 years – 0.61 cases per 100,000 person-years; 40% survival 14 to 25 years – 1.44 cases per 100,000 person-years; 37% survival Often have preceding symptoms- most commonly syncope, dyspnea and/or seizures Most have no known medical problems Studies show actually most commonly occurs in sleep (38%) or at rest (27%). Less commonly during exercise (11%) or after exercise (4%)

Sudden Cardiac Arrest Most common causes in children: Primary arrythmia (22%) Long QT syndrome (see upcoming slide)- SEE UPCOMING SLIDE WPW Brugada syndrome Short QT syndrome Catecholaminergic polymorphic vtach Myocarditis (7-35%) Cardiomyopathy (16-20%) Includes HCM, dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy Congenital heart disease (15%) Tetralogy of fallot, hypoplastic left heart syndrome, transposition of the great arteries, etc. Other cardiac disease (4-8%) Includes coronary arteritis, anomalous origin of coronary arteries, aortic dissection, pulmonary hypertension, and mitral valve prolapse Unknown (7%)

Sudden Cardiac Arrest Long QT A disorder of myocardial repolarization Most often an inherited condition in children May have no previous symptoms Associated with increased risk of polymorphic vtach AKA torsades de pointes If diagnosed may have defibrillator When in doubt respiratory support and AED!

Sudden Cardiac Arrest Commotio cordis Sudden cardiac death secondary to chest wall impact 75% of cases occur in sports Treatment is standard BLS and ACLS Those who survive should undergo an extensive cardiac evaluation

Syncope Differential diagnosis: Catecholamine induced (Vtach, SVT) WPW Most structural heart diseases Coronary artery anomalies Heat illnesses Anaphylaxis Vasovagal Hypoglycemic ***All syncope is important and should have a full work-up ***Energy drinks, supplements and stimulants put patients are higher risk

NOT syncope Seizures Posterior migraine Hyperventilation Narcolepsy

Atrial Septal Defect This is a congenital condition Birth prevalence of 1-2/1000 live births Most do not cause any symptoms in infancy/childhood and are found upon auscultation of the heart Soft, systolic murmur in LUSB If symptomatic may tachypnea, rales, failure to thrive, hepatomegaly, recurrent respiratory failure or rarely embolic strokes

Superventricular Tachycardia (SVT) Heart rate >100 bpm at rest, can be up to 270 bpm Expect higher with exercise This is the most common arrythmia in kids Often due to a reentrant electrical pathway Symptoms can include palpitations, syncope or near-syncope, lightheadedness, dizziness, diaphoresis, chest pain or shortness of breath Symptoms usually start and stop abruptly Determine if they are hemodynamically stable or not If there is any hypotension, chest pain suggestive of coronary ischemia, shock, and/or decreased level of consciousness call 911 If stable can try vagal maneuvers

SVT continued

Pacemakers in Students There is no difference in resuscitation in patients with pacemakers!

What to do in cardiac emergencies: Stay calm! Check vitals (temperature, HR, BP, O2 sat, RR) If vital signs are stable it is very unlikely to result in harm or death Always be prepared for BLS/AED

What physicians need school nurses to know

Measles

Diabetes Most commonly type 1 in kids (insulin requiring) Carbohydrate counting Insulin pumps Continuous glucose monitors Hypoglycemia

Sources https://www.uptodate.com