Pediatric Cardiology Emergencies Esmail Redha,MD,FAAP Consultant Pediatric Cardiologist

Age specific Emergencies: Newborn Emergencies Infant & Childhood Emergencies

Newborn Problems Cyanosis Low Cardiac Output

Newborn Problems - Cyanosis Cardiac Cyanosis Does not respond to oxygen Does not respond to ventilation Usually no respiratory distress

Newborn Problems - Cyanosis Evaluation Chest x-ray Arterial blood gasses(Hyperoxytest) Echocardiogram : Obstructive Lesion/Abnormal Circulation

Newborn Problems - Cyanosis Right sided obstructive lesions Pulmonary atresia Tricuspid atresia Tetralogy of Fallot

Tricuspid Atresia

Newborn Problems - Cyanosis Abnormal Circulations Transposition of the great arteries Total anomalous pulmonary venous return

Transposition of the Great Arteries

TAPVR

Newborn Problems - Cyanosis Treatment PGE1 Restoration of acid/base balance Surgical Evaluation

Newborn Problems - Cyanosis PGE mcg/kg/min starting dose Any intravenous site UAC UVC Peripheral Interosseous

Newborn Problems: Low Cardiac Output Shock Metabolic acidosis Circulatory shutdown

Newborn Problems Low Cardiac Output Evaluation Chest x-ray Arterial blood gasses Echocardiogram Electrocardiogram

Newborn Problems Low Cardiac Output Left Sided Obstructive lesions Hypoplastic left heart Critical aortic stenosis Critical coarctation of the aorta

Hypoplastic Left Heart

Severe Coarctation

Without a PDA there is no blood flow to the abdomen and lower extremities. (Blue blood is better than no blood.) Ductal-Dependent Lesion

Newborn Problems: Low Cardiac Output Muscle diseases Myocarditis Cardiomyopathies Sepsis Asphyxia

Newborn Problems : Low Cardiac Output Heart Rate Problems Supraventricular tachycardias Complete heart block

Newborn Problems Low Cardiac Output Supraventricular Tachycardia Narrow Complex Heart Rate > 220 bpm Usually > 240 bpm

Narrow Complex Tachycardia

Newborn Problems Low Cardiac Output Complete Heart Block Heart rate below 60 bpm No relationship between P waves and QRS’s

Complete Heart Block

Newborn Problems Treatment Left heart obstructive lesions Muscle diseases Heart rate problems PGE1 Inotropic support, afterload reduction & Diuretics. Slow down or speed up

Infant and Childhood Problems: Hypercyanotic spells Congestive heart failure Arrhythmias

Infant and Childhood Problems Hypercyanotic Spells Tetralogy of Fallot Pulmonary Atresia

Tetralogy of Fallot

Infant and Childhood Problems Hypercyanotic Spells Sudden decrease in pulmonary blood flow, usually in the morning Provocation

Raised apex

Hypercyanotic Spells Treatment Calming Oxygen Morphine Positioning Beta Blocker Phenylepherine

Hypercyanotic Spells Phenylepherine Increase systemic vascular resistance which leads to less R - > L shunting and improved saturation

Hypercyanotic Spells Long Term Treatment with Propranolol Indication for surgery, either palliative shunt or total repair

Congestive Heart Failure Differing etiology at different ages

Congestive Heart Failure Presentation in Infancy Structural Diseases: Left Heart Obstructions First days:Hypoplastic Left Heart Syndrome Critical aortic stenosis First month: Coarctation of the aorta First 2 months: Left-to-right Shunts VSD, PDA, Truncus Arteriosus

Congestive Heart Failure Presentation after infancy Progression of structural heart disease Arrhythmias Infectious diseases Later onset myopathies Toxins: Anthracyclines Diphtheria

Congestive Heart Failure Pre-load Afterload ContractilityHeart Rate Determinants of Cardiac Output

Heart Failure Heart Failure Sympathetic Tone Renin & angiotension Arterial & venous constriction + HR & coronary vasoconstriction Ventricular preload & afterload Myocardial blood flow Worsening heart failure

CHF Management Sites of action of drugs used to treat heart failure:

Congestive Heart Failure Preload reduction Diuretics Fluid Restriction High caloric density

Congestive Heart Failure Afterload reduction ACE inhibitors Nitroprusside

Congestive Heart Failure Heart Rate modification Beta Blockers(eg.:Carvedilol) Also treats diastolic dysfunction & remodeling

Contractility Acute Treatment Beta Agonists Dobutamine Afterload reduction also Epinepherine Dopamine Increased myocardial demands Milrinone(makes wonders)

Contractility Milrinone increases contractility and reduces afterload without increasing myocardial oxygen demand

Contractility Chronic Treatment Digoxin New Treatments: Biventricular Pacing, Assist Device.

Arrhythmias Narrow Complex Tachycardias

Arrhythmias Supraventricular Tachycardia

Arrhythmias Re-entrant Tachycardias AV node re-entry Wolff-Parkinson-White

Wolff-Parkinson White

Wolff-Parkinson White S (WPW) 1. Short PR interval. 2. Delta wave (initial slurring of the QRS complex). 3. Wide QRS duration.

Arrhythmias Treatment Pre-hospitalization Diving reflex Ice Bag to the face Valsalva Carotid Massage(no longer recommended)

Arrhythmias Hospitalization Adenosine Diagnostic and therapeutic

Arrhythmias Adenosine 100 mcg/kg IV rapid push Repeat every 5 minutes with increasing doses

Arrhythmias Shock requires Shock Synchronized cardioversion 1 joule/kg

Arrhythmias Digoxin Loading Beta Blocker Calcium Channel Blocker(not indicated in infants). Felcainide Amiodarone Procainamide loading Repeat adenosine

Image 3 Wide QRS Tachycardia

Ventricular arrhythmias Common cause of sudden death in repaired congenital heart disease and acquired pediatric heart disease and cardiomyopathy 0.001% annual risk in general pediatric population 1-3% annual risk in many repaired CHD 4-6% risk in HCM 25-30% risk in dilated cardiomyopathy Final common pathway for cardiac arrest in many conditions From Cardiac Arrhythmias in Children and Young Adults with Congenital Heart Disease. Walsh, et al. (2001) From Cardiac Arrhythmias in Children and Young Adults with Congenital Heart Disease. Walsh, et al. (2001).

Remember: Prolonged QT interval This pt.C/O recurrent fainting attacks

Ventricular tachycardia Differential diagnosis Ventricular tachycardia Supraventricular rhythm with aberrant conduction Rate related Permanent bundle branch block Preexcited rhythm Supraventricular rhythm with preexcitation Antidromic tachycardia Two-pathway tachycardia Paced rhythm Treatment depends on appropriate diagnosis!

Wide Complex Tachycardias Treat all as if Ventricular Tachycardia

Wide Complex Tachycardias Unstable rhythm requires Cardioversion 2 joules/kg(shock requires shock).

Image 4 Ventricular Fibrillation

Ventricular tachycardia Treatment Address treatable causes Electrolytes Acidosis Pharmacotherapy Class Ib – lidocaine Class III – amiodarone Electrical therapy Cardioversion Implantable defibrillator

Wide Complex Tachycardias Surgical Therapy Automatic Implantable Cardioverter- Defibrillator

Remember: 1- Sinus tachycardia 2- Supraventricular tachycardia 3- Ventricular tachycardia 4- Atrial flutter 5- Atrial fibrillation

Ventricular fibrillation ‘nuff said

Automated External Defibrilator

Step I

Step II

Step III

Step IV

Step VI

Messages to Take Neonatal Screening: Upper & Lower Extremities O2 Sat. check. Don’t Panic with Arrhythmias: Shock when in Shock. Introduce Autamated External Defibrilator.

THANK YOU