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

2. Age specific Emergencies: Newborn Emergencies Infant & Childhood Emergencies

3. Newborn Problems Cyanosis Low Cardiac Output

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

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

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

8. Tricuspid Atresia

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

10. Transposition of the Great Arteries

11. TAPVR

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

13. Newborn Problems - Cyanosis PGE1 0.05-0.1 mcg/kg/min starting dose Any intravenous site UAC UVC Peripheral Interosseous

14. Newborn Problems: Low Cardiac Output Shock Metabolic acidosis Circulatory shutdown

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

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

17. Hypoplastic Left Heart

18. Severe Coarctation

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

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

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

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

23. Narrow Complex Tachycardia

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

25. Complete Heart Block

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

27. Infant and Childhood Problems: Hypercyanotic spells Congestive heart failure Arrhythmias

28. Infant and Childhood Problems Hypercyanotic Spells Tetralogy of Fallot Pulmonary Atresia

29. Tetralogy of Fallot

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

31. Raised apex

32. Hypercyanotic Spells Treatment Calming Oxygen Morphine Positioning Beta Blocker Phenylepherine

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

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

35. Congestive Heart Failure Differing etiology at different ages

36. 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

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

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

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

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

42. Congestive Heart Failure Preload reduction Diuretics Fluid Restriction High caloric density

43. Congestive Heart Failure Afterload reduction ACE inhibitors Nitroprusside

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

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

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

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

48. Arrhythmias Narrow Complex Tachycardias

49. Arrhythmias Supraventricular Tachycardia

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

51. Wolff-Parkinson White

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

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

54. Arrhythmias Hospitalization Adenosine Diagnostic and therapeutic

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

56. Arrhythmias Shock requires Shock Synchronized cardioversion 1 joule/kg

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

58. Image 3 Wide QRS Tachycardia

59. 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).

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

61. 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!

62. Wide Complex Tachycardias Treat all as if Ventricular Tachycardia

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

64. Image 4 Ventricular Fibrillation

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

66. Wide Complex Tachycardias Surgical Therapy Automatic Implantable Cardioverter- Defibrillator

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

68. Ventricular fibrillation ‘nuff said

69. Automated External Defibrilator

70. Step I

71. Step II

72. Step III

73. Step IV

74. Step VI

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

76. THANK YOU