1. HI! I’m Emily and here to tell you to pay attention...this is a really great talk!!!!!!!!!! Have you seen my brother?…he’s sooooa annoying

2. Congestive Heart Failure in Children Thomas R. Burklow, MD LTC, MC Asst C., Pediatric Cardiology

3. Odenwald mountains Emily!!! Where are you!!!!

4. Case Presentation ª 4 month old presents to ER with cc: “cold sx” ª 5 day history of increasing cough; afebrile, no rhinorrhea, no ill contacts. ª PMH: unremarkable. vigorous feeder (25-30oz/d) until the last couple of days. ª FHx: father had a “leaky valve” but was cleared to join the Marines

5. Physical Examination ª VS: HR 165, RR 60, Nl BPs throughout; RA O 2 sat mid 80’s, increases to 97% on 1/4 L/ O 2 ª Small for age male, nondysmorphic, mild cyanosis, moderate increased work of breathing ª Left chest prominent ª Prominent PMI, RRR, S 2 obscured by murmur, gr III pansystolic SRM over apex to left axilla ª Liver edge 4 cm below RCM ª 1+ pulses throughout

6. Electrocardiogram

7. Chest X ray

8. Neckargemund Emily!!! Where are you!!!!

9. Cause of Congestive Heart Failure ª Excessive work load: pressure or volume ª Normal workload faced by a damaged myocardium

10. Etiologies ª Neonate ã dysfunction ã volume ã pressure ª Infant ã Volume ã Dysfunction ª Child ã Palliated congenital heart disease ã AV valve regurgitation ã Acute rheumatic fever ã Myocarditis ã Endocarditis

11. Clinical manifestations ª Infant ã feeding difficulties ã failure to thrive ã diaphoresis ã tachycardia ã tachypnea ª Child ã breathlessness ã tachycardia ã tachypnea ã peripheral edema ã cardiomegaly

12. Treatment ª Digitalis ã oral: 8-10 mcg/kg/day ã I.V.: 80% of oral dose ã Because of varying metabolism, appropriate dose varies by age ã Rapid digitalization ã May be performed over 12-24 hours, 6-12 hours in dire situations ã Calculate TDD (varies by age); administer 1/2 of TDD, followed by 1/4, then 1/4 of TDD ª Case example: patient weight is 5.5 kg

13. Effiel Tower at Dusk Emily!!! Where are you!!!!

14. Case example ª 5.5 kg in a 4 month old ª Oral TDD for 1 month-2 years is 30-50 mcg/kg ã TDD is 220 mcg ã Administer 110 mcg now, then 55 mcg in 12 hours, then 55 mcg in 6 hours ã IV dose is 80% of the above amounts ª Maintenance digoxin is approximately 1/4 of TDD, divided b.i.d., or at 50 mcg/cc, 0.1 cc/kg per dose b.i.d.

15. Digoxin toxicity ª Levels are helpful only in cases of suspected toxicity, not for management ª GI symptoms are common presenting symptoms: nausea, vomiting, anorexia ª Most common sign of cardiac toxicity is arrhythmia: bradycardia, AV block, PVCs ª Treatment includes holding doses for 1-2 half lives, atropine for sinus bradycardia, and “FAB” fragments in cases of significant toxicity

16. Nutrition ª What are maintenance calories for a normal infant? ª What is the metabolic state of an infant in congestive heart failure? ª What are the caloric requirements for an infant in congestive heart failure?

17. Other medications ª Diuretics ã Furosemide (Lasix); 0.5-1.0 mg/kg/dose ã Chlorothiazide (Diuril); 20-50 mg/kg/day ã Spironolactone (Aldactone); 1-2 mg/kg/day ª Afterload reduction ã Captopril (Capoten); 0.1-0.5 mg/kg/dose t.i.d. ã Enalapril (Vasotec); 0.1 mg/kg/day ª Beta-blocker ã Labetolol

18. Elliott!!! Wasn’t my dad great!?!?