Pediatric Cardiology Emergencies Dr. Zahra Jalili Imam Ali cardiovascular center

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 Echocardiogram

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 PGE1 0.1 mcg/kg/min 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

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 and afterload reduction 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

Hypercyanotic Spells Treatment Calming Oxygen Morphine 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 Contractility Heart Rate Determinants of Cardiac Output Afterload

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 Also treats diastolic dysfunction

Contractility Acute Treatment Beta Agonists Dopamine Dobutamine Afterload reduction also Epinepherine Dopamine Increased myocardial demands Milrinone

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

Contractility Chronic Treatment Digoxin New Treatments

Arrhythmias Narrow Complex Tachycardias

Arrhythmias Supraventricular Tachycardia

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

Wolfe-Parkinson White

Arrhythmias Treatment Pre-hospitalization Diving reflex Valsalva Ice Bag to the face Valsalva Carotid Massage

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 If adenosine fails: Calcium Channel blockers Not in infants!

Arrhythmias Digoxin Loading Procainamide loading Repeat adenosine

Ventricular Tachycardia Image 3 Ventricular Tachycardia

Wide Complex Tachycardias Treat all as if Ventricular Tachycardia

Wide Complex Tachycardias Unstable rhythm requires Cardioversion 2 joules/kg

Ventricular Fibrillation Image 4 Ventricular Fibrillation

Wide Complex Tachycardias Medical therapy Lidocaine Amiodarone

Wide Complex Tachycardias Surgical Therapy Automatic Implantable Cardioverter-Defibrillator

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