1. Julie Kuzin, MSN, RN, CPNP-AC/PC
Care of the Cardiac Patient: Identification of Red Flags and Interventions
Elise Balasa, BSN, RN, CPN
Julie Kuzin, MSN, RN, CPNP-AC/PC
Trang Vu, BSN, RN, CPN

2. Objectives
Identify common cardiac conditions seen in the pediatric population
Recognize “red flags,” that indicate a change in the pediatric cardiac patient’s condition
Identify nursing interventions implemented to prevent pediatric cardiac complications

3. Background Care of the cardiac patient is a complex task
Many different types and variations of cardiac conditions
Over 28,000 patient encounters at Texas Children’s Heart Center last year
926 surgeries performed

4. Background High risk for rapid deterioration
124 RRT’s (rapid response) in FY 2017
93 acute care, 31 stepdown
27 REACT’s in 2017, 12 REACT’s in 2018
Warning signs or “red flags” may indicate worsening assessment

5. Examples of Cardiac Conditions
Ventricular Septal Defect
Hypoplastic Left Heart Syndrome (HLHS)
Tetralogy of Fallot
Left Ventricular Assist Devices (Berlin and Heartware)

6. Ventricular Septal Defect (VSD)

7. Hypoplastic Left Heart Syndrome (HLHS)
Small or hypoplastic left ventricle and left sided structures
1. Mitral valve stenosis or atresia
2. Aortic valve stenosis or atresia
3. Hypoplastic Left Ventricle
4. Hypoplastic Ascending Aorta
5. Coarctation of the Aorta
6. Atrial Septal Defect

8. Hypoplastic Left Heart Syndrome (HLHS)
Surgical Palliation of HLHS
Norwood or Sano Procedure (neonatal period)
Bidirectional Glenn (4 months)
Fontan (3-4 years)

9. Hypoplastic Left Heart Syndrome (HLHS)
Norwood or Sano Procedure (neonatal period)
BT shunt or Sano modification

10. Hypoplastic Left Heart Syndrome (HLHS)
Bidirectional Glenn (4 months)

11. Hypoplastic Left Heart Syndrome (HLHS)
Fontan (3-4 years)

12. Tetralogy of Fallot Cyanotic heart condition
1. Ventricular Septal Defect (VSD)
2. Pulmonary Artery or Pulmonary Valve Stenosis
3. Overriding Aorta (above the VSD)
4. Right Ventricular Hypertrophy

13. Left Ventricular Assist Devices
Heartware
Pump connected from left ventricle to the aorta
Continuous flow of blood
Berlin
“Artificial pump”
Cannulas and external pump

14. Red Flags for Cardiac Patients
Head
Eating
Acute changes
Respiratory status
Total intake/output
Sternal precautions

15. H.E.A.R.T.S. Head- Signs and Symptoms Fatigue or lethargy
Behavior changes
Irritability, inconsolability, fussiness
Signs or symptoms of stroke
Weakness or numbness (one-sided)
Slurred speech or difficulty with comprehension
Seizures
Altered mental status
Headache
Changes in vision

16. H.E.A.R.T.S.
Head
9 to 12 times higher risk of ischemic stroke in young adults (18 to 55 years old) with CHD
Case study showed children with CHD or previous cardiac surgery were 31 times more likely to experience stroke (Ducharme-Crevier, L., & Wainwright, M.S., 2015)
Systematic review found stroke rate of 9.8% in LVAD patients; 1/3 patients died secondary to ischemic, 2/3 patients died secondary to intracranial hemorrhage (Cho, S.M., Moazami, N., & Frontera, J.A, 2017)

17. H.E.A.R.T.S. Head- Interventions Obtain vital signs
Notify team if patient’s fussiness
does not improve after interventions
(pain medication, change in feeding rate)
Activate RRT if sudden lethargy

18. H.E.A.R.T.S. Head- Interventions Stroke interventions:
Stabilize ABC’s=
airway, breathing, circulation
Neuroimaging (MRI, CT)
Labs (PTT, PT, platelet count)
Transesophageal Echocardiogram
Transfer to higher level of care for antithrombotic therapy or other interventions

19. H.E.A.R.T.S. Eating- Signs and Symptoms Feeding intolerance
Persistent vomiting
Disinterest in eating
Irritability while feeding
Slow eating and lethargy
Diaphoresis with feeds
Difficulty with coordination of feeding and breathing
Blood in stool
Abdominal distention

20. H.E.A.R.T.S. Eating- Interventions
Fortification of formula or breast milk
Enteral feeds
Nasogastric tube, G-tube,
ND tube
Use of specialty nipples or
bottles
Administration of reflux
medications
Monitor patient’s respiratory rate
Do not feed if rate > 60
Monitor for blood in stool

21. H.E.A.R.T.S. Acute changes- Signs and Symptoms
Any acute change in the patient’s baseline assessment
Change in heart rate or rhythm
Tachycardia, bradycardia, arrhythmias
Change in skin color or temperature
Cool, clammy, mottled, cyanotic, slow capillary refill
Concern from parents is significant

22. H.E.A.R.T.S. Acute changes- Signs and Symptoms Change in vital signs
Hypotension vs. hypertension
Desaturations or high saturations than expected for heart defect
Large gradient between upper and lower extremity blood pressure
Edema
Complaints of chest pain
Auscultation of murmur
Gallop or friction rub

23. H.E.A.R.T.S. Acute changes- Interventions Utilize vitals trend graph
Chest X-Ray
Heart size or examination of lungs
Echocardiogram
Heart function (ejection fraction)
Evaluation of valves
Assess disease processes, endocarditis or pericardial effusion
EKG
Arrhythmias
ST segment changes
RRT or Code if deterioration in patient condition

24. H.E.A.R.T.S. Respiratory status- Signs and Symptoms Tachypnea Cyanosis
Retractions, new or increased from baseline
Nasal flaring or grunting
Breath sounds diminished, course or with crackles
Hypoxia
Right to left shunting

25. H.E.A.R.T.S. Respiratory status- Interventions Obtain chest x-ray
Apply oxygen, be aware of heart defect prior to administration
May need diuretics if pulmonary edema present
Minimize stimulation
Hold feeds
Activate RRT or Code if deterioration in patient condition

26. H.E.A.R.T.S. Total intake and output- Signs and Symptoms
Fluid balance closely monitored, dehydration affects shunt flow, over hydration affects pulmonary edema
Strict intake and output, ensure diaper scale zeroed and diaper wipes removed
Need daily weights, same time same scale
Goal of fluid balance and weight gain
Includes chest tube output

27. H.E.A.R.T.S. Total intake and output- Interventions
Diuretic adjustment
Monitor vital signs (especially BP)
Monitor weight gain, need to demonstrate 2 days of weight gain for discharge
If unable to increase volume, will need to increase kcal

28. H.E.A.R.T.S. Sternal Precautions- Signs and Symptoms
Breastbone wired together surgically, takes 6 – 8 weeks to heal
Sternotomy vs thoracotomy

29. H.E.A.R.T.S. Sternal Precautions- Interventions
No tummy time for 6 weeks
Do not lift by under the arms, nor use arms to push or pull greater than 5 pounds for 6 weeks
Avoid repetitive activities and play that may cause chest trauma for 6 weeks
No backpacks for 12 weeks
Always be in age/weight appropriate car seat or wear a seat belt when traveling by car.
Do not hesitate to perform CPR if needed

30. TCH Pediatric Advanced Warning Score (PAWS)
Scoring tools of early warning signs are useful aids in the identification of impending cardiac arrest or death in 48 hours (Smith, M.E., Chiovaro, J.C., Kansagara, D., Quinones, A.R., Freeman, M., et al., 2014)

31. Case Study - Zach
Zach is a 3 year old boy admitted for tachypnea and suspected pneumonia. He has been growing and developing normally but has had 2 other admissions for respiratory illnesses. His mother is often concerned about him as she thinks he gets out of breath after playing, more commonly than other children. CXR this admission was concerning for cardiomegaly therefore cardiology has been consulted.

32. Case Study - Zach
Physical Exam: General: well developed, slim male, non-distressed HEENT: symmetric features, pink, no lymphadenopathy, tympanic membranes normal Chest: clear to auscultation, slightly diminished breath sounds to left chest, normal S1 and S2, grade II systolic murmur at apex Abdomen: flat, soft, liver at 3cm below right costal margin Extremities: warm & well perfused, cap refill brisk, upper extremity pulses 2+, lower extremity 1-2+ Neuro: pleasant, cooperative, normal tone

33. Case Study - Zach
Vital Signs HR: 96 RR: 38 SpO2: 96% BP: 115/65 Temp: 99oF ax

34. 4 extremity BP
115/ /38
Cardiology came by and asked you to obtain a 4 extremity BP
75/ /38

35. Coarctation Clarify anatomy – head and neck vessels related to 4ext BP
Too little systemic blood flow
Rare case – late diagnosis, missing some classis symptoms – (decreased LE pulses, lower half of body pale, mottled, dusky)
Chronic vs. acute presentation, collateral formation

36. 4 extremity BP
95/ /50
Why are the lower extremity BPs higher than the arms?— caused by pulse wave amplification, which is normal! No coarctation suspected here.
105/ /53

37. Assessing for Coarctation
4 extremity blood pressure
Must be done sequentially, one right after the other, while patient is in same state.
Obtain right arm first. (to avoid artificially inflating the right arm BP if child becomes upset after 1st measurement)
Compare the right arm systolic BP to bilateral lower extremity systolic BP. If >15mmHg difference from 2 reliable measurements, consider further workup.

38. Case Study – Everly
Everly is a 9 yr old girl presenting to the EC for nausea, loss of appetite, & vomiting x 2 weeks. The vomiting occurs 1-2 x per day, nausea is persistent. She is afebrile, brother had cough and congestion 3 weeks ago but has recovered fully.

39. Case Study - Everly What’s wrong with Everly?
Physical Exam: General: well developed, fatigued, cooperative, pale, ill appearing HEENT: symmetric features, pale pink, no lymphadenopathy, tympanic membranes normal, dark under eyes, dry lips Chest: clear to auscultation, normal S1 and S2, grade I systolic murmur at apex, S3 gallop Abdomen: flat, soft, liver at 4cm below right costal margin Extremities: hands and feet cool, cap refill 3 sec, pulses 1+ throughout Neuro: sleepy, cooperative, equal strength but weak
Differentials: Gastro. Dehydration. Septic shock. Heart failure. Liver failure. Viral syndrome
Why – what are the clues on exam and history --- gastro for 3 weeks??? She may have a couple of things going on…
CXR next
What’s wrong with Everly?

40. Case Study - Everly
Vital Signs HR: 130 RR: 26 SpO2: 96% BP: 110/72 Temp: 98oF ax

41. Case Study - Everly
There may be several things going on….but 1 thing s for sure – heart failure

42. Case Study - Everly Chief Complaint: nausea & vomiting Let’s bolus!
Dehydration
Likely gastro…
Let’s bolus!

43. Heart Failure in Children
Feeding intolerance in babies
Loss of appetite
Nausea
Abdominal pain
Heart failure is missed in children because of the misleading nature of abdominal symptoms due to heart failure
- Liver dysfunction, gastric vessel engorgement, poor perfusion to gut
Failing heart or unbalanced circulation.

44. Conclusion
Monitoring for red flags is crucial for early detection and prevention of decompensation
Contact Cardiology service at any time with patient concerns
With knowledge and teamwork, cardiac patients receive optimal care hospital wide

45. References
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46. References
 Smith, S.E., & Fox, C. (2017). Ischemic stroke in children and young adults: Etiology and clinical features. Retrieved July 9, 2017, from UpToDate database,
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WWTBF: Which Way The Blood Flows handbook