1. Cardiac 101 for School Nurses
Dr. Mark Martindale

2. Outline: Normal vs. abnormal cardiac standards
School cardiac emergencies
What physicians need school nurses to know

3. Normal vs. abnormal cardiac standards

4. Heart rate Heart rate 70-120 <50 always abnormal
Regular or regularly irregular rhythm
Respiratory sinus arrythmia
***Always confirm manually if abnormal

5. Blood pressure ***Always confirm manually if abnormal
Normal Blood Pressure by Age (mm Hg)
Reference: PALS Guidelines, 2015
Age
Systolic Pressure
Diastolic Pressure
Systolic Hypotension
Birth (12 h, <1000 g)
39-59
16-36
<40-50
Birth (12 h, 3 kg)
60-76
31-45
<50
Neonate (96 h)
67-84
35-53
<60
Infant (1-12 mo)
72-104
37-56
<70
Toddler (1-2 y)
86-106
42-63
<70 + (age in years x 2)
Preschooler (3-5 y)
89-112
46-72
School-age (6-9 y)
97-115
57-76
Preadolescent (10-11 y)
61-80
<90
Adolescent (12-15 y)
64-83
***Always confirm manually if abnormal

6. Capillary refill Less than or equal to 3 seconds
Longer can indicate shock, dehydration and decreased peripheral perfusion

7. O2 sat >90% Usually is closer to 100% in children
***If cyanotic should include the nails and lips

8. Auscultation Normal: separate S1, S2 (“lub dub”)
Still’s (innocent) murmur
7 key features of an innocent murmur:
Sensitive (changes with child’s position or with respiration)
Short duration (not holosystolic)
Single (no associated clicks or gallops_
Small (limited to a small area and nonradiating)
Soft
Sweet (not harsh sounding)
Systolic
Reference: Bronzetti G, Corzani A. The seven “S” murmurs: an alliteration about innocent murmurs in cardiac auscultation. Clin Pediatr (Phila). 2010;49(7):713.

9. Auscultation continued- murmurs

10. School cardiac emergencies

11. Sudden Cardiac Arrest Incidence/survival rate
3 to 13 years – 0.61 cases per 100,000 person-years; 40% survival
14 to 25 years – 1.44 cases per 100,000 person-years; 37% survival
Often have preceding symptoms- most commonly syncope, dyspnea and/or seizures
Most have no known medical problems
Studies show actually most commonly occurs in sleep (38%) or at rest (27%). Less commonly during exercise (11%) or after exercise (4%)

12. Sudden Cardiac Arrest Most common causes in children:
Primary arrythmia (22%)
Long QT syndrome (see upcoming slide)- SEE UPCOMING SLIDE
WPW
Brugada syndrome
Short QT syndrome
Catecholaminergic polymorphic vtach
Myocarditis (7-35%)
Cardiomyopathy (16-20%)
Includes HCM, dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy
Congenital heart disease (15%)
Tetralogy of fallot, hypoplastic left heart syndrome, transposition of the great arteries, etc.
Other cardiac disease (4-8%)
Includes coronary arteritis, anomalous origin of coronary arteries, aortic dissection, pulmonary hypertension, and mitral valve prolapse
Unknown (7%)

13. Sudden Cardiac Arrest Long QT A disorder of myocardial repolarization
Most often an inherited condition in children
May have no previous symptoms
Associated with increased risk of polymorphic vtach AKA torsades de pointes
If diagnosed may have defibrillator
When in doubt respiratory support and AED!

14. Sudden Cardiac Arrest Commotio cordis
Sudden cardiac death secondary to chest wall impact
75% of cases occur in sports
Treatment is standard BLS and ACLS
Those who survive should undergo an extensive cardiac evaluation

15. Syncope Differential diagnosis: Catecholamine induced (Vtach, SVT) WPW
Most structural heart diseases
Coronary artery anomalies
Heat illnesses
Anaphylaxis
Vasovagal
Hypoglycemic
***All syncope is important and should have a full work-up
***Energy drinks, supplements and stimulants put patients are higher risk

16. NOT syncope
Seizures
Posterior migraine
Hyperventilation
Narcolepsy

17. Atrial Septal Defect This is a congenital condition
Birth prevalence of 1-2/1000 live births
Most do not cause any symptoms in infancy/childhood and are found upon auscultation of the heart
Soft, systolic murmur in LUSB
If symptomatic may tachypnea, rales, failure to thrive, hepatomegaly, recurrent respiratory failure or rarely embolic strokes

18. Superventricular Tachycardia (SVT)
Heart rate >100 bpm at rest, can be up to 270 bpm
Expect higher with exercise
This is the most common arrythmia in kids
Often due to a reentrant electrical pathway
Symptoms can include palpitations, syncope or near-syncope, lightheadedness, dizziness, diaphoresis, chest pain or shortness of breath
Symptoms usually start and stop abruptly
Determine if they are hemodynamically stable or not
If there is any hypotension, chest pain suggestive of coronary ischemia, shock, and/or decreased level of consciousness call 911
If stable can try vagal maneuvers

19. SVT continued

20. Pacemakers in Students
There is no difference in resuscitation in patients with pacemakers!

21. What to do in cardiac emergencies:
Stay calm!
Check vitals (temperature, HR, BP, O2 sat, RR)
If vital signs are stable it is very unlikely to result in harm or death
Always be prepared for BLS/AED

22. What physicians need school nurses to know

23. Measles

24. Diabetes Most commonly type 1 in kids (insulin requiring)
Carbohydrate counting
Insulin pumps
Continuous glucose monitors
Hypoglycemia

25. Sources