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Emergency Cardiovascular Problems in Pediatrics
Jarupim Soongswang, M.D.
Professor in Pediatric Cardiology
Dept of Pediatrics, Faculty of Medicine
Siriraj Hospital, Mahidol University
Annual Meeting in Emergency Medicine
Feb 5, 2011
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LOGO
Emergency cardiovascular problems in pediatrics
Cyanosis: hypoxic spell, ductal dependent pulmonary
circulation
Dyspnea, tachypnea: congestive heart failure
Hypotension: cardiogenic shock, low cardiac output,
cardiac tamponade, ductal dependent systemic circ,
pulmonary hypertensive crisis, VT
Palpitation: SVT, atrial flutter
Syncope: complete heart block, long QT syndrome, AS
Chest pain: congenital coronary artery abnormal,
pericarditis
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Case 1
A seven-year-old boy presents with dyspnea,
tachypnea for 1 day. He has had upper
respiratory tract infection for 2-3 days with
rhinorrhea, low grade fever.
PE: T 36.5oC, RR 40/min, HR 140/min, BP 80/60,
dyspnea, capillary refilled 5 second,
restlessness
Lung: fine crepitation,
CVS: Normal S1,S2, S3 gallop, soft SM grade 2/6
at apex
Liver: 3 cm below RCM, rubbery consistency
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Cardiogenic shock
Definition: Inadequate CO and O2
transport to vital organs and functions.
Continuing process of CHF.
Life threatening condition.
Requires aggressive and prompt
treatment.
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Physiology :CO = HR X SV
SV = EDV X (EDV-ESV)
EDV
CO = HR X EDV X EF
Oxygen delivery = CO x Hb X SaO2 x 13.9
CO: cardiac output, HR: heart rate, SV: stroke volume,
EDV: end diastolic volume, ESV: end systolic volume, EF:
ejection fraction, HB: hemoglobin, SaO2: oxygen
saturation
Cardiogenic shock
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Cardiogenic shock
Clinical manifestations
Low cardiac output
• Grayish color
• Poor peripheral perfusion
• Hypotension
• Conscious change
• Urine output decrease<0.5-1 ml/kg/hr.
• Metabolic acidosis
• Decrease oxygen saturation in venous
blood gas
• Increase serum lactate
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Signs and symptoms of low cardiac outputs
Organ System CO CO Shock
CNS - Restless, apathetic Agitated-confused,
Respiration - Ventilation Ventilation
Metabolism - Compensated Uncompensated
mtabolic academia metabolic academia
Gut - Motility lleus
Kidney Specific gravity, Oliguria Oliguria-anuria
volume
Skin Delayed capillary Cool extremities Mottled, cyanotic,
refill cold extremities
CVS Heart rate Heart rate, Heart rate, blood
Peripheral pulses pressure, central
pulses only
CNS, central nevous system; CVS, cardiovascular system;,slightly increases;
,greatly
increased; , slightly decreased; , greatly decreased.
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Minimum blood pressure to diagnose hypotension
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LOGOCardiogenic Shock
1. Congenital heart diseases eg.
Ductal dependent lesion: Left sided obstructive lesions
Etiology:
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Right sided obstructive lesions
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Cardiogenic shock
Etiology
2. Myocardial diseases:
myocarditis, cardiomyopathy
3. Cardiac dysrhythmia
4. Cardiac tamponade
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Specific: correct causes eg arrhythmia,
tamponade, PGE1, etc.
Supportive and symptomatic treatments:
• Augment contractility: inotropes
• Afterload: vasodilators
• Decrease O2 consumption: sedate, bed
rest, respiratory support
• O2 supplement
• Correct metabolic: electrolytes, sugar,
anemia,
Management of cardiogenic shock
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แสดงยาที่ใชใ้นการรกัษา cardiogenic shock
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aPVR , pulmonary vascular resistance; SVR, systemic vascular resistance; and PDE3, phosphodiesterase inhibitor.
Agent Site of action Dose (µg/kg/min) Effecta
Dopamine Dopaminergic
β
> β
0.5-4
4-10
11-12
Renal vasodilator
Inotrope
Peripheral vasoconstriction
Increased PVR
Dysrhythmias
Dobutamine β 1 and β 2 1-20 Inotrope
Vasodilation (β2)
Lowers PVR
Weak a-activity
tachycardia
and extrasystoles
Isoproterenol β 1 and β 2 0.05-2.0 Inotrope
Vasodialtation
Lowers PVR
MVO2
Dysrhythmias
Norepinephrine > β 0.005-2.0 Profound constrictor
Inotrope
MVO2, SVR
Amrinone PDE3 inhibitor 1-20 Inotrope
Chronotrope
Vasodilatation
Milrinone PDE3 inhibitor Load 50 µg/kg > 10
min then 0.375-0.75
µg/kg/min
Same as Amrinone
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Management of cardiogenic shock
Monitoring: Intensive care
Invasive arterial blood pressure:
Central venous pressure:
Pulmonary artery wedge pressure:
Urine output:
Arterial blood gas, venous gas
Serum lactate
Blood chemistry: liver function, kidney
function, sugar, electrolytes
Non-invasive monitoring : ECG, O2 sat, RR, T
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Case 2
A one-year-old boy with history of cyanotic
heart disease presents with deep cyanosis
after crying for 15 min.
He develops dyspnea and unconscious
PE: RR 30/min, PR 120/min, BP 80/65, deep
cyanosis, O2 sat 40-50%,
Heart: normal S1, S2, SM grade 1/6 LUSB
Lung: clear
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Hypoxic spell
Definition: Sudden and transient
uncompensated hypoxia in cyanotic heart
diseases (Rt to Lt shunt)
TOF is the prototype
Majority is self limited in 15-20 mins.
Depend on balance between pulmonary and
systemic pressure and resistance
Precipitating factors: crying, defecation etc.
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RV LV
PVR SVR
PA AO
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Pathophysiology of hypoxic spell
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Hypoxic spell
Signs and symptoms: Increase in
cyanosis, hyperpnea, conscious
change, decrease intensity of SEM, syncope, +/- convulsion
Management:
Knee chest position
O2
Sedate
NaHCO3
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Hypoxic spell
Continue management
Propanolol IV: 0.1 mg/kg/dose dilute IV slowly
(monitor HR)
Correct hypoglycemia: 25% glucose 1-2
cc/kg/dose IV push
Keep normal systemic BP
Correct Hct: PRC infusion (anemia), blood
letting (polycythemia; Hct >65%)
Paralyze and ventilate
Emergency shunt surgery
Closed FU. blood gas, correct acidosis etc.
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Case 3
Ten-year-old girl presents with
palpitation, and chest pain for 10
hours.
PE: BP 100/70, HR 200 /min, RR 18/min,
capillary refill 2 sec, no dyspnea
Lung: clear
Heart: no murmur
Liver: 3 cm rubbery consistency.
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Cardiac Dysrrhythmia
Tachyarrhythmia: Abnormally fast HR and rhythm
HR>220 in infants,
HR>180/min in children < 8 yo.
HR>160/min in children > 8 yo.
1. SVT: tachyarrhythmia which originates
from or involve pathways mostly above bifurcation
of His
2. VT: tachyarrhymia which originates from
myocyte or Purkinje fiber below bifurcation of His.
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Mechanism of SVT in WPW syndrome
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Two syringe technique
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Management of SVT
Physiological treament:
Vagal maneuver - Ice pack
Gag reflex - Carotid massage
Medical treatment
Adenosine: 0.1-0.3 mg/kg/dose: 2 syringe
technique, max 12 mg
Propanolol: 0.1 mg/kg/dose, dilute, IV slowly
Verapamil: 0.1 mg/kg/dose, dilute, IV slowly
Amiodarone: 5-10 mg/kg IV drip in 1-2 hrs.
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Management of SVT
Electrical treament
Direct current synchronous mode
0.5-2 J/kg, max 4 J/kg
Overdrive pacing
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Convert with adenosine
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Electrical Cardioversion
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Tachyarrhythmia
Ventricular tachycardia
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Torsades de Points in Long QT syndrome
Polymorphic VT
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Management of VT
Mechanical: resuscitation
Electrical treatment: DC shock or
synchronized mode 2-4 J/kg
Medical:
Lidocaine:1 mg/kg IV bolus, follow by IV
infusion
Amiodarone: 5 mg/kg IV in 20-60 min , follow
by IV infusion
Procainamide 15 mg/kg IV drip in 30-60 mins
MgSO4: 25-50 mg/kg IV, max 2 gm
Correct hypoMg, hypoCa, hypo&hyperkalemia
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Cardiac dysrrhythmia
Bradyarrhythmia: abnormally slow heart and rhythm
complete heart block: congenital, acquired (post operative CHD)
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Temporary pacemaker
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Case 4
A 3-day-old boy was brought to the ER
due to develop cyanosis 1 hour ago.
PE: RR 65/min, PR 150/min, BP 58/30
O2 sat 60%, active, no dyspnea,
cyanosis,
no dysmorphic features
CVS: normal S1, S2 single, no murmur
Abd: liver just palpable
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Differential Diagnosis
Cyanotic heart diseases with decrease
pulmonary blood flow eg.
VSD with pulmonary atresia supply by
PDA (closing)
Complex heart diseases with pulmonary
atresia
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Cyanotic heart disease with parallel
circuit eg.
D-transposition of great arteries with
inadequate mixing
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Obstructed total anomalous pulmonary venous connection
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Interpretation of oxygen challenge test
Normal 70 (95) >200 (100) 35
Pulmonary disease 50 (85) >150 (100) 50
Neurologic disease 50 (85) >150 (100) 50
Methemoglobinemia 70 (85) >200 (85) 35
Cardiac disease
Separate circulation <40 (<75) <50 (<85) 35
Restricted PBF <40 (<75) <50 (<85) 35
Complete mixing 50 (85) <150 (<85) 35
without restricted PBF
Persistent pulmonary hypertension Preductal Postductal
PFO (no right-to-left shunt) 70 (95) <40 (<75) Variable 35-50
PFO (with right-to-left shunt) <40 (<75) <40 (<75) Variable 35-50
Fio2 = 0.21 Fio2 = 1.00
PaO2 PaO2
(% Saturation) (% Saturation) PaCO2
Adapted J Pediatr. 1970;77:484; Peiatr Rev. 1982;4:13; and Arch Dis Chid. 1976;51:667.
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Management
PGE1 IV drip rate 0.01-0.1 mcg/kg/min
gradually titrate – accept O2 sat > 70%,
PaO2 >30 mmHg
Maintain airway, breathing, metabolic status and vital signs
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Modified Blalock-Taussig shunt
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Major changes in new CPR guideline 2010
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LOGOMajor changes in PALS 2010
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Thank you
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Case 4
A 1-year-old boy with atrioventricular septal
defect and severe pulmonary hypertension,
underwent total repaired.
4 hours PO. he develops hypotension,
PE: On ventilator, BP 60/40, CVP 13 mmHg,
PA pressure 80/55, HR 150/min
O2 sat 98%
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Pulmonary hypertensive crisis
Def: Decrease pulmonary blood flow from
sudden increase in pulmonary vascular
resistant with result in inadequate cardiac
output.
Clinical manifestations:
Low cardiac output: hypotension, tachycardia,
decrease urine output
Increase CVP
Decrease LA pressure
Metabolic acidosis
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Management of PHT crisis
Sedate, paralyze with ventilatory support
Keep serum alkalosis
Pulmonary vasodilator:
Milinone
NO
Iloprost: inhale, IV
Sildenafil
Keep dry:
Decrease pulmonary vasoconstrictor:
adrenaline, high dose dopamine
Correct metabolic disturbance
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Pathways of anti-pulmonary hypertensive drug
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แสดงขนาดและกลไกการออกฤทธิ์ของ Vasodilator แต่ละชนิด
Medication Route Dosage Site action
Captopril PO 0.1-2.0 mg/kg/doseทุก 6-8 ชม.Maximum 6 mg/kg/day
arteriolar and venous
Competitive inhibition ofAngiotensin-convertingenzyme
Enalapril PO 0.1-0.2 mg/kg/dayทุก 12 or 24 ชม.
arteriolar and venous
Competitive inhibition ofAngiotensin-convertingenzyme
Hydralazine IVPO
0.1-0.5 mg/kg/dayทุก 6-8 ชม.0.25-1.0 mg/kg/dayทุก 6-8 ชม.Maximum 7 mg/kg/day
arteriolar Direct vasodilation by unknown mechanism
Prazosin PO 0.01-0.05 mg/kg/dayทุก 6-8 ชม.Maximum 0.1 mg/kg/dose
arteriolar and venous
Competitive blockade ofalpha-1 adrenergic receptors
Nitroprusside IV 0.5-6.0 µg/kg/minMaximum 10 µg/kg/min
arteriolar and venous
Direct vasodilation mediatedby changes in intracellular cGMP
Nitroglycerin IV 1-20 arteriolar and venous
Direct vasodilation
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Tachyarrhythmia
Atrial flutter: reentry circuit in atrium
- Congenital atrial flutter
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Emergency in Pediatric Cardiovascular
Conditions
Cardiogenic shock
Congestive heart failure
Hypoxic spells
Cardiac arrhythmia:
Tachyarrhythmia
Bradyarrhythmia
Pulmonary hypertensive crisis
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Normal conducting system