pediatric cardiovascular problems in emergency setting 1 (5 feb- 2011)
TRANSCRIPT
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
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
LOGO
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
LOGO
LOGO
LOGO
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.
LOGO
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
LOGO
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
LOGO
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.
LOGO
Minimum blood pressure to diagnose hypotension
LOGOCardiogenic Shock
1. Congenital heart diseases eg.
Ductal dependent lesion: Left sided obstructive lesions
Etiology:
LOGO
Right sided obstructive lesions
LOGO
Cardiogenic shock
Etiology
2. Myocardial diseases:
myocarditis, cardiomyopathy
3. Cardiac dysrhythmia
4. Cardiac tamponade
LOGO
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
LOGO
LOGO
LOGO
แสดงยาที่ใชใ้นการรกัษา cardiogenic shock
LOGO
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
LOGO
LOGO
LOGO
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
LOGO
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
LOGO
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.
LOGO
RV LV
PVR SVR
PA AO
LOGO
Pathophysiology of hypoxic spell
LOGO
Hypoxic spell
Signs and symptoms: Increase in
cyanosis, hyperpnea, conscious
change, decrease intensity of SEM, syncope, +/- convulsion
Management:
Knee chest position
O2
Sedate
NaHCO3
LOGO
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.
LOGO
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.
LOGO
LOGO
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.
LOGO
LOGO
Mechanism of SVT in WPW syndrome
LOGO
Two syringe technique
LOGO
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.
LOGO
Management of SVT
Electrical treament
Direct current synchronous mode
0.5-2 J/kg, max 4 J/kg
Overdrive pacing
LOGO
Convert with adenosine
LOGO
Electrical Cardioversion
LOGO
LOGO
LOGO
Tachyarrhythmia
Ventricular tachycardia
LOGO
LOGO
LOGO
Torsades de Points in Long QT syndrome
Polymorphic VT
LOGO
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
LOGO
Cardiac dysrrhythmia
Bradyarrhythmia: abnormally slow heart and rhythm
complete heart block: congenital, acquired (post operative CHD)
LOGO
Temporary pacemaker
LOGO
LOGO
LOGO
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
LOGO
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
LOGO
Cyanotic heart disease with parallel
circuit eg.
D-transposition of great arteries with
inadequate mixing
LOGO
Obstructed total anomalous pulmonary venous connection
LOGO
LOGO
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.
LOGO
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
LOGO
Modified Blalock-Taussig shunt
LOGO
Major changes in new CPR guideline 2010
LOGO
LOGOMajor changes in PALS 2010
LOGO
LOGO
LOGO
LOGO
Thank you
LOGO
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%
LOGO
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
LOGO
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
LOGO
Pathways of anti-pulmonary hypertensive drug
LOGO
LOGO
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
LOGO
Tachyarrhythmia
Atrial flutter: reentry circuit in atrium
- Congenital atrial flutter
LOGO
Emergency in Pediatric Cardiovascular
Conditions
Cardiogenic shock
Congestive heart failure
Hypoxic spells
Cardiac arrhythmia:
Tachyarrhythmia
Bradyarrhythmia
Pulmonary hypertensive crisis
LOGO
LOGO
LOGO
Normal conducting system