Download APLS Cardiovascular 2

Cardiovascular System II
Objectives
• Present the clinical features and
emergency management of
cardiovascular disorders, including:
– Diagnose and treat rhythm disturbances.
– Detect and treat cardiomyopathy.
– Treat shock.
– Create differential diagnosis and
management plan for syncope.
Case Study 1: “Not Breathing”
• 10-day-old boy brought to ED for not
breathing and color change.
• 3 weeks premature, discharged from
hospital 3 days ago with apnea monitor
• Decreased activity since discharge
• Poor feeding today
Initial Assessment (1 of 2)
PAT:
– Abnormal appearance, abnormal
breathing, abnormal circulation
Vital signs:
– HR 220, RR 14, BP 55/36, Wt 3.5 kg (birth
weight 3.7 kg), O2 sat 88% on room air
Initial Assessment (2 of 2)
A:
B:
C:
D:
E:
Patent without evidence of obstruction
Nonlabored but diminished respiratory
rate
Mottled, cool, distal cyanosis,
tachycardic and weak pulse
Weak cry, nonfocal exam
Normothermic, no evidence of trauma,
fontanel flat
Detailed Physical Exam
•
•
•
•
Head/Neck: No abnormalities
Heart: Tachycardia, no murmurs heard
Lungs: Decreased breath sounds
Abdomen: Liver 2 finger breadths below
RCM
• Neuro: Weak cry, lethargic, poor interaction,
responsive to pain and contact
• Extremities: Cyanotic, cool upper and lower
extremities
Question
What is your general impression of this
patient?
General Impression
• Cardiopulmonary failure
– Lethargic but responsive, inadequate
respirations and tachycardia; mottling with
distal cyanosis
What are your initial management
priorities?
Management Priorities
• ABCs
• Open airway.
• Give 100% O2 by BMV, or perform
endotracheal intubation.
• Check rhythm on cardiac monitor.
• Obtain vascular access.
• Obtain blood glucose prn.
• Check rectal temperature.
Case Discussion (1 of 2)
• Tachyarrhythmias:
– Wide complex
• Ventricular tachycardia
• Supraventricular tachycardia (SVT) with
aberrancy
– Narrow complex
• Sinus tachycardia
• SVT
Case Discussion (2 of 2)
• Clinical features can be varied:
– Palpitations in verbal children
– Shock in any age
– Generalized symptoms of malaise and weakness
• Diagnostic studies:
– Cardiac monitor, ECG, sepsis evaluation if young
infant who has signs and symptoms suggestive
of infection
– CXR, echocardiogram
• Management: ABCs, stabilize
Background: Dysrhythmias
• 3 basic types:
– Fast pulse (tachyarrhythmia)
– Slow pulse (bradyarrhythmia)
– Absent pulse (pulseless)
• Dysrhythmias may impair cardiac
function, leading to cardiac arrest.
• Occult dysrhythmias (e.g., prolonged
QT syndrome, WPW syndrome)
Clinical Features: Your First Clue
• Intermittent, paroxysmal presence of
symptoms
• Sudden onset of symptoms with little or
no prodrome
• Presentation of dysrhythmias can
range from stable to cardiopulmonary
arrest.
Distinguishing SVT from ST
ST
SVT
History
Fever, sepsis,
Intermittent,
dehydration,
paroxysmal in onset
hemorrhage,
hypovolemia, precedes
ECG
ST rate is less than 2x
normal rate for age.
Rate varies with
activity.
SVT rate at or
greater than 2x
normal rate for age.
Minimal or no rate
change with activity.
Supraventricular Tachycardia
Diagnostic Studies
• Radiology:
– CXR important to look for signs of:
• Structural congenital heart disease
• Congestive heart failure (prolonged dysrhythmia)
• Signs of infection (pneumonia)
• Laboratory:
– ALWAYS check blood glucose to exclude
hypoglycemia in any child with abnormal mental
status.
Differential Diagnosis: What Else?
•
•
•
•
•
Hypoglycemia
Sepsis
Hyperthyroidism
Volume depletion
Catastrophic illness:
– CNS, GI, trauma (abuse)
• Metabolic disease
Management: Dysrhythmias
•
•
•
•
ABCs
Get baseline ECG.
Obtain vascular access.
For SVT (see AHA algorithm):
– Vagal maneuvers
– Adenosine: 100 mcg/kg bolus, increase as
necessary: 200 mcg/kg
– Cardioversion for unstable SVT
– Procainamide or amiodarone if QRS is wide
– Digoxin to slow rate if cardioversion unsuccessful
– Cardiology consultation
Tachycardia
Management
The Bottom Line:
Dysrhythmias
• Management is driven by presence or
absence of poor perfusion.
• Sinus tachycardia is not an arrhythmia
but its etiology must be determined.
• Provide ventilation and oxygenation for
all patients in cardiopulmonary arrest,
as the primary etiology is often
respiratory failure.
Other Considerations (1 of 2)
• Interface with EMS/Transport:
– Transport issues: Case such as this
should be transported to pediatric referral
center after stabilization.
• ALS transport with monitoring and IV access
• Treatment plan for possible en route for
recurrence – including potential for
cardioversion
• Consult accepting pediatric cardiologist
Other Considerations (2 of 2)
• Documentation:
– Always try to get baseline 12-lead ECG before
and after cardioversion.
– Treatment record from prehospital and ED care
– EMTALA compliance
• Risk management:
– Always check blood glucose.
– Assure rapid triage of infants in distress.
– Do not hesitate to cardiovert when child is
unstable.
Reversible Non-Cardiac
Causes of Dysrhythmias
•
• Four H’s:
– Hypoxemia
– Hypovolemia
– Hypothermia
– Hyper/Hypokalemia
and metabolic
disorders
Four T’s:
– Tamponade
(cardiac)
– Tension
pneumothorax
– Toxins/poisons/
drugs
– Thromboembolism
Case Progression/Outcome
• ECG reveals SVT.
• Infant receives BMV ventilation.
• Preparations are made to cardiovert as IV
access is obtained.
• Adenosine 100 mcg/kg IV push is given
followed by NS bolus (flush).
• ECG shows return of sinus rhythm.
• BMV is discontinued as infant’s condition
stabilized. 100% oxygen NRB mask is
placed.
Case Study 2:
“Unresponsive Episodes”
• 2-year-old girl passed out eating cereal;
awoke after 5 min.
• She was stiff with eyes rolled back ~
approx. 5 min.
• Minimal period of sleepiness, now
awake and alert; no retractions; skin
color is normal
Initial Assessment and
Focused History
PAT:
– Normal appearance, normal breathing, normal
circulation
ABCDEs:
– Normal
– Vital signs: HR 120; RR 24; BP 80/60; T 37.7 C
Wt 12 kg; O2 sat 99%
Focused History:
– Three similar episodes; two associated with
“temper tantrums.”
– PMH and FH: Negative
Question
What is your general impression of this
patient?
General Impression
• Stable
– Patient with syncope
– In no distress; normal exam
– Concerning/ominous history
What are your initial management
priorities?
Case Discussion
• Syncope in young children is a serious
symptom.
• Must attempt to exclude lifethreatening causes
• Differential diagnosis is critical:
– Seizure
– Cardiac
– Breath-holding spell
Clinical Features: Your First Clue
•
•
•
•
Loss of consciousness
Lasted only a few minutes
Minimal or no postictal state
No stigmata of seizure: Urinary
incontinence, bitten tongue, witnessed
tonic-clonic activity
Diagnostic Studies
• Radiology:
– CXR offers little.
– CT or MRI may be indicated if considering
seizures.
• Laboratory is often normal but may include:
– Electrolytes
– CBC with differential
– Ca++, Mg++, PO4
Markedly Prolonged QT Interval
T-wave alternans
Prolonged QT
• 10% present with seizures.
• 15% of patients with prolonged QTc die
during their first episode of arrhythmia.
– 30% of these deaths occur during the first
year of life.
What Else?
Cardiac Causes of Syncope
• Hypertrophic cardiomyopathy
– Syncope with exercise
– At risk for sudden death; positive family history
– Non-specific murmur; ECG can show nonspecific findings.
– CXR is non-diagnostic
– Echocardiogram is diagnostic.
• Chronic cardiomyopathy
– Chronic CHF
• Dysrhythmias
Critical Concepts (1 of 2)
• Consider cardiac arrhythmias in all
patients presenting with brief,
nonspecific changes in level of
consciousness:
– Fainting, syncope, seizures, breathholding, apparent life-threatening events
Critical Concepts (2 of 2)
• Family history may be positive for
sudden, unexplained deaths prior to
55, fainting episodes, or unexplained
accidents.
• Episodes associated with exercise are
particularly concerning.
– Patient instructed not to exercise until
cleared by a cardiologist.
Pulseless Arrest*
VF/VT
Not VF/VT
Shock x 3
Vasopressor
Vasopressor
(Drug - Shock)
CPR x 3 min
Shock
Anti-arrhythmic
*CPR and seek reversible
causes throughout
Case Progression
• This patient has prolonged QT
syndrome.
• She is at risk for fatal dysrhythmia
(ventricular tachycardia or ventricular
fibrillation).
• She needs to be admitted/transferred
to a pediatric cardiology center for
cardiology evaluation.
Case Outcome
• This child is hospitalized.
• Monitored and confirmed to be at risk
for dangerous dysrhythmia
• Discharged on medications shown to
decrease her risk of VT/VF (e.g., ß
blockers)
• She is a candidate to receive an AICD
when she gets older.
Case Study 3: “Chicken Pox”
• 6-month-old with chicken pox lesions
that began 3 days ago. Lesions are
spreading. More scabs today.
• Fever since yesterday, higher today.
• Today, his skin appears to be red.
• He is fussy and not feeding well.
Initial Assessment (1 of 2)
PAT:
– Normal/abnormal appearance, normal
breathing, normal circulation
Vital signs:
– HR 160, RR 40, BP 79/56, T 39°C, Wt 8.1
kg, O2 sat 98% on room air
Initial Assessment (2 of 2)
A:
B:
C:
D:
E:
Patent without evidence of obstruction
Normal
Generalized red erythroderma, warm,
tachycardic (febrile)
Nonfocal exam, irritable
Many impetiginous scabs, pustules and
vesicles; some with surrounding cellulitis
Detailed Physical Exam
•
•
•
•
•
•
Head/Neck: No abnormalities except for skin
Heart: Tachycardic, no murmurs heard
Lungs: Clear breath sounds
Abdomen: Normal except for skin
Neuro: Alert, subdued, no meningismus
Skin: Many vesicles, scabs, pustules; some
with surrounding cellulitis. Generalized warm
erythroderma. Capillary refill 2 seconds.
Question
What is your general impression of this
patient?
General Impression
• Compensated shock
– Tachycardia and mild change in appearance
(fussy)
– Possible septic shock as varicella lesions with
signs of secondary infection (Staph aureus,
group A strep)
– Erythroderma: Scarlet fever versus toxic shock
What are your initial management priorities?
Management Priorities
•
•
•
•
Provide supplemental oxygen.
Obtain vascular access.
Determine rapid glucose.
Begin fluid resuscitation at 20 mL/kg – 160
mL NS.
• CBC, blood culture, other optional labs
• IV antibiotics
• Repeated assessment for signs of shock
Shock
• Inadequate tissue perfusion (delivery of
oxygen and nutrients) to meet the
metabolic demands of the body.
– Hypovolemic
– Cardiogenic
– Distributive
– Septic
Background: Shock
• Compensated:
– Vital organs continue to be perfused by
compensatory mechanisms.
– Blood pressure is normal.
• Decompensated:
– Compensatory mechanisms are overwhelmed
and inadequate.
– Hypotension, high mortality risk
• Aggressive treatment of early shock:
– Halts progression to decompensated shock
Clinical Features: Your First Clue
• Apnea, tachypnea, respiratory distress
• Skin: Pale, cool, delayed capillary refill.
Warm shock will appear normal.
• Lethargic, weak, orthostatic weakness
• Tachycardia, hypotension
• Specific types of shock:
– Neurologic deficits (spinal cord injury)
– Urticaria, allergen trigger, wheezing
– Petechiae, erythroderma
Hypovolemic Shock
• Fluid loss:
– Diarrhea, vomiting, anorexia, diuresis
– Hemorrhage
• Resuscitation:
– Fluid replacement
– NS or LR 20 mL/kg bolus infusions, reassess,
repeat as needed
– Blood transfusion for excessive hemorrhage
Cardiogenic Shock
• Poor myocardial contractility or impaired
ejection:
– Cardiomyopathy, congenital heart disease,
myocarditis, tamponade, congestive heart failure,
dysrhythmia, septic shock, drugs (e.g.,
thiopental)
• Resuscitation:
– Fluid bolus (10 mL/kg) and reassess
– Inotropes, pressors (e.g., dopamine, dobutamine,
epinephrine)
Distributive Shock
• Inappropriate vasodilation with
maldistribution of blood flow:
– Anaphylactic shock, spinal cord injury, septic
shock
– “Warm shock”
• Resuscitation:
–
–
–
–
Vasoconstrictors (e.g., epinephrine)
Anaphylaxis treatment
Spinal cord injury treatment
Sepsis treatment
Septic Shock
• Elements of distributive shock and
cardiogenic shock:
– Inappropriate vasodilation with a maldistribution
of blood flow
– Myocardial depression
• Resuscitation:
– Fluid bolus
– Pressors and inotropes
– Antibiotics (expect possible deterioration initially
due to toxin release)
Case Progression/Outcome
• Labs drawn
• IV fluids given with decrease in HR to
120
• IV antibiotics given
• Patient admitted and discharged 4
days later
The Bottom Line: Shock
• Early recognition and treatment of
compensated shock may prevent
progression to decompensated shock.
• Decompensated shock has a poor
prognosis.
EIF
• Available
from ACEP,
AAP
• Updated by
PCP and
specialists
• Very helpful
• Medical ID
bracelet
The Bottom Line
• Obtain rapid history and assess children
in shock or respiratory distress for
cardiac disease.
• Utilize the EIF to gather information,
contact specialists, and guide therapy.
• Echocardiography and cardiology
consultation for definitive diagnosis and
cardiac function determination.