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Transcript
Cardiac emergencies and the Pediatrician Thomas R. Burklow, MD Asst C., Pediatric Cardiology Walter Reed Army Medical Center National Capital Consortium Cardiac emergencies Congestive heart failure Hypercyanotic spells Tachyarrhythmias Hypertensive crisis How do you know you are dealing with a cardiac emergency? Case Presentation #1 4 month old presents to ER with cc: “cold symptoms” 5 day history of increasing cough; afebrile, no rhinorrhea, no ill contacts. PMH: unremarkable. vigorous feeder (2530oz/d) until the last couple of days. FHx: father had a “leaky valve” but was cleared to join the Marines Physical Examination VS: HR 165, RR 60, normal BP throughout; RA O2 sat mid 80’s, increases to 97% on 1/4 L/ O2 Small for age male, nondysmorphic, mild cyanosis, moderate increased work of breathing Left chest prominent Prominent PMI, RRR, S2 obscured by murmur, gr III pansystolic SRM over apex to left axilla Liver edge 4 cm below RCM 1+ pulses throughout Electrocardiogram Chest X ray What is the pathological condition which is present in this infant? What information supports this supposition? What do you do? Clinical manifestations Infant feeding difficulties failure to thrive diaphoresis tachycardia tachypnea Child breathlessness tachycardia tachypnea peripheral edema cardiomegaly What causes congestive heart failure? Excessive work load: pressure or volume Normal workload faced by a damaged myocardium Etiologies Neonate dysfunction volume pressure Infant Volume Dysfunction Child Palliated congenital heart disease AV valve regurgitation Acute rheumatic fever Myocarditis Endocarditis Neonatal congestive heart failure Dysfunction Myocarditis Cardiomyopathy—think inborn error of metabolism Coronary artery anomaly Arrhythmias Volume Unrestrictive ventricular septal defect(s) Truncus arteriosus Pressure—think obstruction ductal-dependent left-sided Hypoplastic left heart syndrome Critical aortic stenosis Critical coarctation of the aorta CHF in infants and children Dysfunction Myocarditis Cardiomyopathy—think inborn error of metabolism Coronary artery anomaly Palliated congenital heart disease Arrhythmias Volume Unrestrictive ventricular septal defect(s) Severe atrioventricular valve dysfunction Truncus arteriosus Palliated congenital heart disease How do you know what entity you are dealing with?... Age An apparently well neonate who develops CHF at 1-2 weeks...consider a ductal-dependent lesion An apparently well child without known heart disease develops CHF…consider myocarditis Fetal history of “irregular heart beats” Duration of symptoms Prior history of surgery Family history Travel history Assessment--physical examination Identify signs and symptoms of congestive heart failure Blood pressures Pulse oximetry Presence of murmur MAY be helpful Treatment Digitalis oral: 8-10 mcg/kg/day I.V.: 80% of oral dose Because of varying metabolism, appropriate dose varies by age Rapid digitalization May be performed over 12-24 hours, 6-12 hours in dire situations Calculate TDD (varies by age); administer 1/2 of TDD, followed by 1/4, then 1/4 of TDD Case example: patient weight is 5.5 kg Case example 5.5 kg in a 4 month old Oral TDD for 1 month-2 years is 30-50 mcg/kg TDD is 220 mcg Administer 110 mcg now, then 55 mcg in 12 hours, then 55 mcg in 6 hours IV dose is 80% of the above amounts Maintenance digoxin is approximately 1/4 of TDD, divided b.i.d., or at 50 mcg/cc, 0.1 cc/kg per dose b.i.d. Digoxin toxicity Levels are helpful only in cases of suspected toxicity, not for management GI symptoms are common presenting symptoms: nausea, vomiting, anorexia Most common sign of cardiac toxicity is arrhythmia: bradycardia, AV block, PVCs Treatment includes holding doses for 1-2 half lives, atropine for sinus bradycardia, and “FAB” fragments in cases of significant toxicity Other medications Diuretics Furosemide (Lasix); 0.5-1.0 mg/kg/dose Chlorothiazide (Diuril); 20-50 mg/kg/day Spironolactone (Aldactone); 1-2 mg/kg/day Afterload reduction Captopril (Capoten); 0.1-0.5 mg/kg/dose t.i.d. Enalapril (Vasotec); 0.1 mg/kg/day Beta-blocker Labetolol Carvediolol A couple words regarding critical left sided obstructive lesion… Critical obstruction to cardiac output Hypoplastic left heart syndrome Critical aortic stenosis Critical coarctation of the aorta The common endpoint for these three lesions is loss of systemic cardiac output when the ductus closes…. Physiology of hypoplastic left heart STOP Prostaglandin PGE1 Powerful ductal dilator Mechanism of ductal closure High oxygen tension Circulating prostaglandins Genetic predetermination Prostaglandin dosing Starting dose: 0.1 mcg/kg/min Or… One ampule is 500 mcg/1 cc Mix one amp in 82 cc of normal saline Run resulting mixture at 1 cc/kg/hr, this will be equivalent to 0.1 mcg/kg/min Case presentation #2 Two month old African-american infant presents to the 2 month well baby visit Mother has no concerns: feeding well, no tachypnea. Family history is unremarkable Physical Examination VS: HR 180; RR 25, BP 85/45, room air oxygen saturations 84% Ht 25th percentile, Wt 25th percentile General features: non-dysmorphic infant female Abdomen: Liver edge palpable at RCM Ext: 2+ radial and femoral pulses Cardiovascular examination Prominent right ventricular impulse, subxiphoid Normal S1 with a single S2 Harsh systolic murmur noted at the left mid-upper sternal border, with radiation to back and axilla Diastole: quiet Extra cardiac sounds: none Electrocardiogram Chest radiograph While discussing the most likely diagnosis with the parents, you are called away. However, you are urgently called back to the examination room by the clinic nurse. The parents state that while the infant was crying, her complexion became intensely dark (“she’s never done this before”) and becamely listless… The pulse oximeter is reading a HR of 170 and an pulse oximetry reading of less than 70%. Upon auscultation, you note the murmur is diminished in intensity. Hypercyanotic spell a.k.a. “Tet spell”, “paroxysmal hyperpnea” Etiology uncertain “Infundibular spasm” Decrease in systemic vascular resistance Goal of therapy is to increase pulmonary blood flow PVR SVR Recognition of hypercyanotic spell Symptoms include: irritability, crying, loss of consciousness Physical examination may demonstrate tachypnea, deepening of cyanosis, and loss of systolic ejection murmur Laboratory data would reveal metabolic acidosis Treatment Soothing Knee-chest positioning Morphine, 0.1-0.2 mg/kg IV or SC Oxygen (perhaps limited value) Intravenous volume expansion, 10 cc/kg isotonic Sodium bicarbonate 1-2 mEq/kg/dose Propanolol, 0.15-0.25 mg/kg IV over 2-5 minutes Phenylephrine, 0.1 mg/kg IM or SC General anesthesia The End…for now
