Download Morning Report - LSU School of Medicine

Morning Report
September 23, 2010
ECG
 Rate
 Rhythm
 What do you think?
 What do you want to do?
SA node
 SA node
 Cardiac pacemaker
 Upper wall of the RA
 Sinus Rhythm
 Normal heart rhythm controlled by SA node
 p-wave before every QRS
 PR – 120-200 msec
SA node
 Sinus Arrhythmia
 Healthy children
 Decrease in SA node firing due to activation of the vagus nerve
by exhalation
 HR varies with respiration
 Normal sinus rhythm with prolongation of RR during
exhalation
The Atria
 Premature Atrial Contractions (PACs)
 Ectopic focus stimulates the atria without input from the SA
node
 Causes
 Drug use, caffeine, electrolyte imbalance, mostly unknown
 Symptoms (Usually asymptomatic)
 Skipped beat, pause followed by strong beat
 ECG
 Premature, inverted or oddly shaped P waves, sharp inflections in T waves
 May have narrow, wide or no QRS depending on focus
 Treatment
 Reassurance, avoidance
The Atria
 Atrial Flutter
 250-400 bpm
 Newborns or children with
structural heart disease
 Reentrant circuit confined to RA
 Symptoms
 CHF (infants), dizziness, syncope, CP, SOB
 ECG
 Inverted “saw-tooth”
 Ventricular conduction - 1:1 (300bpm), 1:2 (150-200bpm)
 Treatment
 Urgent cardiac eval and treatment
The Atria
 Atrial fibrillation
 Uncommon in young children
 Rapid fibrillation of the atrial muscle without coordinated
contraction
 Causes
 Structural heart disease

Stretching of atria
 Symptoms
 Palpitations, CP, syncope
 ECG
 Irregularly irregular rhythm
 Absent or low voltage p-waves
 Treatment
 Urgent referral to cards
 Clot formation >24h
The AV node
 Supraventricular Tachycardia
 Rapid tachycardia originating above the bundle of His
 1/250 children
 3 categories
 Reentrant tachycardia with accessory pathway
 WPW
 Reentrant AV nodal tachycardia
 Atrial ectopic tachycardia
SVT
 Heart rates 220-270bpm
 Symptoms
 Infants prolonged
 Poor feeding, pallor, irritability, lethargy, HD compromise 24-48h
 School age
 “beeping in chest”, heart pounding, CP, SOB, sweating, exercise intolerance
 HR may be 180
 ECG
 Narrow complex tachycardia
 P waves difficult to see
 Finding vary with cause
 Treatment
 Cardiac referral
 EP study and ablation
The Ventricles
 Premature Ventricular Contractions (PVCs)
 Ectopic firings within the ventricle
 25% of healthy children
 Symptoms
 Asymptomatic, chest fullness, dizziness, “heart skips”
 ECG
 Premature, bizarre, wide QRS complex not preceded by a p-wave
 Often followed by a compensatory pause
 Treatment
 Benign if single, suppressed by exercise and no family history of death
 Referral to cardiology if history is suspicious
The Ventricles
 Long QTc Syndrome
 Associated with a potentially dangerous arrhythmia, torsades de
pointes
 QTc = QT/√previous RR
 QTc >450 msec is suggestive
 FH of sudden death, deafness
 Symptoms
 Syncope, seizures, palpitations, cardiac arrest (10%)
 Fainting while swimming, playing sports or exercising
 Treatment
 Refer if symptoms or if ECG is abnormal
Ventricular Tachycardia
 Tachycardia of at least 3 successive ventricular beats
 <30 sec – nonsustained
 >30 sec – sustained
 Causes
 Drugs, caffeine, decongestants, electrolyte imbalances
 Symptoms
 Abnormal hearts, asymptomatic, pallor, fatigue, palpitations,
feeding intolerance
Ventricular Tachycardia
 ECG
 Bizarre, wide QRS complex (>120 msec), tachycardia
 May or may not see p-waves
 T waves are opposite polarization to QRS
 Treatment
 ABCs
 Cardiac Evaluation
Ventricular Fibrillation
 Rare cardiac emergency
 Uncoordinated activity of the cardiac muscle fibers
 Often results in cardiac arrest
 Nonpalpable pulses
 ECG
 Bizarre, random waveform without clearly identifiable P waves
or QRS complexes and a roaming baseline
 Treatment
 ABCs
 Defibrillation