Cardiovascular%20Emergencies

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Cardiovascular Emergencies
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Objectives

• Understand the causes and management priorities
  of bradycardia in children.
• Identify risk factors for serious causes of
  syncope in children.
• Describe the resuscitation and stabilization of a
  child presenting with cardiopulmonary failure.
• List the strategies for prevention of submersion
  injuries in infants and children.

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Case Presentation

• You are called to a suburban home for toddler
  found submerged in backyard pool.
• A sobbing mother is performing CPR on
  15-month-old girl on pool deck.
• As you take over resuscitation, the mother tells
  you, The phone rang I was only gone for 5
  minutes!

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General Assessment PAT
Appearance Unconscious, unresponsive poor
muscle tone
Work of Breathing No spontaneous respirations
Circulation to Skin Ashen, cyanosis of hands and
lips

• What is your general impression?

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General Impression and Management Priorities

• General impression
• Sick respiratory arrest possible
  cardiorespiratory failure
• Unresponsive, apneic, abnormal circulation to
  skin
• Physiologic problem global hypoxemicischemic
  event
• Immediate management
• Start oxygenation and ventilation while assessing
  for spontaneous circulation.

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Initial Assessment ABCDEs

• Airway patent
• Breathing good air movement with bag-mask
  ventilation wet crackles on auscultation
• Circulation HR 20 femoral pulse barely
  palpable capillary refill gt 5 seconds BP not
  obtained
• Disability pupils dilated, sluggishly reactive
  unresponsive to pain
• Exposure no bruises, no signs of injury
• What is your overall assessment?

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Case Progression

• Cardiopulmonary failure due to hypoxemia.
• Chest compressions are indicated for HR lt 60.
• No evidence of associated injuries.
• Consider spinal injury.
• Less likely in toddler submersion than with
  adolescent diving injury.
• Consider nonaccidental trauma.
• No red flags
• What are your management priorities?

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Management Priorities

• BLS
• Place on spine board.
• Open airway begin bag-mask ventilations, 100
  02.
• Perform chest compressions.
• Dry to prevent further heat loss/hypothermia.
• ALS
• IV access, consider endotracheal intubation.
• Epinephrine, 0.01 mg/kg IV/IO, or 0.1 mg/kg by
  endotracheal tube repeat every 35 minutes.

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Transport Decision Stay or Go?

• BLS
• Rapid transport to nearest appropriate ED.
• Continuous reassessment for return of pulse and
  circulation en route.
• ALS
• Transport after airway/ventilation is secure,
  IV/IO access is established, and the first dose
  of epinephrine is given.
• Do not delay transport if vascular access fails.

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Key Concepts Bradycardia

• Treatable causes of bradycardia with poor
  perfusion
• Hypoxemia
• Hypothermia
• Hypovolemia
• Heart block
• Toxins, poisoning, drugs
• Tampondae, cardiac
• Tension pneumothorax
• Trauma (Head injury)

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Key Concepts Bradycardiawith Submersion Event

• Bradycardia in near-drowning reflects significant
  hypoxia and myocardial ischemia.
• The brain and other vital organs may also have
  suffered ischemic injury.
• Rapid support of ventilation and oxygenation will
  reduce the risk of secondary injury.
• The drug of choice is oxygen, followed by
  epinephrine.

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Key Concepts Drowning Prevention

• Pool drowning prevention
• Close supervision
• Four-sided pool fence
• Self-locking gate
• Pool alarms
• Open water drowning prevention
• Supervision of all age groups.
• Use of personal floatation devices.
• Educate teens about dangers of alcohol and water
  sports.
• Risk awareness, as toddler drownings may occur in
  shallow water.

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Key Concepts Injury Prevention

• Multiple strategies are necessary for an
  effective injury prevention program.
• Passive strategies
• Legislative action
• Enforcement of laws
• Education

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Case Progression

• Oxygen provided by bag-mask device, compressions
  continued.
• After 30 seconds, the heart rate increases to 80
  per minute and compressions are discontinued.
• After 1 minute, the heart rate is 120 per minute
  spontaneous respirations return.

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Case Progression

• En route
• Supplemental oxygen is delivered by mask.
• Blankets are applied to prevent heat loss.

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ED Course

• In the ED
• The child shows progressive improvement in level
  of consciousness, asking for her mommy.
• She remains hemodynamically stable.
• SaO2 is 94 on 100 O2, and chest X-ray shows
  diffuse infiltrates.
• She is admitted to the pediatric intensive care
  unit and transferred to a ward the next morning.
• Diagnosis near drowning pulmonary edema
• Outcome weaned from oxygen on day 2 home on day
  4 with normal neurologic exam.

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Summary

• Submersion results in hypoxia, leading to
  bradycardia, tissue ischemic injury, and
  eventually, cardiac arrest.
• Early oxygenation and ventilation are the most
  effective ways to restore spontaneous
  circulation.
• Prehospital management is a major determinant of
  outcome in children with submersion injury.
• Submersion injuries are predictable prevention
  is the best treatment!

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Case Presentation

• You are dispatched to a middle-school athletic
  field for a child with loss of consciousness.
• A 13-year-old boy is lying on the grass,
  receiving CPR by his coach.
• The coach tells you that the child collapsed
  while running for a ball, and that this has
  happened before.
• What is the first thing you will do on arrival?

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General Assessment PAT
Work of Breathing No spontaneous respirations
Appearance Unresponsive
Circulation to Skin Pale, cyanotic

• What is your general impression?

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General Impression and Management Priorities

• General impression
• Sick cardiopulmonary failure
• Scenario suggests primary cardiac event.
• Management
• BLS apply AED.
• ALS quick look on monitor/defibrillator.

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Initial Assessment ABCDEs

• Since this was a witnessed collapse, attach the
  AED as soon as available.
• Airway patent
• Breathing no chest movement
• Circulation absent pulses, no heart sounds
  shockable rhythm on AED, ventricular fibrillation
  (VF) on monitor
• Disability unresponsive to pain
• Exposure no bruising or signs of injury
• What is your overall assessment?

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Case Progression

• VF cardiac arrest
• Possible mechanisms
• Primary cardiac disease
• Trauma (direct blow to precordium)
• Toxin/drugs
• What are your management priorities?

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Management Priorities

• BLS
• Establish absence of respirations, pulse.
• Turn on AED.
• Attach AED electrode pads.
• Analyze rhythm.
• Shock if advised, then resume CPR immediately for
  five cycles (2 minutes).
• If no shock is advised, resume CPR for five
  cycles (2 minutes).
• Check for signs of circulation and rhythm every 2
  minutes and repeat sequence from analyze rhythm.

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Management Priorities

• ALS BLS priorities plus
• Place on monitor, check rhythm.
• Defibrillate.
• 2 joules/kg
• Resume CPR for five cycles (2 minutes), check
  rhythm if VF, defibrillate with 4 joules/kg.
• Resume CPR immediately.
• Intubate, secure airway (optional).
• Obtain vascular access.
• Epinephrine 0.01 mg/kg (110,000) IV or 0.1 mg/kg
  ETT (11000) repeat every 3-5 minutes.
• After five cycles (2 minutes) check rhythm. If
  shockable
• Defibrillate (4 joules/kg).
• Resume CPR immediately.
• Consider antiarrhythmic.
• Lidocaine 1mg/kg IV/IO/ET
• Amiodarone 5 mg/kg IV/IO

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Transport Decision Stay or Go?

• Stay on scene and treat until a pulse is
  established or the child is asystolic.
• As in adults, the outcome is strongly linked to
  resuscitation in the field.
• Survival statistics are poor for a child brought
  to the ED in asystole.

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Key ConceptsVentricular Fibrillation

• Airway management and correction of hypoxia while
  making rhythm diagnosis is critical.
• Although pediatric VF is uncommon, early
  recognition and treatment improve the chance of
  successful resuscitation.
• Early defibrillation increases the survival rate.
• Increased availability and use of AEDs in
  community can improve outcomes for both pediatric
  and adult VF victims.

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Key ConceptsHigh-risk Groups/Causes for VF

• Cardiomyopathies
• Coronary artery abnormalities
• Post-Kawasaki disease aneurysms, thrombi
• Congenital anomalies
• Direct blow to chest
• Dysrhythmia syndromes

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Key ConceptIdentifying Cardiac Syncope

• Most fainting spells are benign, but red flags
  can identify serious cardiac causes.
• Was the episode associated with chest pain?
• Was there a brief or absent aura?
• Were there palpitations prior to fainting?
• Did it occur during exercise?
• Is there a family history of sudden death?

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Case Progression

• At scene
• Rescue breathing and cardiac compressions
  started.
• AED shows VF converted to NSR on second shock.
• Vascular access obtained
• En route
• Lidocaine bolus 1 mg/kg IV and then 20
  micrograms/kg/min infusion or bolus every 15
  minutes
• Continues in sinus rhythm

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ED Course

• In the ED
• Lead 2 rhythm strip shows QTc 0.52
• The mother arrives and reports three prior brief
  episodes of exercise-associated syncope sudden
  death at the age of 28 in uncle.
• Outcome child diagnosed with long QTc syndrome.
  A pacemaker is placed. The patient is discharged
  neurologically intact 5 days later.

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Summary

• Most episodes of syncope in children are benign.
• Ventricular fibrillation is a rare cause of loss
  of consciousness in pediatrics.
• Early recognition of VF and defibrillation
  improve survival rates.
• When VF is diagnosed, standard cardiac
  resuscitation protocols should be followed,
  regardless of the age of the patient.

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Summary

• The primary cause of cardiopulmonary arrest in
  children is severe hypoxia associated with
  respiratory failure.
• Asystole or profound bradycardia is the most
  common arrest rhythm on EMS arrival.
• Rapid intervention and return of vital signs in
  the field are associated with good outcome.
• Patients with ventricular fibrillation who have
  return of sinus rhythm have good survival rates.
• Children with asystole as the presenting rhythm
  on scene rarely survive.