Cardiovascular System II

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Cardiovascular System II
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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.

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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

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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

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Initial Assessment (2 of 2)

• A Patent without evidence of obstruction
• B Nonlabored but diminished respiratory rate
• C Mottled, cool, distal cyanosis, tachycardic
  and weak pulse
• D Weak cry, nonfocal exam
• E Normothermic, no evidence of trauma,
  fontanel flat

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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

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Question

• What is your general impression of this patient?

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General Impression

• Cardiopulmonary failure
• Lethargic but responsive, inadequate respirations
  and tachycardia mottling with distal cyanosis
• What are your initial management priorities?

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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.

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Case Discussion (1 of 2)

• Tachyarrhythmias
• Wide complex
• Ventricular tachycardia
• Supraventricular tachycardia (SVT) with aberrancy
• Narrow complex
• Sinus tachycardia
• SVT

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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

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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)

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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.

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Distinguishing SVT from ST
ST SVT
History Fever, sepsis, dehydration, hemorrhage, hypovolemia, precedes Intermittent, paroxysmal in onset
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.
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Supraventricular Tachycardia
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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.

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Differential Diagnosis What Else?

• Hypoglycemia
• Sepsis
• Hyperthyroidism
• Volume depletion
• Catastrophic illness
• CNS, GI, trauma (abuse)
• Metabolic disease

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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

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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.

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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

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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.

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Reversible Non-Cardiac Causes of Dysrhythmias

• Four Ts
• Tamponade (cardiac)
• Tension pneumothorax
• Toxins/poisons/ drugs
• Thromboembolism

• Four Hs
• Hypoxemia
• Hypovolemia
• Hypothermia
• Hyper/Hypokalemia and metabolic disorders

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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 infants condition
  stabilized. 100 oxygen NRB mask is placed.

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Case Study 2Unresponsive 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

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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

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Question

• What is your general impression of this patient?

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General Impression

• Stable
• Patient with syncope
• In no distress normal exam
• Concerning/ominous history
• What are your initial management priorities?

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Case Discussion

• Syncope in young children is a serious symptom.
• Must attempt to exclude life-threatening causes
• Differential diagnosis is critical
• Seizure
• Cardiac
• Breath-holding spell

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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

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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

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Markedly Prolonged QT Interval
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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.

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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 non-specific
  findings.
• CXR is non-diagnostic
• Echocardiogram is diagnostic.
• Chronic cardiomyopathy
• Chronic CHF
• Dysrhythmias

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Critical Concepts (1 of 2)

• Consider cardiac arrhythmias in all patients
  presenting with brief, nonspecific changes in
  level of consciousness
• Fainting, syncope, seizures, breath-holding,
  apparent life-threatening events

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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.

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Pulseless Arrest
VF/VT
Not VF/VT
Shock x 3
Vasopressor
Vasopressor (Drug - Shock)
CPR x 3 min
Shock
CPR and seek reversible causes throughout
Anti-arrhythmic
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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.

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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.

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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.

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Initial Assessment (1 of 2)

• PAT
• Normal/abnormal appearance, normal breathing,
  normal circulation
• Vital signs
• HR 160, RR 40, BP 79/56, T 39C, Wt 8.1 kg, O2
  sat 98 on room air

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Initial Assessment (2 of 2)

• A Patent without evidence of obstruction
• B Normal
• C Generalized red erythroderma, warm,
  tachycardic (febrile)
• D Nonfocal exam, irritable
• E Many impetiginous scabs, pustules and
  vesicles some with surrounding cellulitis

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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.

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Question

• What is your general impression of this patient?

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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?

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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

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Shock

• Inadequate tissue perfusion (delivery of oxygen
  and nutrients) to meet the metabolic demands of
  the body.
• Hypovolemic
• Cardiogenic
• Distributive
• Septic

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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

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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

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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

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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)

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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

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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)

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Case Progression/Outcome

• Labs drawn
• IV fluids given with decrease in HR to 120
• IV antibiotics given
• Patient admitted and discharged 4 days later

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The Bottom Line Shock

• Early recognition and treatment of compensated
  shock may prevent progression to decompensated
  shock.
• Decompensated shock has a poor prognosis.

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EIF

• Available from ACEP, AAP
• Updated by PCP and specialists
• Very helpful
• Medical ID bracelet

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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.

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