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: 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

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 STST 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.

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

circulationABCDEs:

– 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 life-threatening 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 alternansT-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 non-

specific 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, breath-

holding, 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

Anti-arrhythmic

Vasopressor(Drug - Shock)

CPR x 3 min

Shock x 3

Shock

Vasopressor

*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: 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

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.