Pediatric Cardiology Lecture
Pediatric Cardiology Lecture
Pediatric Cardiology Lecture
Dr Nasser Haidar
Dr Mohammed Al Shaof
Dr Khalid Ibrahim
Disclosure
We do not have any financial benefits
with any commercial products.
2
Learning Objectives
Describe the basic assessment of cardiovascular emergencies
Discuss the types and pathophysiology of cardiovascular
emergencies
Apply the basic principles of essential stabilization and
management of shock, cyanosis, arrhythmias, heart failure,
myocarditis, endocarditis, and other conditions
Decide about the patient disposition from PEC.
3
Common Cardiac
Symptoms
4
Common CVS symptoms
5
CYANOSIS
Central cyanosis if Hb Sat. De‐oxygneated Appearance
deoxygenated Hb is Hb
at least 3 gm/dL 20 g/dl 80% 4 g/dl Cyanotic
10/dl 80% 2 g/dl Not cyanotic
Best indicator of
cyanosis is the tongue: Cyanosis is manifest depends
Free of pigmentation on the hemoglobin level
Rich vascular supply
Cardiac Signs
7
HR and BP
Pulse BP measurements
Rate Cuff size
Rhythm 4 limbs
Volume Manual vs Automated
Compare
with other site
Normal Heart Rate by Age (beats/minute)
Age HR RR
Awake Rate Sleeping Rate
Neonate (<28 d) 100‐205 90‐160
30‐53
Infant (1 mo‐1 y) 100‐190 90‐160
22‐37
Toddler (1‐2 y) 98‐140 80‐120
20‐28
Preschool (3‐5 y) 80‐120 65‐100
School‐age 18‐25
75‐118 58‐90
(6‐11 y)
Adolescent 12‐20
60‐100 50‐90
(12‐15 y)
http://www.pedscases.com/pediatric‐vital‐signs‐reference‐chart Reference: PALS Guidelines, 2015 9
Normal Blood Pressure by Age (mm Hg)
Systolic
Age Systolic Diastolic
Hypotension
Neonate (96 h) 67‐84 35‐53 <60
Infant (1‐12 mo) 72‐104 37‐56 <70
Toddler (1‐2 y) 86‐106 42‐63
<70 +
Preschooler (3‐5 y) 89‐112 46‐72
(age in years x 2)
School‐age (6‐9 y) 97‐115 57‐76
Preadolescent (10‐11 y) 102‐120 61‐80 <90
Adolescent (12‐15 y) 110‐131 64‐83 <90
http://www.pedscases.com/pediatric‐vital‐signs‐reference‐chart Reference: PALS Guidelines, 2015 10
Standard BP measurements ‐ age and gender
From Horan MJ. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics 1987;79:1–25, with permission).
Appropriate BP measurement
If manually done,
mercury column should
be deflated at
2 ‐3 mm per second.
Patient’s arm should be
supported at heart level.
https://www.slideshare.net/HemrajSoni/childhood‐hypertension
4‐Limbs BP measurement
More than 10 mmHg difference or
UL is higher pathology
Aortic coarctation,
Aortic arch hypoplasia or
Interrupted aortic arch
Normally LL is higher
https://www.quora.com/Where‐do‐you‐take‐blood‐pressure‐when‐you‐cant‐use‐the‐arms
Pulse Pressure
Widened in:
High cardiac output states
(anemia, fever, exercise,
thyrotoxicosis), Defined as:
Diastolic run‐off lesions (PDA, AR, The difference between
AV malformations), systolic and diastolic BP
Complete heart block.
Narrow in:
Low cardiac output
Mitral or aortic valve stenosis, or
Pericardial tamponade or constrictive pericarditis.
Signs indicate cardiac‐related problems
Dizziness during the clinical assessment
Skin mottling and prolonged capillary refill time (CRT)
Pulse abnormalities
Heart sounds and murmurs
Congestive heart failure (high HR, high RR,
hepatomegaly, cardiomegaly, and crackles)
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Diagnostic tools for
Cardiac conditions
16
Causes of cyanosis?
Cardiovascular,
Pulmonary, History & PE Hyperoxia test
Neurologic
Hyperoxia test
PO2 mmHg
in Room air 100% oxygen
More than 250 Less than 100 ‐150 100 ‐ 250
Pulmonary Intra‐cardiac
Rt to Lt shunting May have CHD as
Neurogenic mixed lesions
CCHD
ECG
The standard paper speed is 25 mm per
second
single 1‐mm box = 0.04 second,
and
large (5‐mm) box = 0.20 second.
Rhythm,
Rate,
Axes (P, QRS, and T waves)
Intervals (PR, QRS, and QT)
waveform voltage, and
P, QRS, and T wave morphology
Chest X‐Ray
It can provide important
information for:
Cardiac size,
Pulmonary vascularity,
Specific cardiac abnormalities.
Heart is most vertical in
standing position
&
inspiration
Thymic shadow Cardiothoracic ratio > 60%
(Modified from Sapire DW. Understanding and diagnosing pediatric heart disease. East
Norwalk, CT: Appleton & Lange, 1991:64, with permission).
Pulmonary Vascularity
large left‐to‐right Right‐sided obstructive Congestive
shunt (ASD, VSD, PDA) lesion right‐to‐left shunt. heart failure.
https://emedicine.medscape.com/article/157452‐overview
Specific Cardiac Lesions
Imbalance
O2 supply
O2 demand
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Types of Shock
Anaphylactic Neurogenic
Distributive
Septic
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Be Systematic for Recognition
D Level of consciousness
27
Usual question needs an answer
Dr is my baby
going to be Ok?
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In what stage of shock?
Hypotension
Inotropes Multi organ
Lact. > 2 failure (MOF)
High mortality Death
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The overall aim in management
Restoring the imbalance
Supply
Demand
30
The overall aim in management
How?
General and specific
31
Hypovolemic shock
7 months old girl having diarrhea and vomiting for two days
accompanied with low oral intake and did not pass urine for the
lst 24 hrs. Found to have signs of severe dehydration, CRT 5
seconds, HR 180, RR 60, and BP 65/45.
Red flags in the history?
More sings in Physical examination
Work up?
Initial management?
Shock
Dehydration
GE Dehydration
Renal
e.g DKA, DI Hypovolemic Assess severity
Shock
Intake
stomatitis
A virus can kill
Bleeding
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Degree of Dehydration
Mild Moderate Severe
Finding
(3 to 5%) (6 to 9%) (≥10%)
Rapid and weak or
Pulse Full, normal rate Rapid
absent
Systolic pressure Normal Normal to low Low
Deep, rate may be Deep, tachypnea or
Respirations Normal
increased decreased to absent
Buccal mucosa Tacky or slightly dry Dry Parched
Anterior fontanelle Normal Sunken Markedly sunken
Eyes Normal Sunken Markedly sunken
Skin turgor Normal Reduced Tenting
Cool, mottled,
Skin Normal Cool
acrocyanosis
Normal or mildly
Urine output Markedly reduced Anuria
reduced
Systemic signs Increased thirst Listlessness, irritability Grunting, lethargy, coma
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Management of dehydration
10 kg child with a 10 % fluid loss:
TBW(n): 0.6 x body weight = 6 L
Total fluid deficit: 10 percent of 6 L = 0.6 L
+ Maintenance (100, 50, 20 /kg/day)
+ Ongoing loss to be measured as frequent as needed
Duration of replacement depends on the type of
dehydration (Na level) after the needed resuscitation
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Shock
Distributive Shock
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Distributive ‐ Septic shock
3 years old girl presented with fever, cough, and in ability to play as
usual. Generally sick but no cyanosis, RR 45, HR 140, BP 110/65,
and crackles on right side of the chest
Red flags in the history?
One hour later, became more
More sings in Physical tachypneic and tachycardiac.
examination? Pale looking and BP 85/30, but
with good pulse volume.
Work up?
Initial management?
37
Definitions
Septic
Infection Sepsis
Shock
38
Indicators for higher mortality
Sepsis
life-threatening organ dysfunction caused by a
dysregulated host response to infection
Organ dysfunction
39
Surviving Sepsis Guidelines
First 5 Minutes
First 15 Minutes
In PICU?
40
American College of Critical Care Medicine. Crit Care Med 2009; 37:666–688.
Case Scenario
2 years old boy known to be allergic to eggs. Suddenly felt dizzy
so unable to stand and walk with skin rash. HR 160, RR 50,
capillary refill time 6 seconds, and BP 70/35.
Red flags in the history?
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Shock
History Examination
Anaphylactic
shock
Severity
Management
Case Scenario
10 years old boy brought post RTA. Unable to walk with sever
back pain then become more drowsy. HR 75, capillary refill time 6
seconds, and BP 70/35.
Red flags in the history?
Any inconsistency in vitals?
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Shock
Examination &
History
clue to the Dx.
No tachycardia
Neurogenic Priapism
shock
Severity Management
Unlikely to be corrected by
fluid resuscitation
vasopressors
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Case Scenario
10 years old boy brought after FFH. EMS confirmed progressive
distress and reduction in LOC. HR 150, RR55, BP 60/40. Chest
examination should no air entry to the right side.
Red flags in the history?
Physical examination
Work up? CXR tension pneumothorax
Initial management?
Shock
Tension Pericardial
Pneumothorax effusion
Obstructive
Shock
Restrictive
PHTN
pericarditis
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Case Scenario
10 days old girl brought PEC with decreased feeding and
irritability for the last 2days then became less responsive.
ABC
Red flags in the IV access
history? What immediate BS,Culture,gas, etc
action is needed? Prostaglandin E1
Any more Antibiotics till confi.
questions to Correct met. Acid.
the family? NPO
Definitive treatment
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Shock
Arrythmias Myocarditis
Cardiogenic Pericarditis
CHD Shock
Infective
Cardiomyopathy
endocarditis
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CHD
https://www.slideshare.net/dpark419/the‐crashing‐cardiac‐baby 49
CHD
Usual presentations to PEC
Shock Cyanosis
Syncope Palpitations
50
CHD
Shock √ Cyanosis
https://www.slideshare.net/dpark419/the‐crashing‐cardiac‐baby 51
CHD: Ductal dependent circulations
In a normal neonate ductus close in the first few days of life
In left sided In right sided obstructive lesions
obstructive lesions PDA maintain adequate pulmonary blood flow
PDA maintain adequate
• Critical PS/ PA
systemic blood flow
• TA with pulmonary atresia
• Univentricular heart with PA
• Critical AS
• Severe Ebstein’s anomaly of tricuspid valve
• Severe CoA / Interrupted AA
(functional PA)
• HLHS.
Parallel circulation
PDA ensure adequate mixingTGA
Neonate Presenting with Circulatory Collapse
Critical aortic stenosis Hypoplastic left heart
Severe myocardial dysfunction, CHF or shock. syndrome
The less severe forms present later in life. All the left sided structures
including MV, LV, ascending
aorta, arch are too small.
Critical coarctation systemic output is
Critical narrowing of the aortic isthmus dependent on the right side
lower body affected. of heart with PDA.
Aortic arch interruption
Physical examination
Pulses
All limbs Femoral
Electrocardiography
Critical AS Coarctation • RVH
HLHS Interruption • LVH
Mild cyanosis
Single ventricle physiology
(HLHS)
Chest x‐ray
Cardiomegaly
Pulmonary venous
hypertension
Echocardiography
Increased pulmonary
blood flow with HLHS
Other cardiac
problems and its
presentations
56
Duct‐dependent CHD
Shock Cyanosis √
57
Cyanotic
CHD
58
Classic CCHD
Just count your one hand fingers
1 2 3 4 5
Duct dependent pulmonary circulation
Why we should be worried?
Severe hypoxemia metabolic acidosis
death
PA or severe PS
Ebstein’s anomaly of tricuspid
PDA needed to maintain pulmonary circulation
https://www.stanfordchildrens.org/en/topic/default?id=congenital‐heart‐disease‐90‐P02346
Diagnosis
Cyanosis Physical examination ABG
Metabolic
Quiet precordium acidosis,
low pO2,
No significant normal pCO2,
murmur, failure of 100%
rarely continuous oxygen to
murmur of PDA increase pO2 >
100 mmHg
CXR
No cardiomegaly
except in
Ebstein’s anomaly
Dark lung fields
Absence of main
PA segment
http://criticalcare.imedpub.com/neonatal‐cardiac‐emergencies‐evaluation‐and‐management.php?aid=8723
Management
At least physiological diagnosis (clinical, ECG, chest X‐ray,
and blood gas with hyperoxia test.)
Correction of metabolic abnormalities as
acidosis, dehydration, hypoglycemia.
Temperature maintenance:
PGE1 infusion in all cyanotic newborn
Ionotropic agents may be needed
Transposition complex (TGA)
Both pulmonary and systemic dependency
Determines the :
Adequate mixing Determine Presentation,
Prognosis, survival
Management
Intracardiac (ASD/ PFO
or VSD) No mixing
or neonatal severe
extra cardiac (PDA / hypoxemia
collaterals).
Good mixing
4‐6 weeks later
Mild hypoxemia
Diagnosis of Mixed CHD lesions
Cyanosis ABG ECG:RAD
CHF Metabolic
With: acidosis, With Large VSD
large VSD low pO2, cardiomegaly,
PDA normal pCO2, congested lungs
No significant egg on side
murmur, rarely Hyperoxia test
continuous pO2 < 100 mm
murmur of PDA Hg
Echocardiography
Management: Supportive, PGE 1 palliative definitive
Obstructed total Anomalous Pulmonary Venous
The pulmonary veins connected to right side of heart
only source of blood flow to left side is through
interatrial communication.
Unobstructed Obstructed
presents on
CHF beyond the
day 1 or 2 of life
neonatal period
with cyanosis and
with mild cyanosis.
respiratory distress.
TAPVC Diagnosis
Continuous and
ejection systolic murmur
ABG
Metabolic acidosis,
low pO2,normal or elevated pCO2,
pO2 < 100 mmHg with 100% O2
NO cardiomegaly,
ECG Prominent PA segment
RAD Hazy lung fields‐
May get RA pulmonary edema
enlargement (may mimic RDS).
Heart Failure
https://emedicine.medscape.com/article/895187‐overview 68
Heart Failure: Congenital causes
CHF in Heart failure
insidious manner. + mild cyanosis (mixed lesions)
Neonate with septal defects 2‐8 weeks of age with CHF –
fall in PVR (pulmonary vascular resistance).
Heart Failure: Acquired causes
Myocarditis
Septicemia
Dilated cardiomyopathy
Arrhythmias
Asphyxia
Rheumatic Heart Disease
Metabolic causes‐Hypoglycemia, hypocalcemia
Arrythmias
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Arrhythmia
Asphyxia, hypothermia, metabolic and electrolyte imbalances
High index of suspicion
Suspicion is aroused when
A) The heart rate shows no variability and is fixed between 150 to
180 per minute.
B) Abnormal P wave axis
C) Atrioventricualr dissociation
Prompt return to sinus rhythm
complete return of LV function to normal.
72
Sinus Tachycardia
Rate of sinus node discharge that is higher than normal
for the patient's age Fever
Most common rhythm disturbance Pain/anexiety
Hypovolemia
Physiological response to Hypoxia
CO or oxygen needs
Tt underlying cause
CO = SV x HR
Occult Cardiac disease
Tachyarrhythmia: Narrow QRS
accessory pathway Junctional Atrial flutter
(WPW syndrome) ectopic or atrial
commonest tachycardia) fibrillation,
very rare
Rarely More often
CHF CHF ,
rarely sustained sustained.
Facial immersion , Five seconds
Adenosine
If unstable synchronized cardioversion
Referral to Cardiology after stabilization, if knew or complicated
74
Tachyarrhythmia: wide QRS
Rare in neonatal period
Usually with some structural damage (e.G. Myocarditis, cardiac
tumor etc.)
Management
ABC
Not critical adenosine first
Amiodarone
Circulatory collapse DC cardioversion
Referral to Cardiology after stabilization
75
Bradyarrhythmias
Complete heart block ‐ Commonest
heart failure even in fetal life.
Permanent pacemaker
if:
Heart failure
Heart rate < 55 beats
&
70 per minute with
structural defects.
Referral to Cardiology after stabilization
76
Long QT Syndrome
Acquired, but more often is congenital
torsades de pointes , a malignant form of VT.
Syncope or presyncope by exercise, fright
Seizures (about 10% of cases)
VT VF and sudden death
Incidental ECG finding
Precipitated by stress
Family history may be +ve
May be normal ECG in the ED
Referral to Cardiology after stabilization
Infective endocarditis
7years old known aortic incompetence presented with fever
lethargy for 7 days. HR 120, RR 40 , CRT 2, BP 110/60. Temp 39
Detailed history Source of fever ?
More signs? New murmur
Splenomegaly
Osler’s node
Dx: Vegetations, positive B/C, etc
Management: supportive and AB, and Cardiologist consultation
78
Pericarditis
Chest pain Management:
Fever
supportive and treatment of
Weak
Breathing difficulty underlying cause
+/‐ drainage under
Tamponade shock ultrasound guidance if
leading to hemodynamic
Dx: history, PE, CXR,
instability
Echo (bedside US) .
Referral to Cardiology
after stabilization
79
Chest pain
http://www.childheartspecialist.com/london/chest‐pain‐in‐children/ 80
Common Causes Chest pain
Most are benign or self‐limited illnesses.
Costochondritis Precordial Catch Syndrome
Adolescent and pre‐adolescent females, Unknown benign cause.
Viral illness or by frequent coughing ‐ adolescents , sudden ,intense,
weeks. sharp pain along the chest or back.
Tenderness. with inspiration.
lasts several minutes.
Acid Reflux
Burning sensation Injury
below the Anxiety
sternum, dull or non‐specific
may vary in and worsens with
relation to meals stress or anxiety.
81
Chest pain
Extremely Pericarditis
uncommon Sharp and mid‐sternal and may shoulders.
Alleviated by sitting or leaning forward
Pneumonia Coronary Artery
Effusion Cardiac Abnormalities:
Pneumothorax congenital or
Asthma
chest acquired diseases like
Pain Kawasaki d.
Hypertrophic cardiomyopathy, An arterial aneurysm
and prolonged tachycardia Marfan syndrome.
82
Post Cardiac Surgery
3 years old known CHD case, post BT shunt, presented with
respiratory distress and lethargy.
HR 160, RR 50 , CRT 5 seconds, BP 90/40.
normal temperature, No murmur over the shunt
Physiological status?
Cause of Shock?
Dx and Management
83
Disposition from PEC
Normal No No serous No signif. No serious
vital significant symptoms lab radiological
signs sings findings sings
Yes to all
No
Even after observation
Home
Stable/ no
+/‐ Follow Unstable
potential
Up /potential
instability
Ward PICU/CICU
84
85
Summary
In Emergencies always start with ABCD assessment and manag.
Detailed history and PE after ABCD assessment for specific treatm.
Deal with CHD emergencies as group Shock or cyanosis, initially
Could it be something else e.g. Sepsis, respiratory, etc.
Prostaglandin E2 is a life saving drug without waiting for echo.
Understanding pathophysiology of a condition is the key
86
References
Neonatal Cardiac Emergencies:
Evaluation and Management
Thanks
http://criticalcare.imedpub.com/neonatal‐
cardiac‐emergencies‐evaluation‐and‐
management.php?aid=8723
5 Minutes Pediatric Consult
Up‐to‐date
Pediatric Emergency Medicine
By Jill M. Baren
87