Cvs in a and e

Cardiovascular System II

Continuing Education Modules 1

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


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 ST
ST SVT
History Fever, sepsis, Intermittent,
dehydration, paroxysmal in onset
hemorrhage,
hypovolemia, precedes
ECG ST rate is less than 2x SVT rate at or
normal rate for age. greater than 2x
Rate varies with normal rate for age.
activity. 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.
 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: • Four T’s:
– Hypoxemia – Tamponade
– Hypovolemia (cardiac)
– Hypothermia – Tension
pneumothorax
– Hyper/Hypokalemia
and metabolic – Toxins/poisons/
disorders 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
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


Question
patient?


General Impression
 Stable
– Patient with syncope
– In no distress; normal exam
– Concerning/ominous history



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


 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 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
Shock x 3 Vasopressor

Vasopressor CPR x 3 min
(Drug - Shock)

Shock
*CPR and seek reversible
causes throughout
Anti-arrhythmic


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.


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


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
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



Management Priorities
 Provide supplemental oxygen.
 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


 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.


Cvs in a and e

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