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Cardiovascular Emergencies. 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.

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Cardiovascular Emergencies

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Cardiovascular emergencies l.jpg

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

What is your general impression?

Appearance

Unconscious, unresponsive;

poor muscle tone

Work of Breathing

No spontaneous respirations

Circulation to Skin

Ashen, cyanosis of hands and lips


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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 hypoxemic–ischemic 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 > 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 < 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 3–5 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

What is your general impression?

Work of Breathing

No spontaneous respirations

Appearance

Unresponsive

Circulation to Skin

Pale, cyanotic


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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 (1:10,000) IV or 0.1 mg/kg ETT (1:1000); 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 Concepts:Ventricular 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 Concepts:High-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 Concept:Identifying 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.


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