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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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objectives
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.
case presentation
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!”
general assessment pat
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

general impression and management priorities
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.
initial assessment abcdes
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?

case progression
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?

management priorities
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.
transport decision stay or go
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.
key concepts bradycardia
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)
key concepts bradycardia with submersion event
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.
key concepts drowning prevention
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.
key concepts injury prevention
Key Concepts: Injury Prevention
  • Multiple strategies are necessary for an effective injury prevention program.
    • Passive strategies
    • Legislative action
    • Enforcement of laws
    • Education
case progression14
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.
case progression15
Case Progression
  • En route:
    • Supplemental oxygen is delivered by mask.
    • Blankets are applied to prevent heat loss.
ed course
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.
summary
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!
case presentation18
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?

general assessment pat19
General Assessment: PAT

What is your general impression?

Work of Breathing

No spontaneous respirations

Appearance

Unresponsive

Circulation to Skin

Pale, cyanotic

general impression and management priorities20
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.
initial assessment abcdes21
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?

case progression22
Case Progression
  • VF cardiac arrest
    • Possible mechanisms:
      • Primary cardiac disease
      • Trauma (direct blow to precordium)
      • Toxin/drugs

What are your management priorities?

management priorities23
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.
management priorities24
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
transport decision stay or go25
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.
key concepts ventricular fibrillation
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.
key concepts high risk groups causes for vf
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
key concept identifying cardiac syncope
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?
case progression29
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
ed course30
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.
summary31
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.
summary32
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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