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Pediatric Cardiology Emergencies

Pediatric Cardiology Emergencies. Esmail Redha,MD,FAAP Consultant Pediatric Cardiologist. Age specific Emergencies:. Newborn Emergencies Infant & Childhood Emergencies. Newborn Problems . Cyanosis Low Cardiac Output. Newborn Problems - Cyanosis. Cardiac Cyanosis

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Pediatric Cardiology Emergencies

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  1. Pediatric Cardiology Emergencies Esmail Redha,MD,FAAP Consultant Pediatric Cardiologist

  2. Age specific Emergencies: Newborn Emergencies Infant & Childhood Emergencies

  3. Newborn Problems • Cyanosis • Low Cardiac Output

  4. Newborn Problems - Cyanosis • Cardiac Cyanosis • Does not respond to oxygen • Does not respond to ventilation • Usually no respiratory distress

  5. Newborn Problems - Cyanosis • Evaluation • Chest x-ray • Arterial blood gasses(Hyperoxytest) • Echocardiogram : Obstructive Lesion/Abnormal Circulation

  6. Newborn Problems - Cyanosis • Right sided obstructive lesions • Pulmonary atresia • Tricuspid atresia • Tetralogy of Fallot

  7. Tricuspid Atresia

  8. Newborn Problems - Cyanosis • Abnormal Circulations • Transposition of the great arteries • Total anomalous pulmonary venous return

  9. Transposition of the Great Arteries

  10. TAPVR

  11. Newborn Problems - Cyanosis • Treatment • PGE1 • Restoration of acid/base balance • Surgical Evaluation

  12. Newborn Problems - Cyanosis • PGE1 • 0.05-0.1 mcg/kg/min starting dose • Any intravenous site • UAC • UVC • Peripheral • Interosseous

  13. Newborn Problems: Low Cardiac Output • Shock • Metabolic acidosis • Circulatory shutdown

  14. Newborn Problems Low Cardiac Output • Evaluation • Chest x-ray • Arterial blood gasses • Echocardiogram • Electrocardiogram

  15. Newborn Problems Low Cardiac Output • Left Sided Obstructive lesions • Hypoplastic left heart • Critical aortic stenosis • Critical coarctation of the aorta

  16. Hypoplastic Left Heart

  17. Severe Coarctation

  18. Ductal-DependentLesion Without a PDA there is no blood flow to the abdomen and lower extremities. (Blue blood is better than no blood.)

  19. Newborn Problems: Low Cardiac Output • Muscle diseases • Myocarditis • Cardiomyopathies • Sepsis • Asphyxia

  20. Newborn Problems :Low Cardiac Output • Heart Rate Problems • Supraventricular tachycardias • Complete heart block

  21. Newborn Problems Low Cardiac Output • Supraventricular Tachycardia • Narrow Complex • Heart Rate > 220 bpm • Usually > 240 bpm

  22. Narrow Complex Tachycardia

  23. Newborn Problems Low Cardiac Output • Complete Heart Block • Heart rate below 60 bpm • No relationship between P waves and QRS’s

  24. Complete Heart Block

  25. Newborn Problems • Treatment • Left heart obstructive lesions • Muscle diseases • Heart rate problems • PGE1 • Inotropic support , afterload reduction & Diuretics. • Slow down or speed up

  26. Infant and Childhood Problems: • Hypercyanotic spells • Congestive heart failure • Arrhythmias

  27. Infant and Childhood Problems • Hypercyanotic Spells • Tetralogy of Fallot • Pulmonary Atresia

  28. Tetralogy of Fallot

  29. Infant and Childhood Problems • Hypercyanotic Spells • Sudden decrease in pulmonary blood flow, usually in the morning • Provocation

  30. Raised apex

  31. Hypercyanotic Spells • Treatment • Calming • Oxygen • Morphine • Positioning • Beta Blocker • Phenylepherine

  32. Hypercyanotic Spells • Phenylepherine • Increase systemic vascular resistance which leads to less R - > L shunting and improved saturation

  33. Hypercyanotic Spells • Long Term Treatment with Propranolol • Indication for surgery, either palliative shunt or total repair

  34. Congestive Heart Failure • Differing etiology at different ages

  35. Congestive Heart Failure • Presentation in Infancy • Structural Diseases: Left Heart Obstructions • First days: Hypoplastic Left Heart Syndrome • Critical aortic stenosis • First month: Coarctation of the aorta • First 2 months: Left-to-right Shunts • VSD, PDA, Truncus Arteriosus

  36. Congestive Heart Failure • Presentation after infancy • Progression of structural heart disease • Arrhythmias • Infectious diseases • Later onset myopathies • Toxins: • Anthracyclines • Diphtheria

  37. Congestive Heart Failure Pre-load Contractility Heart Rate Determinants of Cardiac Output Afterload

  38. Heart Failure Sympathetic Tone Arterial & venous constriction HR & coronary vasoconstriction Renin & angiotension + Ventricular preload & afterload Myocardial blood flow Worsening heart failure

  39. CHF Management • Sites of action of drugs used to treat heart failure:

  40. Congestive Heart Failure • Preload reduction • Diuretics • Fluid Restriction • High caloric density

  41. Congestive Heart Failure • Afterload reduction • ACE inhibitors • Nitroprusside

  42. Congestive Heart Failure • Heart Rate modification • Beta Blockers(eg.:Carvedilol) • Also treats diastolic dysfunction & remodeling

  43. Contractility • Acute Treatment • Beta Agonists • Dobutamine • Afterload reduction also • Epinepherine • Dopamine • Increased myocardial demands • Milrinone(makes wonders)

  44. Contractility • Milrinone increases contractility and reduces afterload without increasing myocardial oxygen demand

  45. Contractility • Chronic Treatment • Digoxin • New Treatments: Biventricular Pacing, Assist Device.

  46. Arrhythmias • Narrow Complex Tachycardias

  47. Arrhythmias • Supraventricular Tachycardia

  48. Arrhythmias • Re-entrant Tachycardias • AV node re-entry • Wolff-Parkinson-White

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