PEDIATRIC CARDIOLOGY

1. PEDIATRIC CARDIOLOGY PALS AND OEMS DAN MUSE MD

2. PEDIATRIC ASSESSMENT PRIMARY ASSESSMENT • Rapid assessment: • Respiratory • Cardiac • Neurologic

3. PEDIATRIC ASSESSMENT PRIMARY ASSESSMENT • Airway • Breathing • Circulation • AVPU: Alert, Voice, Pain, Unresponsive

4. PEDIATRIC ASSESSMENT CARDIOPULMONARY ASSESSMENT • In infants and children cardiopulmonary collapse is due primarily to: • Respiratory failure • Shock

5. PEDIATRIC ASSESSMENT CARDIOPULMONARY ASSESSMENT • As the kids grow up cardiac issues may present • They are predominantly arrhythmias. • Ischemia is not one of them!

6. PEDIATRIC ASSESSMENT CARDIOPULMONARY ASSESSMENT • Congenital • Tetrology of Fallot • Brugada’s Syndrome • Prolonged QT

7. PEDIATRIC ASSESSMENT CARDIOPULMONARY ASSESSMENT • Developmental • WPW/Svt’s • Idiopathic Hypertrophic Cardiomyopathy • Cardiomyopathy

8. PEDIATRIC ASSESSMENT CARDIOPULMONARY ASSESSMENT • Accidental • CommodioCordis • Drugs

9. PEDIATRIC ASSESSMENT CARDIAC ARRHYTHMIAS • Defined as • Bradyarrhythmias • Tachyarrhythmias • Pulseless arrest

10. BRADYARRHYTHMIAS • Defined as • Slow heart rate based on normal rate for age. • Primary Bradycardia: Due to congenital or acquired heart conditions. • Secondary Bradycardia: Due to underlying conditions such as hypoxia, sepsis, acidosis, hypotension, drugs…

11. BRADYARRHYTHMIAS BRADYARRHYTHMIAS ARE FREQUENTLY PREARREST RHYTHMNS IN CHILDREN AND OFTENTIMES DUE TO HYPOXIA

12. BRADYARRHYTHMIASOEMS PROTOCOLS EMT/EMT-INTERMEDIATE/ADVANCED EMT STANDING ORDERS • Routine Patient Care • If pulse is less than 60 in a child, AND the patient is severely symptomatic, consider starting Cardiopulmonary Resuscitation (CPR).

13. BRADYARRHYTHMIASOEMS PROTOCOLS PARAMEDIC STANDING ORDERS IF PATIENT IS SEVERELY SYMPTOMATIC: • Epinephrine 1:10,000, 0.01 mg/kg IV/IO (max. dose 0.5 mg) OR, • Atropine 0.02 mg/kg IV/IO (min. single dose 0.1 mg, max. single dose 1 mg). If increased vagal tone or AV block suspected.

14. BRADYARRHYTHMIASOEMS PROTOCOLS MEDICAL CONTROL MAY ORDER • Additional doses of above medications • Additional fluid boluses (10-20mL/kg) • Transcutaneous pacing, if available.

15. BRADYARRHYTHMIASOEMS PROTOCOLS MEDICAL CONTROL MAY ORDER • Epinephrine 1:10,000 – 0.01-0.03 mg/kg IV/IO (max. single dose of 0.5 mg) • Epinephrine Infusion 1:1,000, 0.1-1 mcg/kg/min IV/IO. For example, mix 1mg of Epinephrine 1:1000 in 250mL of Normal Saline, (15 micro drops/minute = 1 mcg / min.) • Treat other conditions according to specific protocols.

16. TACHYARRHYTHMIAS • Abnormally rapid rates that originate in the atria or the ventricles • Certain arrhythmias such as SVT’s and Ventricular Tachycardia can lead to shock and death.

17. TACHYARRHYTHMIAS SVT • Heart rate : • Infants greater than 220 • Children greater than 180 • P waves are abnormal or hidden: NOT SINUS • PR interval may be absent or short • R-R interval is constant • Complex's are usually narrow. • SVT with aberrancy

18. TACHYARRHYTHMIASOEMS PROTOCOLS EMT/EMT-INTERMEDIATE/ADVANCED EMT STANDING ORDERS • Routine Patient Care • If tachycardia is related to acute injury or volume loss, see 2.16P Shock.

19. TACHYARRHYTHMIASOEMS PROTOCOLS PARAMEDIC STANDING ORDERS • IV Normal Saline (KVO). If hypovolemic component is suspected, administer 20 mL/kg IV Bolus of Normal Saline.

20. TACHYARRHYTHMIASOEMS PROTOCOLS MEDICAL CONTROL MAY ORDER • Additional doses of above medications • Synchronized cardioversion 0.5 joules/kg for symptomatic patients.* Subsequent cardioversion may be done at up to 1 joule/kg. If cardioversion is warranted, consider administration of 7.6 Sedation for Electrical Therapy, per protocol. • See A2 Pediatric Color Coded Medication Reference for dosing. • Adenosine 0.1 mg/kg rapid IV/IO. If no effect, repeat Adenosine 0.2 mg/kg Rapid IV push. MAXIMUM single dose of Adenosine must not exceed 12 mg. •  Consider Vagal maneuvers (see Reminder below). • Treat other conditions according to specific protocols

21. TACHYARRHYTHMIASOEMS PROTOCOLS OEMS WARNING Synchronized cardioversion should be considered for only those children whose heart rate is in excess of 220, and who demonstrate one or more of the following signs of hypoperfusion: Decreased level of consciousness, weak and thready pulses, capillary refill time of more than 4 seconds, or no palpable BLOOD PRESSURE.

22. TACHYARRHYTHMIASOEMS PROTOCOLS OEMS WARNING REMINDER: Vagal maneuvers may precipitate asystole and therefore should be employed with caution in the field and only in a cardiac-monitored child with IV access.

23. VENTRICULAR TACHYCARDIA WITH PULSES OEMS PROTOCOLS EMT/EMT-INTERMEDIATE/ADVANCED EMT STANDING ORDERS • Routine Patient Care

24. VENTRICULAR TACHYCARDIA WITH PULSES PARAMEDIC STANDING ORDER • Unstable pediatric patients, synchronized cardioversion per Pediatric Color-Coded Appendix. • If cardioversion is warranted, see 7.6 Sedation for Electrical Therapy • Stable pediatric patient administer Amiodarone dose per Pediatric Color-Coded Appendix

25. CARDIAC ARRESTOEMS PROTOCOLS EMT / EMT-INTERMEDIATE / ADVANCED EMT STANDING ORDERS • Routine Patient Care—with focus on high quality CPR • Apply AED and use as soon as possible (with minimum interruption of chest compressions). From birth to age 8 years use pediatric AED pads. • If pediatric AED pads are unavailable, providers may use adult AED pads, provided the pads do not overlap.

26. CARDIAC ARRESTOEMS PROTOCOLS EMT / EMT-INTERMEDIATE / ADVANCED EMT STANDING ORDERS • If unable to ventilate child after repositioning of airway, assume upper airway obstruction and follow Pediatric Upper Airway Obstruction Protocol. • Consider treatable causes

27. CARDIAC ARRESTOEMS PROTOCOLS PARAMEDIC STANDING ORDERS • Defibrillate once at 2-4J/kg. • Epinephrine: 0.01mg/kg IV/IO (1:10,000, 0.1mL/kg); repeat every 3-5 minutes. • Defibrillate 4-10 J/kg (do not exceed 10J/kg) every 2 minutes. • Amiodarone5 mg/kg IV/IO • Defibrillate 4 J/kg 30-60 seconds after each medication.

28. CARDIAC ARRESTOEMS PROTOCOLS MEDICAL CONTROL MAY ORDER • Additional doses of above medications • Sodium Bicarbonate 1 mEq/kg IV/IO. • All other treatment modalities based upon suspected cause of VT/FT. • Treat other conditions according to specific protocols.