1 / 54

Approach to Common Cardiac Emergencies

Approach to Common Cardiac Emergencies. Agustin E. Rubio, MD Sibley Heart Center Cardiology Children’s Healthcare of Atlanta Emory School of Medicine. Topics. Cyanosis & Ductal Dependent Emergency Room Diagnoses: Tetralogy of Fallot Hypoplastic Left Heart Syndrome Coarctation of Aorta

marrim
Download Presentation

Approach to Common Cardiac Emergencies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Approach to Common Cardiac Emergencies Agustin E. Rubio, MD Sibley Heart Center Cardiology Children’s Healthcare of Atlanta Emory School of Medicine

  2. Topics • Cyanosis & Ductal Dependent • Emergency Room Diagnoses: • Tetralogy of Fallot • Hypoplastic Left Heart Syndrome • Coarctation of Aorta • SVT • Shunt Dependent vs Non-shunt Dependent

  3. Epidemiology • Cardiac malformations • 10% of infant mortality • Incidence: • 4-6/1000 live births • Most common lethal diagnosis: • Left ventricular outflow tract obstruction • Hypoplastic left heart syndrome • Coarctation of aorta • Aortic stenosis

  4. Circulatory Transitions • Conversion from right sided (placental oxygenation) to left sided circulation (pulmonary oxygenation) • Progression is secondary: • Decreasing PVR • Closure of ductal shunts • Clinical presentations: • Cyanosis • Respiratory failure • Shock

  5. Cyanosis • Typically, 2 g/dL of reduced hemoglobin • 5g/dL of reduced Hb  clinical cyanosis • Hb 15  cyanosis at 75-80% • Hb 20  cyanosis at 80-85% • Hb 6  cyanosis at 45-50%

  6. Ductal Dependent Lesions Cyanosis CHF/Shock • Lt Ventricular Outflow Tract Obstruction: • HLHS • Coarctation of Aorta/ AS • Truncus arteriosus • TGA with VSD • TAPVR • Rt to Lt shunting: • Tricuspid atresia • TOF/ Pulm atresia • Ebstein’s anomaly

  7. Left Ventricular Outflow Tract Obstruction • Major source of neonatal M&M from CHD • Accounts for ~ 12% of congenital cardiac disease in infancy • ~ 75% discharged from hospital w/o diagnosis • ~ 65% - normal newborn screen examination • 6% died before diagnosis • 96% symptoms by 3 wks of life

  8. Symptoms Timeline of Clinical Diagnosis Week #1 HLHS Coarctation of aorta TAPVR - obstucted Week #2-6 Transposition of Great Arteries Total Anomalous Venous Return Truncus arteriosus

  9. Tetralogy of Fallot

  10. Tetralogy of Fallot • Prevalence: • - 10% of CHD • Most common cyanotic heart defect beyond infancy

  11. Tetralogy of Fallot • +/- Cyanosis • Small to Nl cardiac silhouette • pulmonary vasculature

  12. Tetralogy of Fallot • “Tet spell” • Hyperpnea • Worsening cyanosis • Disappearance of murmur • RBBB pattern on ECG

  13. Tetralogy of Fallot • “Tet spell” • Treatment objectives: • Reverse the right-to-left shunt • systemic vascular resistance (SVR) • Correct potential acidosis with NaHCO3 & volume • Consider peripheral vasoconstriction (phenylephrine – 0.02 mg/kg IV) • Ketamine • increase SVR and sedates 2 mg/kg over 1 min • Morphine sulphate • Oxygen

  14. Tetralogy of FallotSurgical Options • Blalock-Taussig shunt • Delayed repair • Trans-annular patch • VSD closure

  15. Tetralogy of FallotPost-operative Concerns • Post-pericardiotomy syndrome • ~ 4 weeks post-op (25-30% of open heart pts) • Fever, elevated ESR and CRP • Increased work of breathing (? pericardial effusion) • Cardiomegaly, pleural effusions • ECG – persistent ST segment elevation with flat or inverted T waves in limb & left lateral limb leads • Pericardiocentesis – performed when tamponade physiology present

  16. Tetralogy of FallotPost-operative Concerns • Endocarditis • Dx after >2 BCx or echo evidence • Residual VSD • Arrhythmias • AV block, ventricular arrhythmias • Remember: • Any incision in the ventricle produces a RBBB pattern (rSR’ in V1; wide complex QRS)

  17. Tetralogy of FallotPost-operative Concerns • Arrhythmias • TOF - 40% increased incidence of lethal arrhythmias • Syncopal events- lethal ventricular arrhythmias ??

  18. Hypoplastic Left Heart Syndrome

  19. HLHS

  20. HLHS • Uncommon form of cyanotic heart disease • Most common cause of death in the first month of life • Critically ill infant within the first 7 days with low O2 saturations

  21. HLHS • Clinically: • Progressive cyanosis and hypoxemia • Hx of poor feeding, tachypnea and poor weight gain • Cardiovascular shock • Severe acidosis • Congestive heart failure

  22. Consequences and Complications • Polycythemia (erythrocytosis) • Clubbing (>6 mos of age) • Hypoxic spells • CNS • Cyanotic heart disease accounts for 5-10% of brain abscesses • Cerebral venous thrombosis - <2 yrs, cyanotic and microcytic anemia • Dyscrasias

  23. HLHSPre-operative Resuscitation • Medical management: • Intubation • Ventilate and oxygen • Intravenous access • Central/ umbilical/ intra-osseos • Glucose • Na HCO3 • PGE1(get that PDA open!!) • PGE1 0.05 mcg/kg/min • Volume – NS/ 5% Albumin/ PRBC’s • NIRS probe

  24. HLHSNorwood/ Blalock-Taussig Shunt • Post-operative changes • Uncontrolled PBF • Re-constructed aortic outflow tract • Fluid balance sensitive • Widened pulse pressures • Tenuous coronary circulation • Single ventricle for all circulation

  25. HLHSNorwood/ Sano shunt • Post-operative changes • Direct PA communication with RV • Uncontrolled PBF • Neo-aortic reconstruction • Higher diastolic pressures • Better coronary perfusion

  26. HLHSPost-Operative Resuscitation • Limit oxygen (remember: relative uncontrolled PBF) • Hemoglobin • Auscultate for murmur: • Continuous murmur at RUSB (? BT shunt) • Systolic murmur at RLSB/ LUSB (Sano shunt) • Fluid balance: • Palpate liver • +/- rales and CXR to evaluate for CHF • Reverse dehydration • Reverse acidosis

  27. Coarctation of Aorta

  28. Coarctation of Aorta • Common cause of left sided heart failure • 95% located in juxtaductal region • Associated with other congenital anomalies • May be short segments or long segments

  29. Coarctation of Aorta • Associations: • HLHS • Aortic stenosis • TOF • Truncus arteriosus • VSD • DORV • Turner’s syndrome

  30. Coarctation of Aorta • Clinical • Poor feeding, dyspnea & poor weight gain • Upper arm vs lower extremity BP discrepancy • >10-20 mmHg systolic upper vs. lower • 20-30% develop CHF by 2-3 months • Hx of lower extremity weakness or pain after exercise • 50% will have no murmur

  31. Coarctation of Aorta • Acute clinical presentation: • Cardiovascular shock • Somnolent & lethargic • Poor po intake/ dehydrated, poor U/O • Cold, clammy & diaphoretic • Poor pulses • +/- organomegaly • Bradycardia/ tachycardia

  32. Coarctation of Aorta • Laboratory Evaluation: • CBC & ABG/VBG • CMP, Magnesium & Phos • Lactate • BNP level • CXR & 12 lead ECG • Blood cultures • NIRS probe

  33. Coarctation of Aorta • Neonatal Coarctation • rSR’ in the right precordial leads (V1 & V2) • Deep S waves in the lateral leads • RAD

  34. Coarctation of Aorta • Infant Coarctation • LVH apparent (left lateral leads) • Deep S waves in the right chest • Large R waves in lateral leads

  35. Coarctation of AortaSurgical repairs

  36. Coarctation of AortaPost-operative State • Re-coarctation • Occurs most commonly within the first 12 months • Evaluated by 4 extremity BP’s • Physical examination of upper & lower extremity pulses

  37. Tachyarrhythmia:Sinus Tach vs. SVT

  38. Clinical Signs of Tachyarrhythmia

  39. Neonate: Sudden onset of irritability& sudden relief Poor po intake & somnolence Inconsolable “Rapid heart beat”– felt by parents Older Child: Stops activity abruptly “Palpitations”/ “feels funny” Sudden relief with vasovagal manuever Chest pain - rare Symptoms from History

  40. ECG Findings Sinus Tach Sinus Tach

  41. Rhythms SVT • Regular rhythm, narrow QRS, HR >200, p buried in T wave Sinus Tach • Regular rhythm <200, distinct p waves, nl intervals

  42. Sinus Tachycardia vs. SVT

  43. SVT – Hemodynamically Stable

  44. SVT – Hemodynamically Unstable ** Cardioversion should be performed in a location which can provide for continuous monitoring and potential complications of sedation.

  45. Medications for SVT

  46. Laboratory Evaluation • Electrolytes • Calcium, Magnesium & Phosphorus • CBC with diff • CXR & 12 lead EKG • looking for pre-excitation – WPW

  47. Shunt Dependent vs. Non-dependent What’s the big deal !!!

  48. The Difference • Shunt Dependent • The only source of PBF = SHUNT • Non-Dependent • Two sources of PBF = Shunt + some antegrade flow through diminuitive PV

  49. Shunt Dependent • Oxygen therapy • Limit O2 therapy for cyanosis • Maintain sats 75-85% • Sats can drop significantly and quickly • If sats >85%: • PVR  PBF  Pulmonary edema and circulatory shock • Use blended O2 with range of up to FiO2 0.4

  50. Non-Dependent • Oxygen therapy • Two sources of PBF: • One with fixed obstruction and the other is uncontrolled • If BT shunt present: • Limit O2 • O2 saturations should not drop as far nor as quickly

More Related