CARDIAC EMERGENCIES

OBJECTIVES

— To recognize common life-threatening cardiac emergencies

— To discuss the management of common cardiac emergencies
¡ ARRHYTHMIA

¡ HYPERCYANOTIC SPELL

¡ CARDIAC TAMPONADE

¡ CONGESTIVE HEART FAILURE

¡ SYNCOPE
 Emergency Severity Index

— five-level triage algorithm that categorizes emergency department

patients by evaluating both patient acuity and resource needs
— Rapid identification of patients that need immediate attention
— Quick sorting of patients in the setting of constrained resources
— Acuity – determined by stability of vital functions and the potential
threat to life, limb or organ
— Resource needs – number of resources a patient is expected to consume
in order for a disposition decision (discharge, admission, or transfer) to
be reached
— High risk situation
¡ A patient whose condition could
deteriorate or who present with
symptoms suggestive of a condition
requiring time sensitive treatment

— Severe pain/Distress
¡ Clinical observation
¡ Pain rating of ≥ 7/10
 Normal Vital Signs According to Age
AGE HR (bpm) BP (mm Hg) RR (breaths/min)
Premature 120-170* 55-75/35-45† 40-70‡
0-3 mo 100-150* 65-85/45-55 35-55
3-6 mo 90-120 70-90/50-65 30-45
6-12 mo 80-120 80-100/55-65 25-40
1-3 yr 70-110 90-105/55-70 20-30
3-6 yr 65-110 95-110/60-75 20-25
6-12 yr 60-95 100-120/60-75 14-22
12+ yr 55-85 110-135/65-85 12-18
Estimated Blood Pressure by Age
Neonates: >60mmHg 2Diastolic + Systolic
1mo-1yo: >70mmHg Mean Arterial 3
Systolic BP (lower limit)
1-10yo: Age x 2 + 70mmHg Pressure* 50th: (Age x 1.5) + 55
>10yo: >90mmHg 5th: (Age x 1.5) + 40
Endotracheal Tube Formula* Temperature
Uncuffed ETT Size: (age in yrs/4) + 4 1 °C Temp = RR by 4
Cuffed ETT: (age in yrs/4) + 3 CR by 10
ETT Depth (lip to mid-trachea) ET size x 3
Nelson’ s 20th; *Harriet Lane
 NB/Small in Infant Small child Child Child Large Child Adult
Equipment Toddler 10-11kg
3-5kg 6-9kg 12-14kg 15-18kg 19-23kg 24-30kg >32kg
Resuscitation
Infant Child Child Child Child Child Child/Adult Adult
bag
Oxygen mask
Newborn Newborn Pediatric Pediatric Pediatric Pediatric Pediatric Adult
(NRB)
Child/Small Child/Sm
Oral airway Infant/Small 50- Small Small Small Child Medium Adult
adult Adult
(mm*) 60mm 50mm 60mm 60mm 60 80
70 80
Laryngo blade 2 straight or 2 straight or 2-3 straight or 3 straight or
0-1 straight 1 straight 1 straight 2 straight
(size) curved curved curved curved

PT: 2.5 3.5 uncuff. 4.0 uncuff. 4.5 uncuffed 5.0 uncuffed 5.5 uncuff
ET tube (mm) 6.0 cuffed 6.5 cuffed
FT: 3-3.5 3.0 cuffed 3.5 cuffed 4.0 cuffed 4.5 cuffed 5.0 cuffed
3kg 9-9.5
ETT length
4kg 9.5-10 10-10.5 11-12 13.5 14-15 16.5 17-18 18.5-19.5
(cm at lip)
5kg 10-10.5
Suction cath
6-8 8 10 10 10 10 10 12
(F)
BP cuff Neonatal #5 Infant Child Child Child Child Child/Adult Adult

IV catheter (ga) 22-24 22-24 20-24 18-22 18-22 18-20 18-20 16-20

IO (ga 18/15 15 15 15 15 15 15

NGT (F) 5-8 5-8 8-10 10 10 12-14 14-18 16-18

Urine cath (f) 5-8 5-8 8-10 10 10-12 10-12 12 12

Chest tube (F) 10-12 10-12 16-20 20-24 20-24 24-32 28-32 32-38
12
Adapted from Broselow Pediatric Resuscitation Tape; *Harriet Lane
 Commonly encountered pediatric cardiac emergencies

— 1. Cardiopulmonary arrest
2. Shock
3. Arrhythmias
4. Hypercyanotic (“Tet”) spells
5. Cyanosis in the newborn
6. Congestive heart failure
7. Cardiac emergencies in the patient with a functional single ventricle
8. Cerebrovascular accidents
9. Brain abscess
ARRHYTHMIAS
 SUPRAVENTRICULAR TACHYCARDIA

— most common sustained arrhythmia in children

— abnormally rapid rhythm that originates proximal to the bifurcation of
the bundle of His
— reentrant in type (70%)
¡ accessory pathway (Wolff-Parkinson-White syndrome {WPW})
— No discernable P wave
— Abrupt onset and termination
— HR: >250bpm (neonates)
>220bpm (infants)
>150bpm (older children)
SUPRAVENTRICULAR TACHYCARDIA
 SIGNS AND SYMPTOMS

Neonates/Infants Children

¡ Fuzzy, irritable, poor feeding — Irritability

¡ Congestive heart failure
— Vomiting
÷ Pallor
÷ Tachypnea — Palpitations
÷ Diaphoresis — Headache
÷ Poor perfusion
— Chest pain
÷ Hypotension
— Dizziness
— Syncope
 Vagal maneuvers

Neonates/Infants Older children

— Cold stimulus - crushed ice on — Valsalva maneuver
plastic bag gentluy on face ¡ Expiring against a closed glottis
— Rectal stimulation with rectal ¡ Blow through an occluded straw
thermoter — Coughing
— insertion of nasogastric tube to — Cold Stimulus to the Face
simulate Valsalva — Carotid Massage
Hemodynamically stable: Hemodynamically UNstable:

— ADENOSINE — SYNCHRONIZED CARDIOVERSION:

1stdose–0.1mg/kg (max: 6mg) 1st – 0.5-1 joules/kg
2nd dose–0.2mg/kg (max: 12mg)
2nd – 2 joules /kg
— ESMOLOL
200-400mcg/kg over 10 mins ff by — Transesophageal pacing
75mcg/kg

— AMIODARONE
Bolus 5mg/kg over 20-60mins ff by 10-
15mg/kg/day cont. infusion

— PROCAINAMIDE
LD: 7-15mg/kg over 30-45mins ff by
MD 40-50mcg/kg/min

— VERAPAMIL
0.1mg/kg SIVP; may increase to 0.2mg/kg
in 15 mins if no response (max 5mg)
 VENTRICULAR TACHYCARDIA

— three or more premature — Causes :

ventricular contractions (PVCs) in ¡ Underlying structural heart disease
a row at a rate faster than 120 bpm ¡ Prolonged QT syndrome
— Ventricular rate may vary from ¡ Acute hypoxemia
near normal to >200 bpm ¡ Acidosis
— Compromise stroke volume and ¡ Electrolyte imbalance
cardiac output and may ¡ Drug toxicity
degenerate into ventricular
fibrillation or pulseless ventricular
tachycardia
 Signs and Symptoms

— Dizziness
— Palpitations
— Shortness of breath
— Some people might have nausea
— Lightheadedness
— Unconsciousness
— Cardiac arrest
AMIODARONE:
5mg/kg IV over 20-60mins

PROCAINAMIDE:
15mg/kg IV over 30-60mins

WITHOUT PULSE:

DEFIBRILLATION
1st shock – 2 joules/kg
2nd shock – 4 joules/kg
Subsequent shock - >4 j/kg
Maximum 10j/kg
HYPERCYANOTIC SPELLS
 HYPERCYANOTIC SPELLS

— Mostly seen between 1-12months old

— May last for a few minutes to a few hours
— Most frequent in the morning after waking from sleep
— Precipitating factors: defecation, crying and feeding
— Manifestation:
¡ hyperpnea and cyanosis

¡ limp and syncope

¡ short and soft or inaudible murmur due to severe RVOTO

 HYPERCYANOTIC SPELLS

— usually self-limited
— serious complications: syncope, seizure-like episodes, cerebrovascular
accidents, or even death
— inciting factors:
¡ agitation
¡ intercurrent illness
¡ dehydration
¡ invasive procedures without adequate prior sedation
 HYPERCYANOTIC SPELLS

— provoked by crying à abrupt worsening of cyanosis à breathlessness

à loss of consciousness
— Postspell somnolence (milder cases)
— If severe untreated cases à death
— Physiology: acute imbalance bet. systemic and pulmonary blood flow
¡ acute changes in inotropy
¡ increased systemic oxygen consumption
¡ leading to reduced mixed venous oxygen content
¡ acute reduction in systemic vascular resistance
¡ decreased RV preload associated with tachycardia
— TREATMENT:
— Aim is to redress the imbalance and disrupt the pathophysiologic spiral
— relieving pain and anxiety (to reduce heart rate and systemic oxygen
consumption)
— increase systemic vascular resistance
— increase pulmonary blood flow
 TREATMENT

— Knee chest position

¡ compresses the femoral arteries and increases peripheral SVR

— Oxygen
— Bolus of intravenous crystalloid or colloid fluids
¡ increase intravascular volume, maximize preload, and improve cardiac output

— Morphine IV/IM (0.1 to 0.2 mg/kg)

¡ Reverse endogenous catecholamine release, reduce HR, and lowers RR

— Propanolol (0.015-0.02mg/kg) or esmolol (0.5 mg/kg given over 1

minute, then as continuous infusion) IV
¡ Lowers HR and improve diastolic ventricular filling à increasing preload
¡ act acutely to increase SVR
— Sodium bicarbonate IV (1 mEq/kg)
¡ Corrects acidosis and eliminates the respiratory center stimulating effects of acidosis
 TREATMENT

— Phenylephrine (0.005-0.001mg/kg IV bolus)

— Norepinephrine (0.05 – 1.0 mg/kg IV)
¡ increase SVR

— Anesthesia/Intubation
¡ to reduce the work of breathing

¡ reduce oxygen consumption

¡ improve mixed venous oxygen content

— severe life-threatening spells may require emergent surgical

intervention or mechanical circulatory support
CARDIAC TAMPONADE
 CARDIAC TAMPONADE

— Occurs when the heart is compressed by a fluid filled pericardium

¡ Causes restriction of ventricular and atrial filling and decreased cardiac output

¡ results from a sudden increase in pericardial fluid volume

¡ from progressive increase in volume beyond the point of potential pericardial

distention

— Becks Triad:
¡ Distant heart sounds

¡ Hypotension

¡ Elevated CVP with jugular venous distention

 CARDIAC TAMPONADE

— Tachycardia
— Tachypnea
— Narrow pulse pressure
— Pulses paradoxus
¡ Decrease in systolic blood pressure of greater than 10 mmHg during inspiration
Chest Xray
 Echocardiography

— Pericardial effusions appear as echo-free spaces around the heart

— Fibrinous strands, thrombi, adhesions, or metastases, detecting other
structural and myocardial causes of cardiomegaly
— small effusion – posteriorly, only in systole
— large effusions – swing to-and-fro within the pericardial space
— Earliest sign of hemodynamic impairment: collapse of RV free wall in
early to mid-diastole, indented RA free wall in late diastole
 MANAGEMENT

— IV fluids – to increase diastolic filling pressure temporarily

— Avoid diuretics and vasodilators
— Pericardiocentesis
¡ low cardiac output

¡ hypotension

¡ pulsus paradoxus >10 mm Hg

¡ suspected bacterial pericarditis

¡ pericardial effusions in immunocompromised hosts

¡ diagnostic purposes when the etiology is unclear

— Surgical drainage
 PERICARDIOCENTESIS

— 30 degree head up position and

adequately sedated
— Emergency
¡ Needle is introduced subxiphoid and
advanced toward the left shoulder
— Non-emergency
¡ Echo-guided
CONGESTIVE HEART FAILURE
 CONGESTIVE HEART FAILURE

— Inadequate cardiac output to maintain end organ perfusion during rest

or exercise
— Conditions precipitating CHF:
— large left to right shunts (VSD, PDA)
— single ventricle lesions w/o PS
— primary myocardial dysfunction (myocarditis, DCM)
— ductal dependent lesions (HLHS, severe CoA or IAA)
 CONGESTIVE HEART FAILURE

History and clinical manifestation in infants

— Poor feeding, tachypnea, diaphoresis
— Poor weight gain
— Decreased peripheral perfusion
— Weak pulses
— Delayed capillary filling
— Pallor
 CONGESTIVE HEART FAILURE

History and clinical manifestation in children

— Shortness of breath, orthopnea
— Easy fatigability, signs of edema
— Decreased exercise tolerance
— Decreased appetite
 CONGESTIVE HEART FAILURE

PE findings
— Compensatory responses to impaired cardiac function
¡ tachycardia, cardiomegaly, increased sympathetic discharges

— Pulmonary venous congestion (left-sided failure)

- Tachypnea, dyspnea on exertion, orthopnea, wheezing

— Systemic venous congestion (right-sided failure)

- Hepatomegaly, puffy eyelids, distended neck veins and ankle edema,
 CONGESTIVE HEART FAILURE

— The goals of management is

- reduce the preload
- enhance cardiac contractility
- reduce the afterload
- improve oxygen delivery
- enhance nutrition
 PRELOAD REDUCTION

Meds Dose

Furosemide 1-2 mkdose PO or IV BID or TID

Hydrocholorothiazide 1-2 mkday BID or QID

Used with loop
Spironolactone 1-2 mkdose BID
diuretic
 DIGOXIN

• dec HR LD: 0.04 x wt LD max : 1 mg in 24 hrs

• inc force and velocity of - if IV: 75% divided into 4 or 0.25 mg every 6 hours
ventricular contraction every 6 hrs PO
• ameliorates
sympathetic tone MTN: 0.004 x wt MD max : 0.25 mg/day
given as one dose or in 2
divided doses
 INOTROPES

DOPAMINE
• Inc renal blood flow in low doses 3-5ug/kg/min Titrate to desired
• May cause rhythm disturbance 10-20 ug/kg/min effect
DOBUTAMINE
• inotropic effect 5-25 ug/kg/min Titrate to desired
• increase contractility effect
• Increases CO
• decrease SVR
 INOTROPES

MILRINONE LD: 50 mcg/kg IV over 15mins

• inodilator: inotropic for the MD: 0.5-1 mcg/kg/min Titrate to
myocardium desired effect
• pulmonary vascular dilator
through phosphodiesterase
inhibition
 AFTERLOAD REDUCTION

<6 y: 0.1-2mkday q 6-12h Max 6mg/kg/d

CAPTOPRIL
>6 y: 6-25mg/dose q 6-12h Max 50-75mg/d

ENALAPRIL >6 y: 2.5mg OD to 15 mg BID Max 0.5mg/kg/d

NITROGLYCERIN
0.5-6 mcg/kg/min
- systemic venous dilator
SYNCOPE
 SYNCOPE

— sudden brief loss of consciousness and muscle tone from which

recovery is spontaneous and does not suggest any other altered state
of consciousness
— Circumstance, collateral history, medications, medical history and
family history
— Postural syncope: Dizziness or light-headedness, visual changes,
feeling hot, or nausea
— Syncope without prodrome should be considered more significant for
the possibility of a sudden severe arrhythmia
 BREATH HOLDING SPELL

— child experiences an emotional or minor physical trauma à breath-

hold à brief loss of consciousness
— facial cyanosis
— progressive pallor
— appearance of being disoriented
— involuntary muscle twitching
— benign self-limited episodes
— do not require further investigation or treatment
— Some infants with breath-holding spells will have VVS later in life
— SYMPTOMS:
— warm or clammy sensation, nausea, light-headedness, or visual changes
(eg, seeing spots, grey out, tunneling), irritability, confusion, auditory
changes, dyspnea, or abdominal symptoms = VASOVAGAL SYNCOPE
— absence of a prodrome, a midexertional event, and chest pain or
palpitations preceding the event = CARDIAC CAUSE
— CIRCUMSTANCES:
— Syncope occuring midexertion, before the child has a chance to stop the
activity = CARDIAC
— Postexertional syncope = benign
— recent change of position, poor hydration or nutritional status, or a
warm environment, standing = VVS
— Other precipitating factors (VVS):
¡ phlebotomy, the sight of blood or disfiguring injury (eg, fractures or soft tissue
injuries), hair grooming, micturition/defecation, emotional upset, mild physical
trauma or pain, intercurrent illness, especially those with gastrointestinal symptoms,
and hot or crowded conditions
— COLLATERAL HISTORY:
— Details like duration of the loss of consciousness and required degree of
intervention, should be solicited whenever possible
— Pallor or loss of colour, involuntary movement = VVS
¡ Single muscle twitch to violent jerks affecting entire body, Proximal and distal
muscles are equally affected and facial involvement (syncopal myoclonus)
— Myoclonus not rhythmic, rarely sustained for more than half minute =
epilepsy (syncopal myoclonus)
— loss of consciousness precedes movements in most cases of true
syncope
— MEDICATIONS, MEDICAL HX, FAMILY HX
— b blockers, calcium channel blockers, and diuretics
— medical history
¡ previous syncopal events, cardiac disease, diabetes, seizures, medication or drug use,
and psychiatric or psychological problems
— A family history of sudden death in young, apparently healthy
individuals, or from unknown or incongruous causes
— Any family history of structural cardiac disease, arrhythmias, migraine,
or seizures is also relevant
— PE:
— Complete cardiac and neurologic examinations
— postural vital signs
— cyanosis, a pathologic murmur, diminished pulse volume, or a
sternotomy scar
— Persistent neurologic deficits
— INVESTIGATION
— History and PE
— Bloodwork, Hypoglycemia
— 15L ECG
— Echocardiogram
— Treadmill test / Holter monitor
— EEG
— Brain imaging
Red light = malignant arrhythmia in
certain contexts
Yellow light = non-urgent evaluation in
cardiology
Green light = normal variants with no
further management needed
 TREATMENT

— VASOVAGAL SYNCOPE
— Education
— Avoidance of precipitating factors
— Increase in dietary salt and fluid intake
— Physical techniques like squatting, crossing legs, or buttocks-clenching
while upright prevented syncope
THANK YOU! J