Paediatric Cardiology Dr Ratna Merugumalla Consultant in Emergency Medicine Peterborough City...

Paediatric Cardiology

Dr Ratna MerugumallaConsultant in Emergency Medicine

Peterborough City Hospital

Cardiovascular presentations

• Collapse

• The blue baby

• Syncope

• Palpitations

• Chest pain

The normal Heart Rate

THE ECG

ECG in a 2 year old

ECGs in children• Heart rate >100 beats/min• Rightward QRS axis > +90°• T wave inversions in V1-3 (“juvenile T-wave pattern”)• Dominant R wave in V1• RSR’ pattern in V1• Marked sinus arrhythmia• Short PR interval (< 120ms) and QRS duration

(<80ms)• Slightly peaked P waves• Q waves in the inferior and left precordial leads.

The normal ECG

• QRS variable with age - Newborn 50-80ms, at 16 years 75-115ms

• cQTC under 6/12: 490ms, 440ms otherwise

• Notched t waves; may be normal in V2&3

• Transient Wenckebach during sleep

The normal ECG• Parameters vary through age

• Right ventricular dominance owing to high pulmonary pressures, normalise at ~6/12

• T waves; usually upright in most leads for first 7/7, then downwards in most leads until adolescence.

•Upright t waves in childhood may reflect RVH.

CHEST PAIN

Chest painCommon but usually benign presentation 4436 presentations age < 19 yrs over 3 1/2 year period in a tertiary PED in USA•0.6% deemed cardiac

•37% arrhythmia•29% pericardial•17% myocarditis•13% AMI•4% PE

American Journal of Emergency Medicine Volume 29, Issue 6 , Pages 632-638, July 2011)

Non cardiac chest pain

• 56% musculoskeletal

• 12% asthma/ wheeze

• 8% infection

• 6% GI – gastritis and GORD

• 4% sickle cell disease

Texidor’s twinge

• Precordial catch syndrome:

• acute, non-radiating left sided chest pain in an adolescent

• occurs suddenly, exacerbated during inspiration and resolves in a few minutes

SYNCOPE

Syncope• 15-20% all children will have an episode

Neurally mediatedVasovagalReflex anoxic seizuresOrthostatic

CardiacStructuralCardiomyopathyArrythmias

Non CVSPsychogenicFactitiousNeurological non syncope e.g. Seizure

Syncope Red Flags

• History of cardiac disease• Family history of SCD• Recurrent episodes• Exertional• Prolonged LoC• Associated chest pain / palpitations• Medications that can alter cardiac conduction

Sudden Cardiac Death

• Myocarditis• HOCM• Cyanotic / Acyanotic congenital heart disease• Valvular heart disease• Complete heart block• WPW, long QT syndrome• Marfan’s syndrome• CAD• Anomalous coronary arteries

PALPITATIONS

Cardiac arrhythmias in children

• Likely to be the result rather than the cause of acute illness

• Often preceded by hypoxia, acidosis and / or hypotension

• Primary cardiac arrhythmias are uncommon

Heart rate

Age Bradycardia Tachycardia

< 1 y < 80 min-1 > 180 min-1

> 1 y < 60 min-1 > 160 min-1

Bradycardia

Bradycardia - causes

• Bradyarrythmias rare in structurally normal hearts

• Usually pre-terminal following hypoxia and ischaemia

• Vagal stimulation• Raised ICP• Poisoning with digoxin/ beta-blockers• Congenital CHB seen in infants of mothers with

anti ro and la antibodies

Bradycardia Treatment

• Oxygenation

• Adrenaline – 10mcg/kg

• Atropine - Consider when vagal stimulation e.g. airway instrumentation – 20mcg/kg

• Pacing (rarely required)

Tachycardiardia

Narrow QRS complex Broad QRS complex

ST VT or SVTSVT Treat as VT

Sinus Tachycardia

ST – Treat the cause

• Physiological response:

CryingExerciseAnxiety/fearPain

• Compensatory mechanism for:

Respiratory failureHypovolaemiaSepsisAnaemia

Supraventricular tachycardia

Supraventricular Tachycardia

• Most common primary cardiac arrhythmia in children

• Paroxysmal, regular, narrow QRS complexes

• Caused by re-entry mechanism through an accessory pathway or AV conduction system

• HR > 220 bpm in infants or > 180 bpm in children

ST or SVT

SVT - Management• Valsalva manoeuvre

• IV Adenosine 100 mcg/kg200 mcg/kg maximum 1st dose 6mg, 2nd dose 12mg

• Amiodarone in refractory SVT

• DC cardioversion – for decompensated children

Ventricular Tachycardia

Ventricular Tachycardia Causes

• Congenital HD & surgery

• Poisoning (TCAs, Quinidine)

• Brugada syndrome / Long QT interval

• Renal Disease / Hyperkalaemia

VT - management

Long QT - congenitalNormal QTc < 400ms, > 460 ms abnormal

Easiest to reproducibly measure in II & V5

Channelopathy

Genetic mutations identifies in 90% familial cases

Subtypes 1-14

Risk of torsades and VF

May present with syncope (VT), risk greatest with QT > 500ms

Ask about family history of syncope, sudden death and epilepsy

European registry 1993; 8% 5 yr mortality

Treatment with BB

Atrial Flutter

Atrial Fibrillation

Atrial Flutter and Fibrillation

• Rare

• Underlying CHD, status post-open heart surgery

• Cardioversion in decompensated

• In haemodynamically stable children, amiodarone or elective cardioversion

Pre-excitation syndromes• Commonest WPW

• Ventricular Pre-excitation in SR, short PR and delta wave

• Commonest arrhythmia is orthodromic AV re-entry tachycardia

• Antidromic less common

COLLAPSE

The collapsed infant

• Wide differential• Always cover for sepsis

Congenital heart disease• May present as lethargy, poor feeding, "not right",

cyanosis to complete cardiovascular collapse

Congenital heart disease Foetal PVR>SVR; blood bypasses lungs through ductus arteriosus and foramen ovale

DA usually closes 24-36hrs post birth – may be much longer

FO closes when left atrium volume increases

Congenital heart disease

• Failure of normal development or

• Persistence of foetal circulation

• 7-9% live births

• Acyanotic or Cyanotic heart disease

Acyanotic Heart Disease

VSD (25%)ASDPDAPV stenosisCoAASHypoplastic left heartHOCMDextrocardia

Cyanotic Heart Disease

TetralogyTranspositionTricuspid atresiaTAPVD

Congenital heart disease

Common presentations:

• Cyanosis

• Heart failure

• Heart murmur

Cyanosis

• Cyanosis – ~4-5g/dL of deoxygenated blood

• Cardiac cause – ‘comfortably blue’, worse with crying, minimal improvement with O2 • Primary pulmonary disease; no R-L sats diff• Primary cardiac; 5-10 % R-L sats diff• Sepsis; no diff

Failure

• Sweating• Poor feeding• Hepatomegaly• SOB• Creps• Tachycardia

Innocent murmurs

Evaluation

• Pre-natal (USS)• Family history • Birth history (birth state, trauma, risk infection)• Is this cardiac? (murmur + cyanosis + absent pulses)

Pre- and post ductal oxygen saturations

ABG

4 limb BP (>10mmHg difference suggests coarctation)

ECG

CXR

Echo

ED management

• ABC – sats 75-85%• Correct metabolic acidosis and shock with fluid and

bicarb • 2 lines/ UVC if possible• Antibiotics anyway!• Gentle handling• Keep warm• Prostoglandin – ductal patency• Inotropes• Ventilate – in air if possible, PEEP 4-6cmH2O

Prostaglandin

• PGE2 infusion (dinoprostone)• In duct dependent lesion• Hyperoxia test suggestive, femoral pulses diminished, metabolic acidosis persistent after volume and inotropes• Ensure antibiotics given!• Beware of apnoea. May cause hypotension, jitteriness and jerks• No absolute contraindications

ProstaglandinPossible Adverse Effects

• Apnoea• Hypotension• Hyperthermia (transient)• Tachycardia• Bradycardia• Seizures• Diarrhoea• Skin flush

Administration

• Intravenous infusion• Consider intubation• Dose• 0.01 – 0.1 mcg/kg/min

Hyperoxia test

• 10 mins on 100% O2PaO2 <20 KPa, cyanotic heart disease likely Pao2 <27KPa but >20, equivocal PaO2 >27 KPa, respiratory disease

Caution, severe pulmonary diseaseCare duct dependent lesions

ACQUIRED HEART DISEASE

• 18 month old girl

6 days of high feverMiserableSwollen hands and feet with pain and redness

Immediate action?Investigations?Working diagnosis?Further management?

Diagnosis?

Kawasaki Disease

• Commonest cause of acquired heart disease in children in the UK

• Febrile, exanthematous, multi-system vasculitis in children <5y

• Coronary arteritis with aneurysm formation in 20-30% in untreated patients

Diagnosing Kawasaki disease

• Fever of 5 days plus any 4 physical exam findings:

Rash Cervical lymphadenopathy (at least 1.5 cm in diameter) Bilateral conjunctival injection Oral mucosal changes Peripheral extremity changes

Kawasaki disease

• Admission as in-patient• ECG, ECHO• IV immunoglobulins• Aspirin high dose• Paediatric/Cardiology F/U (repeat ECHO at 6

weeks)

Any Questions?