Cardiovascular System II - aplsonline.com · Cardiovascular System II 2 Initial assessment: ... System II Cardiovascular System II11 Case Development ... Cardiovascular System II12

Cardiovascular

System II

Cardiovascular System II 1

Cardiovascular System II

Objectives• Present the clinical features and emergency management of cardiovascular

disorders, including:– Diagnose and treat rhythm disturbances.– Detect and treat cardiomyopathy.– Treat shock.– Create differential diagnosis and management plan for syncope.

Case Study 1: “Not Breathing”A 10-day-old male infant is brought to ED for not breathing and color change. The childwas 3 weeks premature, and was discharged from hospital 3 days ago with an apneamonitor. Decreased activity since discharge. Poor feeding today.

Instructor InformationBegin discussion of assessment and management of a patient with cardiopulmonaryfailure.

The PAT is as follows:• Appearance: Abnormal• Breathing: Abnormal• Circulation: Abnormal

Vital signs include:• Heart rate: 220 bpm• Respiratory rate: 14 breaths/min• Blood pressure: 55/36 mm Hg• Weight: 3.5 kg (birth weight 3.7 kg)• Oxygen saturation: 88% on room air

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Initial assessment:• A: Patent without evidence of obstruction• B: Nonlabored but diminished respiratory rate• C: Mottled, cool, distal cyanosis, tachycardic and weak pulse• D: Weak cry, nonfocal exam• E: Normothermic, no evidence of trauma, fontanel flat

Detailed physical exam:• Head/Neck: No abnormalities• Heart: Tachycardia, no murmurs heard• Lungs: Decreased breath sounds• Abdomen: Liver 2 finger breadths below RCM• Neurologic: Weak cry, lethargic, poor interaction, responsive to pain and contact• Extremities: Cyanotic, cool upper and lower extremities

Key QuestionsWhat is your general impression of this patient? Categorize this patient into one of the following categories:

• Stable• Respiratory Distress• Respiratory Failure• Shock• Primary CNS Dysfunction• Cardiopulmonary Failure/Arrest

Core Knowledge Points—General ImpressionCardiopulmonary failure because all arms of the PAT are abnormal.

Patient appearance is lethargic but responsive, with inadequate respirations andtachycardia; mottling with distal cyanosis.

Key QuestionsWhat are your initial management priorities?

Critical ActionsCheck ABCs.Open airway.Give 100% oxygen by BMV, or perform endotracheal intubation.

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Check rhythm on cardiac monitor.Obtain vascular access.Obtain blood glucose prn.Check rectal temperature.

Core Knowledge Points—TachyarrhythmiasTachyarrhythmias:

• Wide complex– Ventricular tachycardia (rare rhythm in children but if wide need to

consider of ventricular origin)– Supraventricular tachycardia (SVT) with aberrancy

• Narrow complex– Sinus tachycardia (rates usually < 220)– SVT (Rates usually > 220)

Clinical features can be varied:• Palpitations in verbal children• Shock in any age• Generalized symptoms of malaise and weakness

Diagnostic studies may include:• Cardiac monitor, ECG, sepsis evaluation if young infant who has signs and

symptoms suggestive of infection• Chest radiograph, echocardiogram

Management includes ABCs and stabilization.

Core Knowledge Points—DysrhythmiasThe pediatric patient has 3 basic types of pathologic rhythm disturbances, which includefast pulse (tachyarrhythmia), slow pulse (bradyarrhythmia), and absent pulse (pulseless)(Table 4-3 in the APLS textbook). These can be further divided into 7 classificationsbased on their anatomic function.

Dysrhythmias may be the cause of impaired cardiac function leading to cardiac arrest.

Occult dysrhythmias (e.g., prolonged QT syndrome, Wolf-Parkinson-White syndrome,etc.) may present with intermittent severe symptoms (e.g., palpitations or sudden death).

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Clinical features—consider the following symptoms:• Intermittent, paroxysmal presence of symptoms• Dramatic onset and change in condition• Sudden onset of symptoms with little or no prodrome• Presentation of dysrhythmias can range from stable to cardiopulmonary arrest.

— Infant or child may show subtle signs of major physiological derangement.

Core Knowledge Points—Distinguishing SVT from ST

Sinus Tachycardia (ST) Supraventricular Tachycardia (SVT)History Fever, sepsis, dehydration,

hemorrhage, hypovolemia,precedes

Intermittent, paroxysmal in onset

ECG ST rate is less than 2x normalrate for age. Rate varies withactivity.

SVT rate at or greater than 2x normal ratefor age. Minimal or no rate change withactivity.

Supraventricular tachycardia (SVT) history is intermittent, paroxysmal, with suddenonset. Sinus tachycardia (ST) history suggests sepsis, dehydration, hemorrhage,hypovolemia.

SVT ECG steady rate at or greater than 2x normal rate for age. ST rate is less than 2xnormal rate for age. Minimal or no rate change with activity with SVT.

SVT characteristics (versus sinus tachycardia):• Heart rate is >2 times normal rate for age.• Rhythm is steady.• P waves are absent.• History is not suggestive of volume depletion or sepsis.

Core Knowledge Points—Diagnostic StudiesRadiology studies include chest radiographs; it is important to look for signs of structuralcongenital heart disease, congestive heart failure (due to a prolonged dysrhythmia), orsigns of infection (pneumonia).

Laboratory tests should ALWAYS include a blood glucose check to excludehypoglycemia in any child with abnormal mental status.

Differential diagnoses may include:• Hypoglycemia

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• Sepsis• Hyperthyroidism• Volume depletion• Catastrophic illness, e.g., CNS, GI trauma (abuse)• Metabolic disease

Critical ActionsManage ABCs.Get baseline ECG.Obtain vascular access.For SVT (see AHA algorithm):

• Vagal maneuvers for stable SVT• Adenosine: 100 mcg/kg bolus, increase to 200 mcg/kg (maximum first dose is 6

mg, maximum second and subsequent doses 12 mg) – given for stable SVT ifunresponsive to vagal maneuvers or for unstable SVT if IV access is immediatelyavailable.

• Cardioversion for unstable SVT (poor perfusion)• Procainamide or amiodarone to be considered if possible of ventricular origin;

that is QRS >0.08 seconds• Digoxin to slow rate if cardioversion unsuccessful• Cardiology consultation

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The PALS algorithm for tachycardia (sinus tachycardia, SVT, and ventriculartachycardia) with POOR PERFUSION is shown below:

Management is driven by presence or absence of poor perfusion.

Sinus tachycardia is not an arrhythmia but its etiology must be determined.

Provide ventilation and oxygenation for all patients in cardiopulmonary arrest, as theprimary etiology is often respiratory failure.

Patients such as this should be transported to a pediatric referral center after stabilization.Transport issues include:

• ALS transport with monitoring and IV access• Treatment plan for possible en route for recurrence – including potential for

cardioversion• Consult the accepting pediatric cardiologist

Tachycardia

Management

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Documentation considerations include:• Always try to get baseline 12-lead ECG before and after cardioversion.• Treatment record from prehospital and ED care• Emergency Medical Treatment and Active Labor Act (EMTALA) compliance

Risk management considerations include:• Always check blood glucose.• Assure rapid triage of infants in distress.• Do not hesitate to cardiovert when child is unstable.

Reversible non-cardiac causes of dysrhythmias: Four H’s:• Hypoxemia• Hypovolemia• Hypothermia• Hyper/Hypokalemia and metabolic disorders

Reversible non-cardiac causes of dysrhythmias: Four T’s:• Tamponade (cardiac)• Tension pneumothorax• Toxins/poisons/drugs• Thromboembolism

Case DevelopmentECG reveals SVT.Infant receives BMV ventilation.Preparations made to cardiovert but rapid IV access is obtained.Adenosine 100 mcg/kg IV push is given followed by normal saline bolus (flush).Sinus rhythm returns.BMV is discontinued as infant’s condition stabilized. 100% oxygen nonrebreather maskis placed.Sinus rhythm returns. ECG does not show early repolarization (e.g., WPW).

Case Study 2: “Unresponsive Episodes”2-year-old girl passed out eating cereal; awoke after 5 minutes. She was stiff with eyesrolled back for approximately 5 minutes. Minimal period of sleepiness, now awake andalert; no retractions; skin color is normal.

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Instructor InformationBegin discussion of assessment and management of a patient with syncope.

The PAT is as follows:• Appearance: Normal• Breathing: Normal• Circulation: Normal

Initial assessment:ABCDEs: Normal.

Vital signs include:• Heart rate: 120 bpm• Respiratory rate: 24 breaths/min• Blood pressure: 80/60 mm Hg• Temperature: 37.7°C• Weight: 12 kg• Oxygen saturation: 99%

Focused history:• Three similar episodes; two associated with “temper tantrums.”• PMH: Negative• FH: Negative for sudden death

Key QuestionsWhat is your general impression of this patient?

Categorize this patient into one of the following categories:• Stable• Respiratory Distress• Respiratory Failure• Shock• Primary CNS Dysfunction• Cardiopulmonary Failure/Arrest

Core Knowledge Points—General ImpressionThe patient presents with syncope and normal appearance on exam. She is in no distressand the exam is normal. Her history, however, is concerning and ominous.

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Core Knowledge Points—SyncopeSyncope in young children is a serious symptom. Life-threatening causes must beeliminated. A differential diagnosis is critical:

• Seizure• Cardiac• Breath-holding spell

Clinical features include:• Loss of consciousness• Lasted only a few minutes• Minimal or no postictal state• No stigmata of seizure: Urinary incontinence, bitten tongue, witnessed tonic-

clonic activity.

Core Knowledge Points—Diagnostic StudiesRadiology studies may include:

• Chest radiograph offers little.• CT or MRI may be indicated if seizures are considered.

Laboratory studies often are normal, but if patient has abnormal mental status orconcerning history, may include:

• Electrolytes• CBC with differential• Ca++, Mg++, PO4

Obtain an ECG as this will assist the physician in determining potential life-threateningcardiac causes of syncope.

Core Knowledge Points—Prolonged QTTen percent present with seizures. Fifteen percent of patients with prolonged QTc dieduring their first episode of arrhythmia and 30% of these deaths occur during the firstyear of life.

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Core Knowledge Points—Cardiac Causes of SyncopeAlso consider in differential:

• Hypertrophic cardiomyopathy— Formerly called IHSS (idiopathic hypertrophic subaortic stenosis)— Syncope with exercise— At risk for sudden death— Positive family history— Non-specific murmur— ECG can show non-specific findings.— CXR is non-diagnostic.— Echocardiogram is diagnostic.

• Chronic cardiomyopathy— Chronic CHF

• Dysrhythmias

Cardiac arrhythmias should be considered in all patients presenting with brief,nonspecific changes in level of consciousness:

• Fainting, syncope, seizures, breath-holding, apparent life-threatening events

Family history may be positive for sudden, unexplained deaths prior to 55, faintingepisodes, or unexplained accidents.

Episodes associated with exercise are particularly concerning. No further exercise untilcleared by a cardiologist.

Cardiac causes of syncope can present as a collapse rhythm.

Epinephrine 0.01 mg/kg (0.1 mL/kg 1:10,000) IV or IO• 0.1 mg/kg (0.1 mL/kg 1:1000) tracheal tube

Anti-arrhythmic includes amiodarone, lidocaine and magnesium.

Reversible causes include the 4 H’s (hypoxemia, hypovolemia, hypothermia, Hyper-/hypokalemia) and the 4 T’s (tamponade, tension pneumothorax, toxins,thromboembolism).

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Case DevelopmentThis patient has prolonged QT syndrome. She is at risk for fatal dysrhythmia (ventriculartachycardia or ventricular fibrillation). She needs to be admitted/transferred to a pediatriccardiology center for cardiology evaluation.

This child is hospitalized. She is monitored and confirmed to be at risk for dangerousdysrhythmia. She is discharged on medications shown to decrease her risk of ventriculartachycardia/ventricular fibrillation (e.g., β blockers). She is a candidate to receive anAICD (automatic implantable cardiac defibrillator) when she gets older.

Pulseless Arrest*

VF/VT Not VF/VT

Vasopressor(Drug - Shock)

CPR x 3 min

Shock x 3

Shock

Vasopressor

*CPR and seek reversible causesthroughout

Anti-arrhythmic

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Case Study 3: “Chicken Pox”A 6-month-old boy present with chicken pox lesions that began 3 days ago. The lesionsare spreading and there are more scabs today. He has had a fever since yesterday, and it ishigher today. Today, his skin appears to be red. He is fussy and not feeding well.

Instructor InformationBegin discussion of assessment and management of the patient in compensated shock.

The PAT is as follows:• Appearance: Normal/Abnormal – he is fussy, which may be an early sign of

shock or CNS condition.• Breathing: Normal.• Circulation: Normal.

Vital signs include:• Heart rate: 160 bpm – tachycardia is seen in many conditions, but there is concern

in a patient with infection that it could be a sign of shock• Respiratory rate: 40 breaths/min – without retractions, may indicate metabolic

acidosis• Blood pressure: 79/56 mm Hg – blood pressure is normal, so this is not

decompensated shock• Temperature: 39°C• Weight: 8.1 kg• Oxygen saturation: 98% on room air

Initial assessment:• A: Patent without evidence of obstruction• B: Normal• C: Generalized red erythroderma, warm, tachycardic (febrile)• D: Nonfocal exam, irritable• E: Many impetiginous scabs, pustules and vesicles; some with surrounding

cellulitis

Detailed physical exam:• Head/Neck: No abnormalities except for skin• Heart: Tachycardic, no murmurs heard• Lungs: Clear breath sounds

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• Abdomen: Normal except for skin• Neurologic: Alert, subdued, no meningismus• Skin: Many vesicles, scabs, pustules; some with surrounding cellulitis.

Generalized warm erythroderma. Capillary refill 2 seconds.

Key QuestionsWhat is your general impression of this patient?

Categorize this patient into one of the following categories:• Stable• Respiratory Distress• Respiratory Failure• Shock• Primary CNS Dysfunction• Cardiopulmonary Failure/Arrest

Core Knowledge Points—General ImpressionCompensated shock

• Tachycardia and mild change in appearance (fussy)• Possible septic shock as varicella lesions with signs of secondary infection (Staph

aureus, group A strep)• Erythroderma: Scarlet fever versus toxic shock


Critical ActionsProvide supplemental oxygen.Obtain vascular access.Determine rapid glucose.Begin fluid resuscitation at 20 mL/kg – 160 mL normal saline.CBC, blood culture, other optional labsIV antibioticsRepeated assessment for signs of shock

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Also important to continue assessment to determine if scarlet fever or toxic shockFor toxic shock:

• IV fluid infusion• Start infusion of dopamine.• Consider dobutamine infusion.

Core Knowledge Points—ShockShock is inadequate tissue perfusion (delivery of oxygen and nutrients) to meet themetabolic demands of the body.

Types of shock include:• Hypovolemic• Cardiogenic• Distributive• Septic

Compensated:• Vital organs continue to be perfused by compensatory mechanisms.• Blood pressure is normal.

Decompensated:• Compensatory mechanisms are overwhelmed and inadequate - hypotension, high

mortality risk.

Aggressive treatment of early shock:• Halts progression to decompensated shock

Clinical features:• Apnea, tachypnea, respiratory distress• Skin: Pale, cool, delayed capillary refill. Warm shock will appear normal.• Lethargic, weak, orthostatic weakness• Tachycardia, hypotension

Specific types of shock:• Distributive shock: Neurologic deficits (spinal cord injury); anaphylaxis

(urticaria, allergen trigger, wheezing)• Septic shock: Petechiae, erythroderma

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Core Knowledge Points—Hypovolemic ShockFluid loss:

• Diarrhea, vomiting, anorexia, diuresis• Hemorrhage

Resuscitation:• Fluid replacement• Normal saline or lactated Ringer’s 20 mL/kg bolus infusions, reassess, repeat as

needed• Blood transfusion for excessive hemorrhage

Core Knowledge Points—Cardiogenic ShockPoor myocardial contractility or impaired ejection:

• Cardiomyopathy, congenital heart disease, myocarditis, tamponade, congestiveheart failure, dysrhythmia, septic shock, drugs (e.g., thiopental)

Resuscitation:• Fluid bolus (10 mL/kg) and reassess• Inotropes, pressors (e.g., dopamine, dobutamine, epinephrine)

Core Knowledge Points—Distributive ShockInappropriate vasodilation with a maldistribution of blood flow:

• Anaphylactic shock, spinal cord injury, septic shock• “Warm shock”

Resuscitation:• Vasoconstrictors (e.g., epinephrine)• Anaphylaxis treatment• Spinal cord injury treatment• Sepsis treatment

Core Knowledge Points—Septic ShockElements of distributive shock and cardiogenic shock:

• Inappropriate vasodilation with a maldistribution of blood flow• Myocardial depression

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Resuscitation:• Fluid bolus• Pressors and inotropes• Antibiotics (expect possible deterioration initially due to toxin release)

Case DevelopmentLabs drawn.IV fluids given with decrease in heart rate to 120 bpmIV antibiotics givenPatient admitted and discharged 4 days later

Option for prolonged observation in ED monitoring for deterioration in vital signs andclinical status.

• Benign observation period suggests scarlet fever.• Worsening suggests possible toxic shock.• Toxic shock: Similar to septic shock requiring fluids, pressors, inotropes, ICU

monitoring

Early recognition and treatment of compensated shock may prevent progression todecompensated shock.

• Identifying early compensated shock is difficult.

Decompensated shock has a poor prognosis.

Core Knowledge Points—Emergency Information FormOverall, parents of patients with underlying cardiac disease should receive informationabout their child’s disease, treatment, and how to reach primary care (PCP) and specialtyphysicians.

Ideally parents of children with cardiac disease should carry an updated emergencyinformation form (EIF) when seeking emergency care. This form provides immediatepertinent medical information. A medical ID bracelet is also useful.

Available from ACEP and AAP.

The EIF should be updated by the patient’s primary care physician and specialists.

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The Bottom Line• Obtain rapid history and assess children in shock or respiratory distress for

cardiac disease including postsurgical complications.• Utilize the EIF to gather information, contact specialists, and guide therapy.• Echocardiography and cardiology consultation for definitive diagnosis and

cardiac function determination.

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Cardiovascular System II - aplsonline.com · Cardiovascular System II 2 Initial assessment: ... System II Cardiovascular System II11 Case Development ... Cardiovascular System II12