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
