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Cardiovascular System I

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Cardiovascular System I Cardiovascular System I Cardiovascular System I Objectives • Present the clinical features and emergency management of cardiovascular disorders, including: – Recognize congenital and acquired heart disease. – Outline management of ductal dependent lesions. – Identify patients with myocarditis. Case Study 1: “Rapid Breathing” A 10-day-old infant is brought to the ED by his mother for rapid breathing and not eating well. The child was a product of normal spontaneous vaginal delivery, and spent two days with mother in the hospital. He had an uneventful course, including circumcision. Birth weight was 3.2 kg. Instructor Information Begin discussion of assessment and management of a patient with compensated shock and cardiopulmonary failure. The child was slow to breastfeed since birth. He would gasp and cry after sucking for a short time. Difficulty feeding. He had 3 to 4 wet diapers per day. There was no congestion or fever. He had no vomiting with feedings. He had two yellow seedy stools since passing meconium after birth. The PAT is as follows: • Appearance: Abnormal. Fussy, pale with central cyanosis, sweaty. • Breathing: Abnormal. Weak cry, tachypnic, rales, grunting, nasal flaring. • Circulation: Abnormal. Tachyardic, gallop rhythm, weak pulses. The child is ill-appearing, in respiratory distress, fussy, and has a weak cry. Additionally, there is nasal flaring and occasional grunting. The child is pale, cyanotic centrally and in all extremities, and sweaty to touch. The patient’s vital signs are as follows: • Heart rate: 170 bpm • Respiratory rate: 70 breaths/min • Blood pressure: 82/40 mm Hg • Temperature: 37°C (rectal) Cardiovascular System I 1 Cardiovascular System I • Weight: 3.4 kg • Oxygen saturation: 90% on room air Initial assessment: • A: No evidence of obstruction. • B: Elevated respiratory rate and labored. • C: Pale, diaphoretic, tachycardia, weak pulse, cyanosis. • D: Glasgow Coma Scale (GCS) grossly normal but in distress and inconsolable. • E: No signs of head injury, fractures, or bruising. Lung sounds equal bilaterally with rales in both bases. Hyperactive precordium with a gallop rhythm. Pulses weak in distal and lower extremities. Distended abdomen with liver palpable 4 cm below right costal margin. Key Questions What is your general impression of this patient? Core Knowledge Points—General Impression Categorize this patient into one of the following categories: • Stable • Respiratory Distress • Respiratory Failure • Shock • Primary CNS Dysfunction • Cardiopulmonary Failure/Arrest The infant is in impending cardiopulmonary failure (compensated shock): Appearance, work of breathing, and circulation are abnormal, indicating cardiopulmonary failure. Key Questions What are your initial management priorities? Critical Actions ABCs. Give 15L oxygen by nonrebreather mask or 100% oxygen by bag-mask ventilation (BMV), or perform endotracheal intubation. Start an IV and obtain blood glucose. Cardiovascular System I 2 Cardiovascular System I Perform an ECG and monitor rhythm on cardiac monitor. Get a chest radiograph. Administer fluid challenge: 10 cc/kg NS to support circulation in shock. Administer prostaglandin E1 (PGE1) at 0.05 to 0.1 mcg/kg/min. Intubate to protect against apnea and relieve stress from work of breathing. Consider furosemide (0.5 to 1 mg/kg) if patient has not responded to initial therapy. Do a sepsis work-up and then give antibiotics. Defer lumbar puncture if the infant continues to be in respiratory distress and is unstable from cardiovascular compromise. Consult Cardiology or transfer to pediatric cardiology center emergently. Perform an echocardiogram. If blood pressure and perfusion do not improve, add an inotropic agent, such as: • Dobutamine: 2 to 20 mcg/kg/min • Epinephrine: 0.1 to 1.5 mcg/kg/min Case Development This infant is in congestive heart failure (CHF): • Poor feeding and easy fatigability • Gallop rhythm and enlarged liver • Diminished pulses The infant is in shock, showing altered mental status and compensated shock (tachycardia, diaphoresis, respiratory distress, and normal blood pressure in upper extremities). The infant has a possible ductal dependent lesion: • Right age for presentation of shock triggered by closure of the ductus arteriosus • Measure blood pressure in four extremities. • Assess oxygenation response to supplemental oxygen. There are several possible etiologies of this infant’s condition. Version 1: A blood pressure differential is noted in the lower extremities. Oxygenation improves to 99% with supplemental oxygen. A chest radiograph shows cardiomegaly and pulmonary edema. An echocardiogram demonstrates coarctation of the aorta. The infant improves with PGE1 infusion, diuretics, and inotropes. Cardiovascular System I 3 Cardiovascular System I Version 2: Oxygenation fails to improve with supplemental oxygen (remains 90%). Oxygenation declines further to <80%. The chest radiograph is nonspecific. An echocardiogram demonstrates transposition of the great vessels. The infant improves with PGE1 infusion. Surgical intervention is scheduled. Core Knowledge Points—Structural Congenital Heart Disease Congenital heart disease is present in 5 to 8 cases per 1,000 live births. Children with congenital anomaly usually do not show cardiovascular problems in utero. Changes at birth place great stress on infant’s cardiovascular system. Some cyanotic heart conditions are highly dependent on shunting through the ductus arteriosus. Closure can be a terminal event. The first clues include: • Age – First weeks of life, consider ductal dependent lesions; CHF usually in first months of life but may occur with acquired heart disease at any age. • Progressive deterioration (mild) followed by suddenly progressing to critical condition • Cyanosis • Congestive Heart Failure (CHF) • Consider if concurrent sepsis is present. Core Knowledge Points—Diagnostic Studies Radiological studies should include: • Pulmonary hypoperfusion: pulmonic stenosis, tetralogy of Fallot (TOF), tricuspid atresia (TA) • Congestive heart failure (if large ventricular septal defect [VSD] is present to allow high-output failure, e.g., increased right-sided flow) • Some classic chest radiograph appearances (more classic if condition is permitted to worsen): – Transposition of the great arteries (TGA): Egg on side – Total anomalous pulmonary venous return (TAPVR): Snowman – TOF: Boot shaped An ECG may show: • Right axis (RVH): Normal for newborns Cardiovascular System I 4 Cardiovascular System I • Left axis: Hypoplastic right heart, tricuspid atresia, endocardial cushion defect (AV canal) • ST-T changes, strain, ischemia • Dysrhythmia • Prolonged QT • Low voltage Laboratory studies should include: • Glucose: Any child in distress needs to have hypoglycemia excluded • CBC: Look for anemia, signs of sepsis • Electrolytes: Congenital adrenal hyperplasia, salt-wasting form • Arterial blood gas: Hyperoxia test Core Knowledge Points—Fetal Circulation In the normal fetal circulation, oxygenated blood returns from the placenta via the ductus venosus, mixing with some systemic venous return blood in the inferior vena cava. Oxygenated blood preferentially shunts across the foramen ovale (FO) to the left atrium (LA). The left ventricle ejects the most oxygenated blood to the carotids and coronaries. • Superior vena cava (SVC) returns deoxygenated blood to RA where it mixes with oxygenated blood from the placenta. • Preferentially enters RV. • RV ejects into PA. • No pulmonary capillary flow, so PA is shunted into the descending aorta via the ductus arteriosus. The right ventricle (RV) pumps less oxygenated blood into the pulmonary artery (PA). The pulmonary vascular bed is vasoconstricted, so most of the blood is shunted through the ductus arterious to mix with the systemic arterial circulation in the descending aorta (distal to the coronary and carotid arteries), thus delivering less oxygenated blood to the rest of the systemic arterial circulation. Core Knowledge Points—Transposition of the Great Arteries Transposition of the great arteries (TGA) is also known as transposition of the great vessels (TGV). The right ventricle pumps deoxygenated blood into the aorta, while the left ventricle pumps oxygenated blood into the pulmonary artery. Cardiovascular System I 5 Cardiovascular System I A shunt between the left and right circulations is required to maintain sufficient oxygenation. In the diagram, a ventricular septal defect (VSD) permits mixing between the left and right ventricles to permit some oxygenated blood from the lungs to reach the systemic circulation. Without a VSD, the ductus arteriosus must remain patent to maintain sufficient oxygenation. Once the ductus closes, oxygenation will markedly decline. Ductus patency can be maintained with a prostaglandin E1 infusion. Differential diagnoses include: • Other cyanotic and acyanotic congenital structural heart disease • Ductal dependent coarctation • Hypothermia • Sepsis • TORCH – Group of infections that can lead to birth defects including congenital heart disease. Includes toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex. • CAH (congenital adrenal hyperplasia) • Hypoglycemia • Shaken baby syndrome/intracranial lesion • Catastrophic gastrointestinal process, e.g., volvulus Core Knowledge Points—Normal CV System Function Normal cardiovascular system (CVS) function in pediatric patients is represented by normal vital signs and oxygen saturation, as well as the overall appearance of the child. A normal cardiac output is required to meet the body’s
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