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Paediatric Cardiology

Paediatric Cardiology. Dr Ratna Merugumalla Consultant 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.

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Paediatric Cardiology

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

  2. Cardiovascular presentations • Collapse • The blue baby • Syncope • Palpitations • Chest pain

  3. The normal Heart Rate

  4. The ECG

  5. ECG in a 2 year old

  6. 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.

  7. 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

  8. 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.

  9. Chest pain

  10. Chest pain Common 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)

  11. Non cardiac chest pain • 56% musculoskeletal • 12% asthma/ wheeze • 8% infection • 6% GI – gastritis and GORD • 4% sickle cell disease

  12. 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

  13. syncope

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

  15. 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

  16. 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

  17. palpitations

  18. 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

  19. Heart rate Age Bradycardia Tachycardia < 1 y < 80 min-1 > 180 min-1 > 1 y < 60 min-1 > 160 min-1

  20. Bradycardia

  21. 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

  22. Bradycardia Treatment • Oxygenation • Adrenaline – 10mcg/kg • Atropine - Consider when vagal stimulation e.g. airway instrumentation – 20mcg/kg • Pacing (rarely required)

  23. Narrow QRS complex Broad QRS complex ST VT or SVT SVT Treat as VT Tachycardiardia

  24. Sinus Tachycardia

  25. ST – Treat the cause • Physiological response: Crying Exercise Anxiety/fear Pain • Compensatory mechanism for: Respiratory failure Hypovolaemia Sepsis Anaemia

  26. Supraventricular tachycardia

  27. 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

  28. ST or SVT

  29. SVT - Management • Valsalva manoeuvre • IV Adenosine 100 mcg/kg 200 mcg/kg maximum 1st dose 6mg, 2nd dose 12mg • Amiodarone in refractory SVT • DC cardioversion – for decompensated children

  30. Ventricular Tachycardia

  31. Ventricular Tachycardia Causes • Congenital HD & surgery • Poisoning (TCAs, Quinidine) • Brugada syndrome / Long QT interval • Renal Disease / Hyperkalaemia

  32. VT - management

  33. Long QT - congenital Normal 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

  34. Atrial Flutter

  35. Atrial Fibrillation

  36. Atrial Flutter and Fibrillation • Rare • Underlying CHD, status post-open heart surgery • Cardioversion in decompensated • In haemodynamically stable children, amiodarone or elective cardioversion

  37. 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

  38. collapse

  39. 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

  40. 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

  41. Congenital heart disease • Failure of normal development or • Persistence of foetal circulation • 7-9% live births • Acyanotic or Cyanotic heart disease

  42. Acyanotic Heart Disease Cyanotic Heart Disease Tetralogy Transposition Tricuspid atresia TAPVD VSD (25%) ASD PDA PV stenosis CoA AS Hypoplastic left heart HOCM Dextrocardia

  43. Congenital heart disease Common presentations: • Cyanosis • Heart failure • Heart murmur

  44. 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

  45. Failure • Sweating • Poor feeding • Hepatomegaly • SOB • Creps • Tachycardia

  46. Innocent murmurs • Common in children • Never diastolic • Soft, Short, midsystolic, low intensity • Localised • Often vibratory or musical • Increase with output, (fever) • No thrill/ heave or radiation • Asymptomatic • May resolve in few months • Commonest at lower left sternal edge • Venous hum

  47. 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

  48. 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

  49. 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

  50. Prostaglandin Possible Adverse Effects Administration Intravenous infusion Consider intubation Dose 0.01 – 0.1 mcg/kg/min • Apnoea • Hypotension • Hyperthermia (transient) • Tachycardia • Bradycardia • Seizures • Diarrhoea • Skin flush

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