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Paediatric Cardiology PowerPoint Presentation

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Description : Check out this medical presentation on Congenital Heart Defect, which is titled "Paediatric Cardiology", to know about paediatric cardiology, ECGs in children, chest pain in children, texidor’s twinge, syncope, and cardiac arrhythmias in children, etc.

Tags : Congenital Heart Defect, Paediatric Cardiology, ECGs, children, chest pain

Published on : Jul 01, 2021 | Views : 1971 | Downloads : 6

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Slide 1-

Paediatric Cardiology Dr Ratna Merugumalla Consultant in Emergency Medicine Peterborough City Hospital
Slide 2-

Cardiovascular presentations Collapse The blue baby Syncope Palpitations Chest pain
Slide 3-

The normal Heart Rate
Slide 4-

The ECG
Slide 5-

ECG in a 2 year old
Slide 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.
Slide 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
Slide 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.
Slide 9-

Chest pain
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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)
Slide 11-

Non cardiac chest pain 56% musculoskeletal 12% asthma/ wheeze 8% infection 6% GI – gastritis and GORD 4% sickle cell disease
Slide 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
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syncope
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Syncope 15-20% all children will have an episode
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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
Slide 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
Slide 17-

palpitations
Slide 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
Slide 19-

Heart rate Age Bradycardia Tachycardia < 1 y < 80 min-1 > 180 min-1 > 1 y < 60 min-1 > 160 min-1
Slide 20-

Bradycardia
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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
Slide 22-

Bradycardia Treatment Oxygenation Adrenaline – 10mcg/kg Atropine - Consider when vagal stimulation e.g. airway instrumentation – 20mcg/kg Pacing (rarely required)
Slide 23-

Tachycardia rdia Narrow QRS complex Broad QRS complex ST VT or SVT SVT Treat as VT
Slide 24-

Sinus Tachycardia
Slide 25-

ST – Treat the cause Physiological response: Crying Exercise Anxiety/fear Pain Compensatory mechanism for: Respiratory failure Hypovolaemia Sepsis Anaemia
Slide 26-

Supraventricular tachycardia
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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
Slide 28-

ST or SVT
Slide 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
Slide 30-

Ventricular Tachycardia
Slide 31-

Ventricular Tachycardia Causes Congenital HD & surgery Poisoning (TCAs, Quinidine) Brugada syndrome / Long QT interval Renal Disease / Hyperkalaemia
Slide 32-

VT - management
Slide 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
Slide 34-

Atrial Flutter
Slide 35-

Atrial Fibrillation
Slide 36-

Atrial Flutter and Fibrillation Rare Underlying CHD, status post-open heart surgery Cardioversion in decompensated In haemodynamically stable children, amiodarone or elective cardioversion
Slide 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
Slide 38-

collapse
Slide 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
Slide 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
Slide 41-

Congenital heart disease Failure of normal development or Persistence of foetal circulation 7-9% live births Acyanotic or Cyanotic heart disease
Slide 42-

Acyanotic Heart Disease VSD (25%) ASD PDA PV stenosis CoA AS Hypoplastic left heart HOCM Dextrocardia Cyanotic Heart Disease Tetralogy Transposition Tricuspid atresia TAPVD
Slide 43-

Congenital heart disease Common presentations: Cyanosis Heart failure Heart murmur
Slide 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
Slide 45-

Failure Sweating Poor feeding Hepatomegaly SOB Creps Tachycardia
Slide 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
Slide 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
Slide 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
Slide 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
Slide 50-

Prostaglandin Possible 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
Slide 51-

Hyperoxia test 10 mins on 100% O2 PaO2 <20 KPa, cyanotic heart disease likely Pao2 <27KPa but >20, equivocal PaO2 >27 KPa, respiratory disease Caution, severe pulmonary disease Care duct dependent lesions
Slide 52-

Acquired heart disease
Slide 53-

18 month old girl 6 days of high fever Miserable Swollen hands and feet with pain and redness Immediate action? Investigations? Working diagnosis? Further management?
Slide 54-

Diagnosis?
Slide 55-

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
Slide 56-

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
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Kawasaki disease Admission as in-patient ECG, ECHO IV immunoglobulins Aspirin high dose Paediatric/Cardiology F/U (repeat ECHO at 6 weeks)
Slide 58-

Any Questions?