Paediatric Cardiology
Dr Ratna MerugumallaConsultant 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• 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.
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
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.
CHEST PAIN
Chest painCommon 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)
Non cardiac chest pain
• 56% musculoskeletal
• 12% asthma/ wheeze
• 8% infection
• 6% GI – gastritis and GORD
• 4% sickle cell disease
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
SYNCOPE
Syncope• 15-20% all children will have an episode
Neurally mediatedVasovagalReflex anoxic seizuresOrthostatic
CardiacStructuralCardiomyopathyArrythmias
Non CVSPsychogenicFactitiousNeurological non syncope e.g. Seizure
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
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
PALPITATIONS
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
Heart rate
Age Bradycardia Tachycardia
< 1 y < 80 min-1 > 180 min-1
> 1 y < 60 min-1 > 160 min-1
Bradycardia
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
Bradycardia Treatment
• Oxygenation
• Adrenaline – 10mcg/kg
• Atropine - Consider when vagal stimulation e.g. airway instrumentation – 20mcg/kg
• Pacing (rarely required)
Tachycardiardia
Narrow QRS complex Broad QRS complex
ST VT or SVTSVT Treat as VT
Sinus Tachycardia
ST – Treat the cause
• Physiological response:
CryingExerciseAnxiety/fearPain
• Compensatory mechanism for:
Respiratory failureHypovolaemiaSepsisAnaemia
Supraventricular tachycardia
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
ST or SVT
SVT - Management• Valsalva manoeuvre
• IV Adenosine 100 mcg/kg200 mcg/kg maximum 1st dose 6mg, 2nd dose 12mg
• Amiodarone in refractory SVT
• DC cardioversion – for decompensated children
Ventricular Tachycardia
Ventricular Tachycardia Causes
• Congenital HD & surgery
• Poisoning (TCAs, Quinidine)
• Brugada syndrome / Long QT interval
• Renal Disease / Hyperkalaemia
VT - management
Long QT - congenitalNormal 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
Atrial Flutter
Atrial Fibrillation
Atrial Flutter and Fibrillation
• Rare
• Underlying CHD, status post-open heart surgery
• Cardioversion in decompensated
• In haemodynamically stable children, amiodarone or elective cardioversion
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
COLLAPSE
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
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
Congenital heart disease
• Failure of normal development or
• Persistence of foetal circulation
• 7-9% live births
• Acyanotic or Cyanotic heart disease
Acyanotic Heart Disease
VSD (25%)ASDPDAPV stenosisCoAASHypoplastic left heartHOCMDextrocardia
Cyanotic Heart Disease
TetralogyTranspositionTricuspid atresiaTAPVD
Congenital heart disease
Common presentations:
• Cyanosis
• Heart failure
• Heart murmur
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
Failure
• Sweating• Poor feeding• Hepatomegaly• SOB• Creps• Tachycardia
Innocent murmurs
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
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
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
ProstaglandinPossible 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
Hyperoxia test
• 10 mins on 100% O2PaO2 <20 KPa, cyanotic heart disease likely Pao2 <27KPa but >20, equivocal PaO2 >27 KPa, respiratory disease
Caution, severe pulmonary diseaseCare duct dependent lesions
ACQUIRED HEART DISEASE
• 18 month old girl
6 days of high feverMiserableSwollen hands and feet with pain and redness
Immediate action?Investigations?Working diagnosis?Further management?
Diagnosis?
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
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
Kawasaki disease
• Admission as in-patient• ECG, ECHO• IV immunoglobulins• Aspirin high dose• Paediatric/Cardiology F/U (repeat ECHO at 6
weeks)
Any Questions?