CHAPTER 86 ■ CARDIAC EMERGENCIES CASANDRA QUIñONES, BETH BUBOLZ GOALS OF EMERGENCY THERAPY Pediatric cardiac emergencies encompass a broad spectrum of disease states and thus have a variety of presentations Cardiac emergencies may be caused by congenital heart disease (CHD), arrhythmias, acute heart failure syndromes (AHFS), trauma, infection, ischemia, inflammation, and as sequelae of treatment The common denominators in cardiac emergencies ultimately distill down to either abnormal pulmonary blood flow (PBF) or compromised cardiac output The special challenge for the emergency medicine (EM) provider is to identify cardiac emergencies promptly even when the chief complaint is not cardiac in nature The clinician must consider heart disease when evaluating common symptoms such as feeding difficulty, abdominal pain, wheezing, or respiratory distress An exhaustive knowledge of every anatomic variation of CHD is not necessary By simply maintaining a high index of suspicion for cardiac conditions the provider can recognize cardiac disease by the presenting symptoms and determine the correct approach to such complex patients KEY POINTS CHD should be considered in any neonate presenting with acute decompensation in the first months of life CHD often presents with cyanosis or shock in the first weeks of life, coinciding with closure of the ductus arteriosus (DA) CHD often presents with pulmonary overcirculation and poor feeding around months of life, coinciding with fall in pulmonary vascular resistance (PVR) Pediatric patients with AHFS often present with nonspecific, noncardiac complaints on multiple visits before heart failure is recognized Incessant tachycardia may lead to heart failure at any age Children with implanted cardiac devices may present with complications of implantation or device failure RELATED CHAPTERS Resuscitation and Stabilization Cardiopulmonary Resuscitation: Chapter Medical Emergencies Neonatal Emergencies: Chapter 96 Signs and Symptoms Coma: Chapter 17 Cyanosis: Chapter 21 Dizziness and Vertigo: Chapter 24 Fever: Chapter 31 Heart Murmurs: Chapter 35 Pain: Chest: Chapter 55 Pain: Joints: Chapter 60 Rash: Bacterial and Fungal Infections/Rash: Maculopapular: Chapter 66 Respiratory Distress: Chapter 71 Seizures: Chapter 72 Septic-Appearing Infant: Chapter 73 Syncope: Chapter 76 Tachycardia: Chapter 77 Weight Loss: Chapter 83 Wheezing: Chapter 84 The Children’s Hospital of Philadelphia Clinical Pathways ED Clinical Pathway for the Evaluation/Treatment of Chest Pain in Children without Known Cardiac Disease URL: https://www.chop.edu/clinical-pathway/chest-pain-clinicalpathway Authors: M M’farrej, MD; S Mohan, MD; D Nandi, MD;P Stephens, MD; D Amaya, CRNP; J Lavelle, MD Posted: January 2014, last revised July 2019 Pathway for the Child with Suspected Acute Heart Failure URL: https://www.chop.edu/clinical-pathway/heart-failure-suspectedclinical-pathway Authors: J Rossano, MD; R Shaddy, MD; K Miller, CRNP; R Mansfield, MD; K Lin, MD; T Conlon, MD; D Nandi, MD; C Lebo, CRNP; C Bober, CRNP; S Helman, RN; M Franco, MD; J Lavelle, MD; M O’Connor, MD; R Ryan, RN; A Patton, RN; M Yowell, CRNP; E Ramsey, PharmD Posted: February 2016, last revised February 2018 Pathway for Evaluation and Treatment of Kawasaki Disease or Incomplete Kawasaki Disease URL: https://www.chop.edu/clinical-pathway/kawasaki-diseaseincomplete-kawasaki-disease-clinical-pathway Authors: D Whitney, MD; K Dorland, BSN; J Beus, MD; J Brothers, MD; L Buckley, MD; S Burnham, MD; D Campeggio, MSN; K DiPasquale, MD; M Fein, MD; H Ghanem, MD; J Hart, MD; J Lavelle, MD; C Law, PharmD; S Mehta, MD; S Natarajan, MD; J Ronan, MD; V Scheid, MD; S Swami, MD; H Vaswani, CRNP Posted: January 2018, last revised January 2019 CONGENITAL HEART DISEASE Goals of Treatment The goals of treatment are the rapid recognition and stabilization of patients presenting with congenital or acquired heart disease as well as the stabilization of a child with an underlying heart condition who presents with an emergent noncardiac condition CLINICAL PEARLS AND PITFALLS Recognition of the most common presentation patterns for patients with CHD will guide appropriate therapy CHD should be considered in any neonate presenting with acute decompensation Evaluate femoral pulses in all newborns and infants to detect coarctation of the aorta Palliation or incomplete repair of a congenital heart defect in an infant is a red flag for a patient who may not tolerate other stressors Pediatric patients with cardiac disease often present nonspecific, gastrointestinal, or respiratory symptoms Endotracheal intubation and mechanical ventilation can significantly decrease cardiac demands Current Evidence Congenital heart malformations are the most common birth defects, affecting nearly 1% or approximately 40,000 live births/yr in the United States Nearly half of the deaths from CHD occur in the first year of life Approximately 15% of patients with CHD also have chromosomal abnormalities and 29% with CHD have other major noncardiac malformations This is a complex patient population who often seek medical care in the emergency department (ED) All forms of CHD occur along a spectrum For example, tetralogy of Fallot (TOF) may range from complete pulmonary atresia to very mild pulmonary stenosis, or absent pulmonary valve (no stenosis) Therefore, a newborn with TOF can present with fulminant cyanosis and shock or mild cyanosis or even congestive heart failure (CHF) It is not necessary to know the exact anatomical defect but rather to recognize the cardiac physiology based on vital signs, age, and symptoms Anatomical details will be defined by echocardiogram Full information is not necessary for recognition of common patterns of presentation and stabilization in the ED Clinical Considerations Clinical Recognition Many times when an infant or child presents to the ED, the diagnosis is not evident immediately and management is initiated without complete certainty of the underlying pathology This is especially true with CHD However, a ... congenital heart defect in an infant is a red flag for a patient who may not tolerate other stressors Pediatric patients with cardiac disease often present nonspecific, gastrointestinal, or respiratory... noncardiac malformations This is a complex patient population who often seek medical care in the emergency department (ED) All forms of CHD occur along a spectrum For example, tetralogy of Fallot