Cardiologic critical care in childhood

Август 1, 2022

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Cardiologic critical care in childhood

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2. Plan of the lecture 1. Acute circulatory dysfunction 2. Syncope 3. Collapse 4. Shock 5. Acute
3. Acute circulatory dysfunction Is defined as a pathologic state due to decreased vessel’s smooth muscle tonicity,
4. Syncope - Is sudden short-term loss of conscience with muscle tonicity loss due to transient cerebral
5. Syncope reasons in children: Vessels neurotic dysregulation : vaso-vagal, orthostatic, sinocarotid, reflectory, hyperventilation syndrome Cardiogenic syncope
6. Critical care in syncope Put down in horizontal position with slightly raising legs, loose belts, collar
7. Collapse - Life threatening acute vascular insufficiency with acute vessel dystonia, circulatory blood volume decrease, signs
8. Reasons of collapse Severe course of acute infectious pathology ( intestine infection, flu, pneumonia, angina, pyelonephritis
9. Critical care in collapse Put down to back with throw back head, heat patient, provide air
10. SHOCK Acute threatening life pathologic process characterized by progressive tissue perfusion diminishing, subsequent CNS impaired functioning,
11. Reasons of shock Decreasing of circulatory volume (hypovolemic shock): due to bleeding, dehydration, burns, etc. Main
12. Critical care in shock Put down in horizontal position with slightly raising legs, moisturized oxygen To
13. Acute cardiac failure Pathologic condition characterized by cardiac output decreasing due to myocardial pumping function reduction
14. Acute cardiac failure (ACF) reasons Shock due to rhythm disorders –bradiarhythmia ( sinus or due to
15. ACF reasons: Acute lung and bronchial disorders (pneumonia, atelectasis, hydro- and pneumothorax etc.) Main mechanism of
16. ACF clinical presentation: Little cardiac output syndrome (LCOS): arterial hypotonia, and signs of centralized circulation; Congestive
17. Acute left ventricular failure Algorithm of critical care Patient position in bed sitting or semisitting Oxygen
18. Acute right ventricular failure algorythm of critical care Causative factors eradication (bronchospasm, pneumothorax, foreign body) Oxygen
19. Heart rhythm and conductivity disorders Sinus tachy- bradycardia, arrhythmia Sick sinus node Extrasystoles Paroxysmal tachycardia (
20. Arrhythmia treatment Pharmacologic medications Reflectory methods Psycho-physical methods Electrical methods Surgical methods
21. Antiarrhythmic drugs features Class 1 – membrane stabilizers, block rapid Na channels of cell membrane, retard
22. Antiarhythmic drugs features - subclass IВ– medications that shorten repolarization and the whole action potential. Refractory
23. Antiarrhythmic drugs features Class II – β-adrenoblockers, limit sympathetic influence on heart. They suppress sinoatrial node
24. Sinus tachycardia Clinics. Complaints to heartbeats, heart pain, dyscomfort, HR >10-60% from age norma ECG:shortening or
25. Sinus bradycardia Clinics. Weakness,dizziness, head ache, cardiac pains, HR 95-60% from age norma ECG. Intervals РР,
26. Sick sinus node syndrome Can be inherited or acquired one ( after myocarditis, cardiomyopathies, amyloidosis, hemochromatosis,,
27. Premature contractility Allocation: supraventricular, from AV-node. Left-right-ventricular; functional and organic. Clinics – signs of vegetative dystonia.
28. Supraventricular paroxysmal tachycardia HR 180-220 /min (infants – 250-300/min). Heartbeats, unpleasant sensation or heart , epigastrium
29. Treatment Semisitting position, respiratory therapy Mechanical stimulation of nervous vagus: Ashner reflex- pressing by 2 fingers
30. Treatment IV 0,25% isoptin (verapamil) sol.without dilution for 20-30 sec in dosages: for neonates 0,3-04 ml,
31. Ventricular paroxysmal tachycardia (VPT) Abrupt heartbeating attack, dyspnea, cardialgia Condition is severe with progressive worsening, loss
32. VPT treatment Lidocain IV injection 1 mg/kg for 5 min. If it’s ineffective repeat injection 0,5
33. Atrium fibrillation treatment Isoptin 0,15mg/kg I V slowly diluted with 10-20ml of 5% glucose Propranolol very
34. Anoxic spells- Is paroxysmal attack of dyspnea in child with congenital heart disease with cyanosismore frequently
35. Clinical presentation Sudden onset Irritability, moaning, crying with dyspnea and cyanosis Sitting posture-squatting or lateral decubitus
36. Emergency care To calm child, put into knee-chest position, give humidified oxygen Morohine or promedol 0,1
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Слайд 2

Plan of the lecture
1. Acute circulatory dysfunction
2. Syncope
3. Collapse
4. Shock

5. Acute cardiac failure
6. Heart rhythm and conductivity disorders
7. Emergency care

Слайд 3

Acute circulatory dysfunction
Is defined as a pathologic state due to

decreased vessel’s smooth muscle tonicity, developed arterial hypotension, impaired venous return and blood releasing from depot. It can be realized like syncope, collapse or shock.

Слайд 4

Syncope -
Is sudden short-term loss of conscience with muscle tonicity

loss due to transient cerebral circulation disturbances

Слайд 5

Syncope reasons in children:
Vessels neurotic dysregulation : vaso-vagal, orthostatic, sinocarotid, reflectory,

hyperventilation syndrome
Cardiogenic syncope in:
- bradyarhythmia (АV-blockage of 2-3-й grade, sinus node disfunction),
- Tachyarhythmia (paroxysmal tachycardia,
QT-long syndrome, atrial fluttering)
Mechanical circulatory restriction on the level of heart or big vessels ( aorta stenosis, hypertrophic subaortic stenosis, aorta valves insufficiency)
Hypoglycemic syncope
Cerebrovascular etc.

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Critical care in syncope
Put down in horizontal position with slightly raising

legs, loose belts, collar etc.
Reflectory actions: splash patient by water, pat on face,give to inhale liquid ammonia
In prolonged syncope :
- 10% sol of coffeini benzoatis 0,1 ml/per year intra cutanious or
- Cordiamini sol. 0,1 ml/year IC
In the case of arterial hypotension 1% sol. Mesatoni 0,1 ml/year IV In hypoglycemic condition 20-40% glucose sol. 2 ml/kg IV
In bradycardia and Morganie- Adams-Stocks attack-cardiopulmonary resuscitation – chest compression, 0,1% atropine sol 0,01 ml/kg IV.

Слайд 7

Collapse -
Life threatening acute vascular insufficiency with acute vessel dystonia, circulatory

blood volume decrease, signs of cerebral hypoxia, and life support function depression

Слайд 8

Reasons of collapse
Severe course of acute infectious pathology ( intestine infection,

flu, pneumonia, angina, pyelonephritis etc.)
Acute suprarenal gland failure
Hypotensive medications overdosage\
Acute bleeding
Severe trauma

Слайд 9

Critical care in collapse
Put down to back with throw back head,

heat patient, provide air access
Provide respiratory tract patency
In the case of sympathotonic collapse : IV spasmolytics, in the case of neurotoxicosis – corticosteroids 1-2 mg/kg.
In the case of vagotonic paralytic collapse: IV infusion of reopolyglucin, Ringer solution, corticosteroids 5-10mg/kg
In the case of stable hypotension: mesaton 1% IV slowly or norepinephrine 0,2% 0,1 ml/year IV in 50 ml of 5% glucose 10-20 drops/min
If all efforts aren’t effective – dopamine 8-10 mcg/kg IV titrating dosage

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SHOCK
Acute threatening life pathologic process characterized by progressive tissue perfusion

diminishing, subsequent CNS impaired functioning, respiratory, circulatory failure and metabolic disarrangement.

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Reasons of shock
Decreasing of circulatory volume (hypovolemic shock): due to bleeding,

dehydration, burns, etc. Main mechanism: preloading heart insufficiency because of venous return deficiency.
Blood storage in venous pools (distributive shock) – in anaphylactic reactions, acute suprarenal failure, sepsis, neurogenic or toxic shock. Mechanism – postloading insufficiency.
Little cardiac output ( cardiogenic shock) –cardiac pump function failure or venous inflow obstruction : pericarditis, pneumothorax etc.

Слайд 12

Critical care in shock
Put down in horizontal position with slightly raising

legs, moisturized oxygen
To eliminate reasons for shock
If lung edema is absent but hypotension is obvious – colloid and Ringer sol. infusion with BP, auscultation and diuresis monitoring.
Dopamine IV 6-8-10 mcg/kg slowly wit BP and HR monitoring
Accompanied conditions correction – hypoglycemia, metabolic acidosis, suprarenal insufficiency
Cardiopulmonary resuscitation complex if necessary

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Acute cardiac failure
Pathologic condition characterized by cardiac output decreasing due to

myocardial pumping function reduction or impairment of diastolic myocardial relaxation

Слайд 14

Acute cardiac failure (ACF) reasons
Shock due to rhythm disorders –bradiarhythmia (

sinus or due to AV- blockage, ventricular fibrillation, ventricular group extrasystol) or tachiarhythmia ( acute coronary insufficiency in infants , supraventricular paroxysmal tachycardia, atrium fluttering, ventricular fibrillations);
Cardiogenic shock- acute focus or total myocardium hypoxia ( condition with hypoxia and acidosis);
Acute pericardium tamponade (wounding or rupture of myocardium, pericarditis, pneumomediastinum and pneumopericardium) or extracardial heart tamponade in asthmatic status of 3-4 grade, interstitial emphysema
Terminal stage of congestive heart disease due to congenital heart disease, myocarditis or cardiomyopathies

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ACF reasons:
Acute lung and bronchial disorders (pneumonia, atelectasis, hydro- and pneumothorax

etc.) Main mechanism of ACF is hypoxia, and lung hypertension due to intrapulmonic circulatory blood shunt.
Any conditions accompanied by tissue hypoxia: toxicosis, syndrome of systemic inflammation, burning disease, severe purulent-inflammatory diseases, i.e. conditions with excessive catabolism where oxygen , glucose necessity are not covered by circulation. In these situations minute blood volume (MBV) necessity rises predominantly due to increased HR. Raised loading to myocardium demand more oxygen but diastole decreases so from one side it decreases ventricular filling and reduce cardiac output and from another side coronary circulation is decreased that cause myocardium ischemia and contractility decreasing.

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ACF clinical presentation:
Little cardiac output syndrome (LCOS): arterial hypotonia, and signs

of centralized circulation;
Congestive heart failure (CHF) with pulmonary or/and systemic circulation overloading
Signs of systemic congestion: peripheral edema, hepatomegaly, prominent neck veins, ascites, hydrothorax.
Signs of pulmonary congestion: dyspnea, moist rales in lower pulmonary lobes, lung edema, ineffective oxygen inhalations.

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Acute left ventricular failure Algorithm of critical care
Patient position in bed

sitting or semisitting
Oxygen therapy with 30-40% mixture through mask or nasal catheter
Venous tourniquet to both legs or hips
Furosemide 2-4mg/kg IV
Prednisone 3-5 mg/kg IV
Euphyllin diluted in physiologic solution 1 ml/year ( not more than 5 ml) IV slowly
Hospitalization into intensive care unit
Dobutamine 2-15 mcg/kg/min, Dopamine 5-8 mcg/kg/min
Promedol
Basic-acid condition correction
Wide spectrum activity antibiotic

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Acute right ventricular failure algorythm of critical care
Causative factors eradication (bronchospasm, pneumothorax,

foreign body)
Oxygen therapy by 40-50% mixture
If bradycardia or bronchospasm are present euphyllini 1 ml/year diluted in 10-20 ml of NaCl IV slowly
In the case of circulatory blood volume increasig – lasyx 1% 1-2 mg/kg
Basic –acid condition and electrolyte-fluid correction
Glycosides and vasodilators are contraindicated
HR, BP, ECG – monitoring are necessary

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Heart rhythm and conductivity disorders
Sinus tachy- bradycardia, arrhythmia
Sick sinus node
Extrasystoles
Paroxysmal tachycardia

( supraventricular, ventricular)
Atrium, ventricular fibrillation
Ventricular pre-excitation syndrome (WPW, CLC)
Atrium, atrium-ventricular and ventricular blockages

Слайд 20

Arrhythmia treatment
Pharmacologic medications
Reflectory methods
Psycho-physical methods
Electrical methods
Surgical methods

Слайд 21

Antiarrhythmic drugs features
Class 1 – membrane stabilizers, block rapid Na channels

of cell membrane, retard initial cell depolarization. Subclasses:
- subclass IA – medications that moderately retard Na flow and prolong action potential. In high dosages retard conductivity in atrium and ventricular, widen ventricular complex and interval QT:
chinidin, procainamide, dysopirmid, ethmosin, ethacisin, aimalin, praimalin, cibendzoline, pyrmenol.

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Antiarhythmic drugs features
- subclass IВ– medications that shorten repolarization and the

whole action potential. Refractory and interval QT shorten , improving impulse conduction through AV node:
lidocaine, trimecaine, tocainid, phenotoin,mixelytin, phenotoin, pyromecain.
- subclass IС – medication that abruptly suppress phase 0 and action potential, but slightly influence on repolarization period or duration of action potential. They retard conductivity, widen ventricular complex QRS, slightly change refractory capacity and QT duration :
Flecainid, lorcainid, allapinin, propaphenon, bonecor, recainam

Слайд 23

Antiarrhythmic drugs features
Class II – β-adrenoblockers, limit sympathetic influence on heart.

They suppress sinoatrial node activity, retard impulsespreading throughout conducting system:
propranolol, timolol, metoprolol, acebutalol, esmolol,flestolol.
Class III – medications that prolong repolarization phase and action potential:
amiodoron, bretiliy, clofiliy, pranoliy, sotalol, N-acetylnovocainamid, betanidin
Class IV – slow-Ca- channels blockers.They inhibit cell depolarization with slow electric response. :
verapamil, dyltiazem, beprylil, thyapamil, gallopamil

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Sinus tachycardia
Clinics. Complaints to heartbeats, heart pain, dyscomfort, HR >10-60% from

age norma
ECG:shortening or absence of TP, P-wave is normal, intervals PR and QT are shortened, ST interval can be under isoline, T wave amplitude is decreased, wave U can appear
Treatment. Therapy of the main disease. Such medications as Valeriana, mint, Crataegus, Leonurus, bromides; short courses of β-blockers or Ca-antagonists can be proposed, K containing medications.

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Sinus bradycardia
Clinics. Weakness,dizziness, head ache, cardiac pains, HR 95-60% from age

norma
ECG. Intervals РР, ТР elongation. Wave P amplitude and width are lowered. Interval PQ and QT more long, moderate increasing of QRS and Т waves, with dislocation of interval SТ higher isoline. In the case of severe bradicardia replacing, escape rate from AV node.
Treatment. In moderate grade isn’t necessary. In severe grade –adaptogenes (Panax, Schizandra, Rhodiala rose, Glycyrrhiza root, Urtica, Echinacea). If not efficiant add – M-cholinolytics (amysil), psychostimulant (sydnocarb) short courses Propose green tea and coffee consumption.

Слайд 26

Sick sinus node syndrome
Can be inherited or acquired one ( after

myocarditis, cardiomyopathies, amyloidosis, hemochromatosis,, malignancies, trauma).
Clinics. Asystolia or bradycardia. Weakness, syncopes, seizures, memory loss.
ECG. Alternate tachy- brady-arrhythmia: sinus rhythm can subside frequent ectopic rhythm, paroxysmal tachycardia or atrium fibrillation can occur. Asystolia can be due sinus node arrest. If sinus rhythm will not be restored or subsided by slow ectopic rate cardiac arrest can happen
Treatment –surgical (pacemaker implantation).

Слайд 27

Premature contractility
Allocation: supraventricular, from AV-node. Left-right-ventricular; functional and organic.
Clinics – signs

of vegetative dystonia. Sometimes short heartbeats intervals or gapping sensation
Treatment. In supraventricular ES – verapamil, propranolol, amyadoron, in vagotonia – ethmosin, procainamide, chinidin.
In ventricular ES – propaphenon (rhythmonorm), etcysin,ethmosin, aimalin

Слайд 28

Supraventricular paroxysmal tachycardia
HR 180-220 /min (infants – 250-300/min).
Heartbeats, unpleasant sensation

or heart , epigastrium pains, nausea, weakness,dizziness.
Pulsation of carotid vessels; pulse is weak, rhythmic, can’t be calculated. BP normal or decreased predominantly systolic one. If attack is long signs of cardiac failure become evident.
In infants – dyspnea, cough, irritability later flaccidity; sometimes syncope , convulsions.

Слайд 29

Treatment
Semisitting position, respiratory therapy
Mechanical stimulation of nervous vagus: Ashner reflex- pressing

by 2 fingers onto eyebulbs while eyes are closed for 30-40 sec.; 1-2 min later you can repeat massage of right carotid sinus. Valsalve manoeuvre – straining effort during expiration with respiration retention.
If child is conscious – sedative medications (relanium, sibazon, seduxen, diazepam) 0,2-0,3 mg/kg or 0,1 ml/year IM.

Слайд 30

Treatment
IV 0,25% isoptin (verapamil) sol.without dilution for 20-30 sec in dosages:

for neonates 0,3-04 ml, for infants – 0,4-0,8 ml, toddlers – 0,8-1,2 ml, schoolchildren- 1,2-1,6 ml, teenagers – 1,6-2,0 ml
If effect absent for 3-5 min repeat reflectory manoeuvre, if effect negative repeat verapamil in the same dosages, if not effective 10% novocainomide sol 0,15-0,2 ml/kg ( not more than 10 ml)
If effect isn’t gained trachea intubation and perfoprm mechanical ventilation
Cardioversion 0,5 J/kg, repeat cardioversion if it’s not effective – 1,0 J/kg

Слайд 31

Ventricular paroxysmal tachycardia (VPT)
Abrupt heartbeating attack, dyspnea, cardialgia
Condition is severe with

progressive worsening, loss of conscience is possible, ventricular fibrillation can complicate prognosis
If patient’s condition is satisfactory, with high probability you can exclude VPT!
Treatment at intensive care unit: semisitting position, respiratory treatment, catheterization of central vein.

Слайд 32

VPT treatment
Lidocain IV injection 1 mg/kg for 5 min. If it’s

ineffective repeat injection 0,5 mg/kg ( max dosage -3 mg/kg)
Novocainamide 0,15-0,2ml/kg diluted with 10-20ml of 10% glucose if previuos treatment ineffective
Aimalin 1 mg/kg
Etmosin IV slowly diluted with 10-20 ml of 5% glucose
Kordaron or/and propranolol
If result is absent – cardioversion as previously has been mentioned
Cardio surgeon consultation

Слайд 33

Atrium fibrillation treatment
Isoptin 0,15mg/kg I V slowly diluted with 10-20ml of

5% glucose
Propranolol very slowly 0,1-0,2 mg/kg
Glycosides – digoxin 0,025-0,05 mg/kg
Chinidin 10-15 mg/kg/day ( 3-4 injections) together with verapamil 2 mg/kg/day. Effect can be gained on 3-10 day.
Efficiecy of another medications (procainomide, flecainid, propranolol) is inversely to attack duration
As fibrillation predispose to thromboembolism – indirect anticoagulants

Слайд 34

Anoxic spells-
Is paroxysmal attack of dyspnea in child with congenital

heart disease with cyanosismore frequently in tetralogy of Fallot. Attack is due to right ventricular outflow obstruction.
Provocative factors:
psycho-emotional, physical exertion, intercurrent diseases especially with dehydration, anemia, neuro-reflectory excitability syndrome

Слайд 35

Clinical presentation
Sudden onset
Irritability, moaning, crying with dyspnea and cyanosis
Sitting posture-squatting or

lateral decubitus position
Tachycardia
Systolic murmur of lung artery stenosis become silent
In severe cases – seizures, loss of conscience, coma

Слайд 36

Emergency care
To calm child, put into knee-chest position, give humidified oxygen
Morohine

or promedol 0,1 to0,2 mg/kg subcutaneous injection
Correct acidosis. Obtain pH , Give sodium bicarbonate IV
Propranolol 0,1 mg/kg/IV (during spell) 0,5 to 1,0 mg/kg/4-6 hourly orally
Vasopressors: Cordiamine 0,1-0,5 ml subcutaneously
Nospani, papaverin 0,2-0,5 ml IM
Na oxybutiratis 20% sol. 50-100 mg/kg IV slowly in seizures.
Correct anemia
Consider operation –aortic-pulmonary anastomosis

Cardiologic critical care in childhood

Содержание

Plan of the lecture 1. Acute circulatory dysfunction2. Syncope3. Collapse4. Shock

Acute circulatory dysfunction Is defined as a pathologic state due to

Syncope - Is sudden short-term loss of conscience with muscle tonicity

Syncope reasons in children:Vessels neurotic dysregulation : vaso-vagal, orthostatic, sinocarotid, reflectory,

Critical care in syncopePut down in horizontal position with slightly raising

Collapse -Life threatening acute vascular insufficiency with acute vessel dystonia, circulatory

Reasons of collapseSevere course of acute infectious pathology ( intestine infection,

Critical care in collapsePut down to back with throw back head,

SHOCK Acute threatening life pathologic process characterized by progressive tissue perfusion

Reasons of shockDecreasing of circulatory volume (hypovolemic shock): due to bleeding,

Critical care in shockPut down in horizontal position with slightly raising

Acute cardiac failurePathologic condition characterized by cardiac output decreasing due to

Acute cardiac failure (ACF) reasonsShock due to rhythm disorders –bradiarhythmia (

ACF reasons:Acute lung and bronchial disorders (pneumonia, atelectasis, hydro- and pneumothorax

ACF clinical presentation:Little cardiac output syndrome (LCOS): arterial hypotonia, and signs

Acute left ventricular failure Algorithm of critical care Patient position in bed

Acute right ventricular failure algorythm of critical careCausative factors eradication (bronchospasm, pneumothorax,

Heart rhythm and conductivity disordersSinus tachy- bradycardia, arrhythmiaSick sinus nodeExtrasystolesParoxysmal tachycardia

Arrhythmia treatmentPharmacologic medicationsReflectory methodsPsycho-physical methodsElectrical methodsSurgical methods

Antiarrhythmic drugs featuresClass 1 – membrane stabilizers, block rapid Na channels

Antiarhythmic drugs features - subclass IВ– medications that shorten repolarization and the

Antiarrhythmic drugs featuresClass II – β-adrenoblockers, limit sympathetic influence on heart.

Sinus tachycardiaClinics. Complaints to heartbeats, heart pain, dyscomfort, HR >10-60% from

Sinus bradycardiaClinics. Weakness,dizziness, head ache, cardiac pains, HR 95-60% from age

Sick sinus node syndromeCan be inherited or acquired one ( after

Premature contractilityAllocation: supraventricular, from AV-node. Left-right-ventricular; functional and organic.Clinics – signs

Supraventricular paroxysmal tachycardiaHR 180-220 /min (infants – 250-300/min). Heartbeats, unpleasant sensation

TreatmentSemisitting position, respiratory therapyMechanical stimulation of nervous vagus: Ashner reflex- pressing

TreatmentIV 0,25% isoptin (verapamil) sol.without dilution for 20-30 sec in dosages:

Ventricular paroxysmal tachycardia (VPT)Abrupt heartbeating attack, dyspnea, cardialgiaCondition is severe with

VPT treatmentLidocain IV injection 1 mg/kg for 5 min. If it’s

Atrium fibrillation treatmentIsoptin 0,15mg/kg I V slowly diluted with 10-20ml of

Anoxic spells- Is paroxysmal attack of dyspnea in child with congenital

Clinical presentationSudden onsetIrritability, moaning, crying with dyspnea and cyanosisSitting posture-squatting or

Emergency careTo calm child, put into knee-chest position, give humidified oxygenMorohine

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