Acute scenarios

Question 1

Two aetiologies of heart failure in children

Answer 1

Over-circulation: more than expected flow in either side of the heart, muscle does not keep up

Pump failure: damage to heart muscle, fails to contract

Question 2

Definition of HF

Answer 2

Failure of the heart to maintain adequate perfusion of body tissues.

Congestive heart failure term describes a situation of increased venous congestion in the pulmonary vasculature (LHF), or systemic (RHF) veins. This occurs when the mechanisms regulating CO are no longer adequate or overridden by excess demand. Common in syndromic children.

Question 3

Causes of overcirculatory HF in children

Answer 3

• CHD: HLH, severe AS, interrupted AA/CoA, PDA, TAPVD, large VSD, TGA, truncus arteriosus.
• Postoperative CHD repair
• AV malformation (i.e. hepatic)
• Severe anaemia (i.e. hydrops fetalis)

Question 4

Causes of pump failure HF in children

Answer 4

• Viral myocarditis/cardiomyopathy
• Metabolic cardiomyopathy (i.e. Pompe disease)
• Arrhythmias: SVT, VT, congenital heart block
• Ischemia: Kawasaki disease, early onset MI in FH, ALCAPA
• DMD
• Medications i.e. chemotherapy

Question 5

Symptoms of HF in children

Answer 5

Infant: breathless, cold extremities, wheeze (cardiac asthma) , grunting, feeding difficulties, sweat, fail to thrive, recurrent chest infections

Older: fatigue, exercise intolerance, dizziness, syncope

Question 6

Examination in HF in children

Answer 6

General: tachycardia (not in CHB), absence of heart murmur does not exclude this (TGA, HLH, COA)

Left HF: resp distress, gallop rhythma, displaced apex, tachypnea

Right HF: odema, hepatosplenomegaly, JV distension not often in child

Decompensated HF: hypotension, cool peripheries, shock, low urine output, thread pulse, high capillary refill time, renal and hepatic failure

Question 7

Investigations for HF in children

Answer 7

Bloods: acid base balance, FBC, WCC, viral PCR, cultures for IE

CXR: cardiomegaly, signs of HF (Kerly B, pulmonary odema, increased markings, effusions, cardiomegaly)

ECG: rate, rhythm, hypertrophy or hypoplasia. Evidence of myocarditis or ischaemia

Echo is diagnostic in cases of CHD (see lesions), myocarditis/DCM (thin walled dilated LV), Kawasaki (if CA aneurysms seen)

Might require angiography, genetic testing, chromosomal type

Question 8

Management of HF in children

Answer 8

ABCDE management. Emergency requiring admission to specialist unit.

Investigation of underlying cause and management

Newborn: Duct dependent CHD is most likely cause – IV PGE2 should be initiated.

General blanket principles: reduce preload (loop diuretics) enhance contractility (ionotropes) reduce afterload (ACEi), improve O2 delivery and nutrition.

Mechanical circulatory support as a bridge to cardiac transplantation may be considered.

Question 9

Differentiating cardiogenic vs respiratory cyanosis in children

Answer 9

Hyperoxia test

The PaO2 is measured in the right radial artery (preductal) on room air and after 10 minutes of 100% oxygen supplementation.

Question 10

Aetiology of Kawasaki disease

Answer 10

Epidemiological studies suggest infectious agent in genetically susceptible individuals
* Infectious hypothesis – winter spring seasonality, community outbreaks
* Genetic susceptibility: Japanese individuals more prone
* Superantigen hypothesis ?

Question 11

DDX Kawasaki disease

Answer 11

Streptococcal disease (Scarlet fever) viral infection (measles, EBV, enterovirus) staphylococcal scalded skin syndrome, drug hypersensitivity, JIA,

Question 12

Definition and criteria for KD

Answer 12

Childhood acute febrile illness with small and medium vessel vasculitis.

Classic features: high fever >=4days, presence of >=4 of:
* Erythema, odema of hands and feet
* Diffuse maculopapular rash (within 5 days)
* Bilateral non exudative oconjunctivitis
* Chapped erythemaotus lips and oral mucosa, strawberry tongue
* Cervical lymphadenopathy

Incomplete or atypical disease is suspected with fever of five days or more with two or three of the features.

Question 13

Firstcardiac investigation on suspecting KD

Answer 13

Transthoracic echocardiography should be performed as soon as Kawasaki disease is suspected to evaluate for coronary artery aneurysms.

Question 14

Treatment of KD

Answer 14

IVIG +/-
Consider corticosteroids for severe disease
ASPIRIN NOT RECOMMENDED

Long-term monitoring of coronaries

Question 15

Causes of tachyarryhthmia in children

Answer 15

Sinus tachycardia
SVT
JET
Other atrial tachycardias (MAT/EAT)
VT

Question 16

Management of SVT in children

Answer 16

If signs of shock (chest pain, pulm oedema, hypoxia): Cardiac monitoring, NRB mask, insert IV, sedation, DCCV (1-2 J/kg)

If no signs of shock: Attempt manouvres( Valsalva, diving reflex). If no response, IV cannula and adenosine 100mcg/kg (then 200 then 300 if no response)

Record strips in all cases as this will help determine aetiology

In the long term: ablation, especially if AVRT

Question 17

PALS algorithm - non-shockable rhythm

Answer 17

Re-assess rhythm every 2 minutes
Adrenaline 10 mcg/kg immediately then on alternate 2-min rounds

Question 18

PALS algorithm - shockable rhythm

Answer 18

Re-assess rhythm every 2 minutes
Shock 4 J/kg
Adrenaline 10 mcg/kg at second shock, then every other
Amiodarone 5mg/kg after third shock, then every other

Question 19

Choking child with ineffective cough - conscious

Answer 19

5 back blows
5 chest thrusts
Assess and repeat

Question 20

Choking child with ineffective cough - unconscious

Answer 20

Open aiwrway
2 breaths
CPR 15:2
Check for FB

Question 21

Choking child with effective cough

Answer 21

Encourage coughing
Maintain ongoing assessment until resolved

Question 22

Bradycardia - no shock

Answer 22

Monitor closely for symptoms
Seek opinion

Question 23

Bradycardia with shock

Answer 23

Vagal overactivity? Atropine 20mcg/kg

No clear evidence of vagal overactivity? Adrenaline 10mcg/kg, consider adrenaline infusion, consider pacing

Question 24

Blood and fluid therapy in trauma and massive blood loss

Answer 24

15 mg/kg TXA IV/IO

Consider resuscitating with blood products (RBC:FFP 1:1) immediately. If not available, 10mL/kg warmed NaCl
If shock remains, repeat blood products or warmed NaCl

If shock remains, escalate hemorrage control + 5mL/kg blood product
After 20mL/kg of blood products, request major hemorrhage pack
Continue 5mL/kg boluses of blood products
After further 20mL/kg blood products, give 10-15mL/kg platelets and 0.1mL/kg of 10% Calcium chloride
Repeat blood product bolus loop if no resolution

Question 25

Hyperkalaemia in child

Answer 25

Arrhythmia: as per arrhythmia protocol + Calcium 0.1mmol/kg IV No arrhythmia: - Nebulised salbutamol 2.5mg - Repeat K - If improving, Ca resonium 1g/kg PO - If still high and pH<7.34, Na HCO3 1-2mmol/kg IV - If still high and pH >7.35, Glucose 10% 5mL/kg and insulin 0.05u/kg/h IV + Ca resonium 1g/kg PO Plan dialysis if necessary

Question 26

What is pre-ductal SpO2

Answer 26

SpO2 taken from right arm (pre-ductal)

Question 27

Causes of HF in utero

Answer 27

Severe valvular disease e.g., Ebstein Severe anaemia Paroxysmal SVT AV block Severe mitral insufficiency in AVSD

Question 28

Causes of HF in first day of life

Answer 28

II myocardial dysfunction (anaemia, sepsis, asphyxia, hypoglycaemia) Duct dependent lesions (TTTTP)

Question 29

Causes of HF in the first week of life

Answer 29

Duct dependent lesions (TTTTP) PDA Adrenal insufficiency due to enzyme deficiencies Arrhythtmias e.g., SVT

Question 30

Causes of HF after 2nd week of life

Answer 30

Other congenital diseases that become symptomatic due to the reducing pulmonary pressures or due to worsening cardiac dysfunction

Question 31

Cardiac causes of HF in children

Answer 31

Congenital - Excessive preload - Excessive afterload - Complex congenital heart disease Noncongenital - Myocarditis - Cardiomyopathy - Sepsis - Infarction (e.g., FH) - Hypertension (renal) - Acquired valve diseases - Kawasaki - Arrhythmia Noncardiac - Anaemia - Sepsis - Hyoiglycaemia - DKA - Hypothyroidism - Other endocrinopathies - AV fistula - Renal failure - Muscular dystrophies

Question 32

Signs of heart failure in children with L>R failure

Answer 32

Tachypnea Wheezing Rales nasal flaring or grunting Retractions Cough or chest congestion Poor feeding Irritability

Question 33

Signs of heart failure in children with R>L failure

Answer 33

Hepatomegaly Ascites Pleural effusion Peripheral edema Weight gain JV distension rare in children

Question 34

Signs of heart failure in children with biventricular failure

Answer 34

Tachycardia with S3 gallop Cardiomegaly Decreased pulses Delayed capillary refill Fatigue Pallor Sweating Poor weight gain Dizziness Altered consciousness Syncope

Question 35

Definition of failure to thrive

Answer 35

broadly defined as a faltering of growth from a previously established pattern of growth

Question 36

Three key principles in assessment of child in shock

Answer 36

Primary ABCDE assessment and resuscitation Secondary assessment and emergency treatment Stabilisation and transfer

Question 37

ABCDE in child

Answer 37

A + B - breathing effort, RR and rhythm, stridor or wheeze, ascultation, skin colour C - HR, volume, cap refill, skin temp D - Conscious level, posture, pupils E - fever, rash, bruising

Question 38

Airway assessment in child

Answer 38

Look, listen and feel for airway patency. In an unconscious baby or child, open the airway using the “head tilt chin lift” The differences in airway anatomy as children mature, means that the desirable degrees of tilt is neutral in an infant and a ‘sniffing’ position in a child If this manoeuvre is unsuccessful in establishing airway patency, a jaw thrust may be used

Question 39

Airway management in a child

Answer 39

In an in-hospital setting, adjuncts such as naso-pharyngeal airways and Guedel airways may also be appropriate. In a conscious child, stridor or hoarse voice may indicate a compromised airway and senior help must be sought promptly. If there is any concern that a child’s airway is becoming compromised within the hospital, anaesthetic help must be requested urgently.

Question 40

Breathing assessment in a child

Answer 40

A raised respiratory rate may be caused by airway or lung pathology or be driven by a metabolic acidosis (for example in diabetic ketoacidosis.) Normal RR <1: 30 to 40 1 to 2: 2 t o3 2 to 5: 2 to 30 5 to 12: 15 to 25 >12: 12 to 20 Other signs of respiratory distress include grunting, flaring of the nostrils, tracheal tug and accessory muscle use (intercostal, subcostal or at the most severe sternal recession). Gasping is a late sign of severe hypoxia. Observe chest expansion and ascultate Saturations

Question 41

Breathing management in a child

Answer 41

high flow 15L oxygen mask with a reservoir bag If there is also inadequate respiratory effort, then use a bag-valve mask and consider intubation and ventilation as appropriate In a choking patient > choking APLS algrithm

Question 42

Circulation assessment in a child

Answer 42

Record the patient’s heart rate, pulse volume, capillary refill time and blood pressure. Children are very good at compensating for alterations in their physiology and as such hypotension is a late sign. Assess the effect of any circulatory inadequacy on other organs. These may include a raised respiratory rate (driven by the resultant metabolic acidosis), reduced urine output, mottled skin with pale, cool peripheries (due to poor skin perfusion) or altered mental state.

Question 43

Circulation management in child

Answer 43

If there are signs of circulatory compromise, establish venous or intraosseous access rapidly and give a 20ml/kg bolus of 0.9% sodium chloride. Further boluses should be guided by reassessment and inotropic support considered if more than two boluses are needed. Note in DKA, the initial bolus is 10ml/kg due to the risk of cerebral oedema. Venous access in seriously ill children is often difficult and fluid bolus administration should not be delayed by repeated attempts at cannulation – intraosseous access is rapid and effective and should be considered early.

Question 44

Disability assessment in child

Answer 44

Assess the child’s conscious level using the AVPU score (where A is alert, V is responds to voice, P is responds to pain and U is unresponsive) or GCS. The AVPU scale is quicker to use with a response only to pain correlating with a GCS score of 8. Many children suffering from a severe illness are floppy. Stiff posturing such as that in decorticate (flexed arms, extended legs) or decerebrate (extended arms and legs) suggests serious brain dysfunction. Pupil size and response to light should be recorded. Bedside blood sugar testing should also be performed (although in reality this may have been checked with a blood gas at the time of obtaining IV or IO access). Consider raised intracranial pressure in any child with depressed conscious level. The presence of hypertension and bradycardia in such cases indicates impending coning.

Question 45

Disability management in a child

Answer 45

Consider intubation to stabilise the airway in any child with a conscious level graded as P or U. Treat hypoglycaemia with a bolus of 2ml/kg 10% glucose IV or IO, followed by a glucose infusion to prevent recurrence. In cases of suspected raised intracranial pressure consider mannitol and neuroprotective measures (see full guideline for further details.)

Question 46

Exposure assessment in a child

Answer 46

A swift head to toe examination of the child may provide clues as to the aetiology of the illness, for example a purpuric rash may only be noted on full exposure or surgical scars may prompt you to consider particular histories. Be careful to ensure exposed areas are recovered to help maintain temperature control and preserve the child’s dignity.

Question 47

Secondary assessment

Answer 47

Once immediately life threatening problems have been addressed, move on to assess the patient in further detail. This includes: Reassessing the response to initial resuscitative measures Taking a focused history Performing detailed systems based examinations where appropriate Further investigations – these may include laboratory blood tests, ECG, radiographs or other imaging such as CT

Question 48

AB shows Bubbling sound

Answer 48

Excessive secretions > Suctioning

Question 49

Harsh stridor and a barking cough

Answer 49

Croup > Oral dexamethasone Nebulised budesonide and adrenaline in severe cases

Question 50

Soft stridor, drooling and fever in a sick looking child

Answer 50

Bacterial tracheitis or epiglottitis Intubation by anaesthetist followed by IV antibiotics

Question 51

Sudden onset stridor with history of inhalation

Answer 51

Inhaled foreign body Laryngoscopy for removal

Question 52

Stridor following ingestion or injection of a known allergen

Answer 52

Anaphylaxis IM adrenaline

Question 53

Wheeze

Answer 53

Acute asthma Bronchodilators

Question 54

Bronchial breathing

Answer 54

Pneumonia IV antibiotics

Question 55

duct dependent lesion is suspected

Answer 55

IV dinoprostone should be administered – this helps to keep the duct open, therefore allowing common mixing to occur until a definitive diagnosis and treatment

Question 56

SVT

Answer 56

Vagal manoeuvres followed by a rapid bolus of IV adenosine or synchronous DC shock, depending upon the clinical status of the child.

Question 57

Resuscitation of preterm cutoffs

Answer 57

Recommendations Less than 23 weeks then resuscitation should not be performed Between 23 and 23+6 weeks then there may be a decision not to start resuscitation in the best interests of the baby, especially if parents have expressed this wish. Between 24 and 24+6 weeks, resuscitation should be commenced unless the baby is thought to be severely compromised. Response to initial measures should be considered before the decision is made to commence intensive care. After 25 weeks, it is appropriate to resuscitate and start intensive care

Question 58

Features of JET

Answer 58

Present with HF Usually regular but can be irregular conduction Origin near AV node

Question 59

In post op patient, if JET suspected and they have pacing wires in, what can be helpful

Answer 59

A-wire ECG - to confirm whether atrial activity precedes QRS

Question 60

Management of JET

Answer 60

Amiodarone (note neg inotropic effect) Ivabradine Flecanide (with caution) BB (note neg inotropic effect) Ablation eventually

Question 61

Types of JET

Answer 61

Post operative Congenital

Question 62

Typical rate of AVRT/AVNRT in babies

Answer 62

300

Question 63

DDx for tachycardia with retrograde p waves

Answer 63

AVNRT AVRT JET with origin very close to AVN (usually slower than AVRT/AVNRT and more in babies)

Question 64

Narrow complex tachy with retrograde P's with some missed retrograde P's

Answer 64

More likely JET If AVRNT/AVRT had a non conducted retrograde P they would usually revert to sinus

Question 65

Post-op vasoactive for children who have had congenital surgery (PRIMACORP study)

Answer 65

Milrinone PRIMACORP - Lower risk of low CO with high doses of milrinone vs without

Question 66

Second choice of vasoactive support post congenital surgery in addition to milrinone

Answer 66

Adrenaline or noradrenaline most commonly However lits of variability

Question 67

Features of vasopressin as vasoactive

Answer 67

Pure vasoconstrictor and allows reducing noradrenaline doses * Dose: 0.01 units/kg/min to 0.1 units/kg/min * Use in refractory catecholamine shock * Supports SVR without increasing PVR * Be aware of severe peripheral ischaemia

Question 68

Other interventions to support CO in addition to catecholamines, PD3 inhibitors and ADH

Answer 68

* Calcium infusion, optimal electrolytes, correct acidosis * Hydrocortisone * Control of temperature (control of SVR) * Pacing for optimal output * Levosimendan (controversial)