Pediatric congenital heart disease
- Congenital HD: Two types: Neonates with ductal dependent lesions and infants (2-6months) presents with CHF
- Cyanosis presentation: When ductal-dependent lesion is required for pulmonary blood flow (Will not respond to oxygen)
- Shock presentation: When ductal-dependent lesion is required for systemic blood flow (appear septic and not response to fluids, may get worse with fluids)
- Hypoxic/cyanotic or shocky/acidotic baby treatment = Prostaglandin E1 (PGE1) and transfer to facility with pediatric cardiovascular surgeon.
- PGE1 treatment may cause apnea (monitor closely and consider intubation)
- CHF in infants = wheezing, retractions, tachypnea, sweating/crying, difficulty feeding
EBM in the ED
- EBM = What the evidence shows in the literature + What the physician wants for the patient + what the patient wants for themselves
- Just like we need to practice intubation, central lines –> Learning to read and interpret literature is a skill that needs to be practiced.
- AD: Chest pain plus disease (ex: CP + Neurodeficit)
- If you find your self giving large amounts of strong pain meds (narcotics) while treating what is seemingly ACS…STOP..think about AD or alternative diagnosis of chest pain
- The 3 important questions, aortic dissection is the subarachnoid hemorrhage of the torso, migrating pain, colicky pain + opioids = badness and pain that comes and goes can still be a dissection.
- Treatment: Treat pain, HR, BP
- Pain: Fentanyl 25 – 50 mcg bolus
- HR: Goal of 60 bbpm
- Esmolol 0.5 mg/kg bolus then 50 – 300 mcg/kg/min or
- Labetalol 10 – 20 mg bolus then 0.5-2 mg/minor
- BP control: Goal SBP =110
- Nitroprusside 0.25 – 0.5 mcg/kg/min then titrate (CN toxicity)
- Nicardipine 5 mg/hr
- Warning: Giving a vasodilator without concomitant reduction in ionotropy may cause progression of dissection. Start BB first before vasodilation meds.