Cardiovascular
Emergencies
Objectives
• Understand the causes and management
priorities of bradycardia in children.
• Identify risk factors for serious causes of
syncope in children.
• Describe the resuscitation and stabilization
of a child presenting with cardiopulmonary
failure.
• List the strategies for prevention of
submersion injuries in infants and children.
Case Presentation
• You are called to a suburban home for
toddler found submerged in backyard
pool.
• A sobbing mother is performing CPR on
15-month-old girl on pool deck.
• As you take over resuscitation, the
mother tells you, “The phone rang; I was
only gone for 5 minutes!”
General Assessment: PAT
Appearance
Unconscious,
unresponsive;
poor muscle tone
Work of Breathing
No spontaneous
respirations
Circulation to Skin
Ashen, cyanosis of hands and lips
What is your general impression?
General Impression and
Management Priorities
• General impression:
– Sick: respiratory arrest; possible
cardiorespiratory failure
 Unresponsive, apneic, abnormal
circulation to skin
– Physiologic problem: global
hypoxemic–ischemic event
• Immediate management:
– Start oxygenation and ventilation while
assessing for spontaneous circulation.
Initial Assessment: ABCDEs
• Airway — patent
• Breathing —good air movement with bagmask ventilation; wet crackles on auscultation
• Circulation — HR 20; femoral pulse barely
palpable; capillary refill > 5 seconds; BP not
obtained
• Disability — pupils dilated, sluggishly reactive;
unresponsive to pain
• Exposure — no bruises, no signs of injury
What is your overall assessment?
Case Progression
• Cardiopulmonary failure due to hypoxemia.
– Chest compressions are indicated for
HR < 60.
• No evidence of associated injuries.
– Consider spinal injury.
 Less likely in toddler submersion than
with adolescent diving injury.
– Consider nonaccidental trauma.
 No “red flags”
What are your management priorities?
Management Priorities
• BLS:
– Place on spine board.
– Open airway; begin bag-mask ventilations,
100% 02.
– Perform chest compressions.
– Dry to prevent further heat loss/hypothermia.
• ALS:
– IV access, consider endotracheal intubation.
– Epinephrine, 0.01 mg/kg IV/IO, or 0.1 mg/kg
by endotracheal tube; repeat every 3–5
minutes.
Transport Decision: Stay or Go?
• BLS:
– Rapid transport to nearest appropriate
ED.
– Continuous reassessment for return of
pulse and circulation en route.
• ALS:
– Transport after airway/ventilation is
secure, IV/IO access is established,
and the first dose of epinephrine is
given.
– Do not delay transport if vascular
access fails.
Key Concepts: Bradycardia
• Treatable causes of bradycardia with
poor perfusion:
–
–
–
–
–
–
–
–
Hypoxemia
Hypothermia
Hypovolemia
Heart block
Toxins, poisoning, drugs
Tampondae, cardiac
Tension pneumothorax
Trauma (Head injury)
Key Concepts: Bradycardia
with Submersion Event
• Bradycardia in near-drowning reflects
significant hypoxia and myocardial
ischemia.
– The brain and other vital organs may
also have suffered ischemic injury.
– Rapid support of ventilation and
oxygenation will reduce the risk of
secondary injury.
– The drug of choice is oxygen,
followed by epinephrine.
Key Concepts: Drowning Prevention
• Pool drowning prevention:
– Close supervision
– Four-sided pool fence
– Self-locking gate
– Pool alarms
• Open water drowning prevention:
– Supervision of all age groups.
– Use of personal floatation devices.
– Educate teens about dangers of alcohol
and water sports.
• Risk awareness, as toddler drownings may
occur in shallow water.
Key Concepts: Injury Prevention
• Multiple strategies are
necessary for an effective
injury prevention program.
– Passive strategies
– Legislative action
– Enforcement of laws
– Education
Case Progression
• Oxygen provided by bag-mask device,
compressions continued.
– After 30 seconds, the heart rate increases
to 80 per minute and compressions are
discontinued.
– After 1 minute, the heart rate is 120 per
minute; spontaneous respirations return.
Case Progression
• En route:
– Supplemental oxygen is
delivered by mask.
– Blankets are applied to
prevent heat loss.
ED Course
• In the ED:
– The child shows progressive improvement in
level of consciousness, asking for her mommy.
– She remains hemodynamically stable.
– SaO2 is 94% on 100 % O2, and chest X-ray
shows diffuse infiltrates.
– She is admitted to the pediatric intensive care
unit and transferred to a ward the next morning.
• Diagnosis: near drowning; pulmonary edema
• Outcome: weaned from oxygen on day 2; home on
day 4 with normal neurologic exam.
Summary
• Submersion results in hypoxia, leading to
bradycardia, tissue ischemic injury, and
eventually, cardiac arrest.
• Early oxygenation and ventilation are the
most effective ways to restore spontaneous
circulation.
• Prehospital management is a major
determinant of outcome in children with
submersion injury.
• Submersion injuries are predictable —
prevention is the best treatment!
Case Presentation
• You are dispatched to a middle-school
athletic field for a child with loss of
consciousness.
• A 13-year-old boy is lying on the grass,
receiving CPR by his coach.
• The coach tells you that the child collapsed
while running for a ball, and that “this has
happened before.”
What is the first thing you will do on arrival?
General Assessment: PAT
Work of Breathing
No spontaneous
respirations
Appearance
Unresponsive
Circulation to Skin
Pale, cyanotic
What is your general impression?
General Impression and
Management Priorities
• General impression:
– Sick: cardiopulmonary failure
 Scenario suggests primary cardiac
event.
• Management:
– BLS: apply AED.
– ALS: “quick look” on
monitor/defibrillator.
Initial Assessment: ABCDEs
• Since this was a witnessed collapse, attach the
AED as soon as available.
– Airway: patent
– Breathing: no chest movement
– Circulation: absent pulses, no heart sounds;
shockable rhythm on AED, ventricular
fibrillation (VF) on monitor
– Disability: unresponsive to pain
– Exposure: no bruising or signs of injury
What is your overall assessment?
Case Progression
• VF cardiac arrest
– Possible mechanisms:
 Primary cardiac disease
 Trauma (direct blow to precordium)
 Toxin/drugs
What are your management priorities?
Management Priorities
• BLS:
–
–
–
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Establish absence of respirations, pulse.
Turn on AED.
Attach AED electrode pads.
Analyze rhythm.
 Shock if advised, then resume CPR
immediately for five cycles (2 minutes).
 If no shock is advised, resume CPR for five
cycles (2 minutes).
– Check for signs of circulation and rhythm every 2
minutes and repeat sequence from analyze
rhythm.
Management Priorities
•
ALS: BLS priorities plus:
– Place on monitor, check rhythm.
– Defibrillate.
 2 joules/kg
 Resume CPR for five cycles (2 minutes), check
rhythm; if VF, defibrillate with 4 joules/kg.
– Resume CPR immediately.
– Intubate, secure airway (optional).
– Obtain vascular access.
– Epinephrine 0.01 mg/kg (1:10,000) IV or 0.1 mg/kg ETT
(1:1000); repeat every 3-5 minutes.
– After five cycles (2 minutes); check rhythm. If shockable:
– Defibrillate (4 joules/kg).
– Resume CPR immediately.
– Consider antiarrhythmic.
 Lidocaine 1mg/kg IV/IO/ET
 Amiodarone 5 mg/kg IV/IO
Transport Decision: Stay or Go?
• Stay on scene and treat until a pulse is
established or the child is asystolic.
• As in adults, the outcome is strongly
linked to resuscitation in the field.
– Survival statistics are poor for a child
brought to the ED in asystole.
Key Concepts:
Ventricular Fibrillation
• Airway management and correction of hypoxia
while making rhythm diagnosis is critical.
• Although pediatric VF is uncommon, early
recognition and treatment improve the chance
of successful resuscitation.
– Early defibrillation increases the survival rate.
• Increased availability and use of AEDs in
community can improve outcomes for both
pediatric and adult VF victims.
Key Concepts:
High-risk Groups/Causes for VF
• Cardiomyopathies
• Coronary artery abnormalities:
– Post-Kawasaki disease aneurysms,
thrombi
– Congenital anomalies
• Direct blow to chest
• Dysrhythmia syndromes
Key Concept:
Identifying Cardiac Syncope
• Most fainting spells are benign, but “red flags”
can identify serious cardiac causes.
– Was the episode associated with chest
pain?
– Was there a brief or absent aura?
– Were there palpitations prior to fainting?
– Did it occur during exercise?
– Is there a family history of sudden death?
Case Progression
• At scene:
– Rescue breathing and cardiac
compressions started.
– AED shows VF — converted to
NSR on second shock.
– Vascular access obtained
• En route:
– Lidocaine bolus 1 mg/kg IV and
then 20 micrograms/kg/min
infusion or bolus every 15
minutes
– Continues in sinus rhythm
ED Course
• In the ED:
– Lead 2 rhythm strip shows QTc = 0.52
– The mother arrives and reports three
prior brief episodes of exerciseassociated syncope; sudden death at
the age of 28 in uncle.
• Outcome: child diagnosed with long QTc
syndrome. A pacemaker is placed. The
patient is discharged neurologically intact
5 days later.
Summary
• Most episodes of syncope in children are
benign.
• Ventricular fibrillation is a rare cause of loss
of consciousness in pediatrics.
• Early recognition of VF and defibrillation
improve survival rates.
• When VF is diagnosed, standard cardiac
resuscitation protocols should be followed,
regardless of the age of the patient.
Summary
• The primary cause of cardiopulmonary arrest in
children is severe hypoxia associated with respiratory
failure.
– Asystole or profound bradycardia is the most
common arrest rhythm on EMS arrival.
• Rapid intervention and return of vital signs in the field
are associated with good outcome.
– Patients with ventricular fibrillation who have
return of sinus rhythm have good survival rates.
– Children with asystole as the presenting rhythm on
scene rarely survive.