Pediatric Cardiac Pediatric Cardiac EmergenciesEmergencies

Gavin GreenfieldGavin Greenfield

Peggy ThomsenPeggy Thomsen

►4 year old female presents with fast 4 year old female presents with fast breathing, “grunting”, cough x 5 daysbreathing, “grunting”, cough x 5 days

►seen 2 days earlier and started on seen 2 days earlier and started on steroids and bronchodilatorssteroids and bronchodilators

► initial vitals: HR 150, BP 100/85, RR initial vitals: HR 150, BP 100/85, RR 36, T 37.536, T 37.5

►1 month old with irritability, poor 1 month old with irritability, poor feeding (fatigues), failure to thrive, feeding (fatigues), failure to thrive, fast breathingfast breathing

►no fever or runny noseno fever or runny nose►physical exam: HR 160, RR 60 with physical exam: HR 160, RR 60 with

minimal respiratory distress, gallop minimal respiratory distress, gallop rhythm, ralesrhythm, rales

Infant Cardiac Disease Leading Infant Cardiac Disease Leading to ER Presentationto ER Presentation

►CongenitalCongenital

►AcquiredAcquired CardiomyopathyCardiomyopathy Myocarditis (usually with CHF)Myocarditis (usually with CHF) DysrhythmiasDysrhythmias

Congestive Heart FailureCongestive Heart Failure

►the physiologic state in which cardiac the physiologic state in which cardiac output is unable to meet tissue output is unable to meet tissue metabolic demands (Rosen)metabolic demands (Rosen)

►CO = HR x SVCO = HR x SV►SV dependent upon preload, afterload, SV dependent upon preload, afterload,

contractilitycontractility

CHF - PresentationCHF - Presentation

► infants: irritable, poor feeding (early infants: irritable, poor feeding (early fatigue), failure to thrive, respiratory fatigue), failure to thrive, respiratory symptomssymptoms

►always consider in patients with always consider in patients with respiratory symptoms respiratory symptoms often misdiagnosed as respiratory illness / often misdiagnosed as respiratory illness /

infectioninfection

CHF - EtiologyCHF - Etiology► Increased PreloadIncreased Preload

L to R shunts (VSD, PDA, AV fistula)L to R shunts (VSD, PDA, AV fistula) severe anemiasevere anemia

► Increased AfterloadIncreased Afterload HTNHTN Congenital (aortic stenosis, coarctation of aorta)Congenital (aortic stenosis, coarctation of aorta)

► Decreased ContractilityDecreased Contractility myocarditis, pericarditis with tamponademyocarditis, pericarditis with tamponade cardiomyopathy (dilated or hypertrophic)cardiomyopathy (dilated or hypertrophic) Kawasaki syndrome (early phase)Kawasaki syndrome (early phase) metabolic: electrolyte, hypothyroidmetabolic: electrolyte, hypothyroid myocardial contusionmyocardial contusion toxins: dig, calcium channel blockers, beta blockerstoxins: dig, calcium channel blockers, beta blockers

► Dysrhythmia Dysrhythmia

CHF - EtiologyCHF - Etiology

► presents immediately at birthpresents immediately at birth anemia, acidosis, hypoxia, hypoglycemia, anemia, acidosis, hypoxia, hypoglycemia,

hypocalcemia, sepsishypocalcemia, sepsis► presents at 1 day (congenital)presents at 1 day (congenital)

PDA in premature infantsPDA in premature infants► presents in first month (congenital) presents in first month (congenital)

HPLV, aortic stenosis, coarctation, VSD presents HPLV, aortic stenosis, coarctation, VSD presents later later

► presents later (acquired)presents later (acquired) myocarditis, cardiomyopathy (dilated or myocarditis, cardiomyopathy (dilated or

hypertrophic), SVT, severe anemia, rheumatic hypertrophic), SVT, severe anemia, rheumatic feverfever

MyocarditisMyocarditis

► leading cause of dilated cardiomyopathy and leading cause of dilated cardiomyopathy and one of the most common causes of CHF in one of the most common causes of CHF in childrenchildren

► etiology: idiopathic, viral, bacterial, parasiticetiology: idiopathic, viral, bacterial, parasitic► hallmark is CHFhallmark is CHF► failure to respond to bronchodilators in failure to respond to bronchodilators in

wheezing childwheezing child► treatment includes inotropes, afterload treatment includes inotropes, afterload

reduction, diuretics, antibiotics, antiviralsreduction, diuretics, antibiotics, antivirals

PericarditisPericarditis

►sharp stabbing precordial painsharp stabbing precordial pain►worse with supine and better leaning worse with supine and better leaning

forwardforward►no sensory innervation of the no sensory innervation of the

pericardiumpericardium pain referred from diaphragmatic and pain referred from diaphragmatic and

pleural irritationpleural irritation

EtiologyEtiology

► infectiousinfectious viralviral bacterialbacterial TBTB fungal fungal parasiticparasitic

► Connective tissueConnective tissue RARA Rheumatic feverRheumatic fever SLESLE

► Metabolic / EndocrineMetabolic / Endocrine uremiauremia hypothyroidhypothyroid

► Hematology / OncologyHematology / Oncology bleeding diathesisbleeding diathesis malignancymalignancy

► TraumaTrauma► IatrogenicIatrogenic

PericarditisPericarditis

►usually a benign courseusually a benign course►virulent bacteria (H. flu, E. coli) can virulent bacteria (H. flu, E. coli) can

cause constrictive pericarditis and cause constrictive pericarditis and subsequent tamponade – may need subsequent tamponade – may need urgent pericardiocentesisurgent pericardiocentesis

►uncomplicated pericarditis usually uncomplicated pericarditis usually responds to rest and anti-responds to rest and anti-inflammatoriesinflammatories

Chest PainChest Pain

►4% of children will have a cardiac 4% of children will have a cardiac originorigin

►remainder: MSK, pulmonic (asthma, remainder: MSK, pulmonic (asthma, bronchitis, pneumonia), GIbronchitis, pneumonia), GI

►Cardiac causes: myocarditis, Cardiac causes: myocarditis, pericarditis, structural abnormalities pericarditis, structural abnormalities such as congenital heart disease or such as congenital heart disease or hypertrophic cardiomyopathyhypertrophic cardiomyopathy

►14 year old male collapses at school 14 year old male collapses at school while in classwhile in class

►non-responsive for one minutenon-responsive for one minute►feels fine in the departmentfeels fine in the department►Approach?Approach?

SyncopeSyncope

►20-50% of adolescents experience at 20-50% of adolescents experience at least one episode of syncopeleast one episode of syncope most cases benignmost cases benign

►PathophysiologyPathophysiology vascularvascular orthostatic, hypovolemiaorthostatic, hypovolemia neurally mediatedneurally mediated hypoxia: PE, CNS depression from OD, COhypoxia: PE, CNS depression from OD, CO cardiaccardiac

Cardiac SyncopeCardiac Syncope

►DysrhythmiasDysrhythmias tachytachy bradybrady

►Outflow obstructionOutflow obstruction►Myocardial DysfunctionMyocardial Dysfunction

►cardiac syncope often precedes future cardiac syncope often precedes future sudden cardiac deathsudden cardiac death

Sudden Cardiac DeathSudden Cardiac Death

► includes those causes that directly includes those causes that directly relate to cardiovascular dysfunctionrelate to cardiovascular dysfunction

►one third of all sudden deathsone third of all sudden deaths

Sudden Cardiac DeathSudden Cardiac Death

► EtiologyEtiology myocarditismyocarditis cardiomyopathy (hypertrophic)cardiomyopathy (hypertrophic) cyanotic and noncyanotic congenital heart diseasecyanotic and noncyanotic congenital heart disease valvular heart diseasevalvular heart disease congenital complete heart blockcongenital complete heart block WPWWPW long QT syndromelong QT syndrome Marfan syndromeMarfan syndrome coronary artery diseasecoronary artery disease anomalous coronary arteriesanomalous coronary arteries

Risk Factors for Serious Cause of Risk Factors for Serious Cause of SyncopeSyncope

► history of cardiac disease in patienthistory of cardiac disease in patient► FH of sudden death, cardiac disease, or FH of sudden death, cardiac disease, or

deafnessdeafness► recurrent episodesrecurrent episodes► recumbent episoderecumbent episode► exertionalexertional► prolonged loss of consciousnessprolonged loss of consciousness► associated chest pain or palpitationsassociated chest pain or palpitations►medications that can alter cardiac conductionmedications that can alter cardiac conduction

What to look for in the What to look for in the Department: EKGDepartment: EKG

► Long QT syndromeLong QT syndrome congenital or acquiredcongenital or acquired get paroxysmal v tach with torsades de pointesget paroxysmal v tach with torsades de pointes congenital long QT associated with hypertrophic congenital long QT associated with hypertrophic

cardiomyopathycardiomyopathy long QT defined as corrected QT longer than 0.44 slong QT defined as corrected QT longer than 0.44 s T wave alternans sometimes presentT wave alternans sometimes present can have normal ECG in the departmentcan have normal ECG in the department two clinical syndromes not associated with two clinical syndromes not associated with

structural heart disease: Romano-Ward and Jervell-structural heart disease: Romano-Ward and Jervell-Lange-NielsenLange-Nielsen

Other dysrhythmiasOther dysrhythmias

►WPW and other SVT’sWPW and other SVT’s►AV block AV block

usually acquired, rarely congenitalusually acquired, rarely congenital

►Sick sinus syndromeSick sinus syndrome

Idiopathic Hypertrophic Idiopathic Hypertrophic CardiomyopathyCardiomyopathy

► aka IHSSaka IHSS► both a fixed and dynamic subvalvular both a fixed and dynamic subvalvular

obstructionobstruction► characterized by ventricular hypertrophy with characterized by ventricular hypertrophy with

principle involvement of the ventricular septumprinciple involvement of the ventricular septum► associated with long QTassociated with long QT► autosomal dominantautosomal dominant► often presents with exertional syncopeoften presents with exertional syncope► 10 year mortality is 50% for children diagnosed 10 year mortality is 50% for children diagnosed

by age 14by age 14

Other structural cardiac Other structural cardiac diseasesdiseases

► dilated cardiomyopathydilated cardiomyopathy usually secondary to myocarditisusually secondary to myocarditis syncope and death secondary to ventricular dysrhythmias syncope and death secondary to ventricular dysrhythmias

or severe myocardial dysfunctionor severe myocardial dysfunction► arrhythmogenic RV dysplasiaarrhythmogenic RV dysplasia► congenital cyanotic and non-cyanotic heart diseasecongenital cyanotic and non-cyanotic heart disease► valvular diseasesvalvular diseases

aortic stenosisaortic stenosis► coronary artery anomaliescoronary artery anomalies

exertional syncope or sudden deathexertional syncope or sudden death aberrant artery passes between aorta and pulmonary aberrant artery passes between aorta and pulmonary

arteryartery

►2 week old infant brought in by 2 week old infant brought in by parents with difficulty breathingparents with difficulty breathing

►HR 180, BP 50/P, RR 80, T 37.5HR 180, BP 50/P, RR 80, T 37.5►history and physicalhistory and physical► investigationsinvestigations►repeat vitals: HR 30, no BP, RR 12repeat vitals: HR 30, no BP, RR 12►““definitive treatment”:definitive treatment”:

►4 year old male presents with 2 weeks 4 year old male presents with 2 weeks history of cough, fast breathing, history of cough, fast breathing, fatigue, decreased exercise tolerance, fatigue, decreased exercise tolerance, “puffy eyes”“puffy eyes”

►On exam: tachypneic, moderate On exam: tachypneic, moderate respiratory distress, O2 sats 92%, respiratory distress, O2 sats 92%, bilateral cracklesbilateral crackles

►6 month male presents with failure to 6 month male presents with failure to thrive, fast breathing, blue lipsthrive, fast breathing, blue lips

►On exam tachypnea but no respiratory On exam tachypnea but no respiratory distress, lips and extremities blue, distress, lips and extremities blue, oxygen saturations 70%oxygen saturations 70%

Congenital Heart DiseaseCongenital Heart Disease

►Fetal to Neonatal CirculationFetal to Neonatal Circulation

ClassificationClassification

Congenital Heart Disease Congenital Heart Disease ClassificationClassification

►pink (in failure)pink (in failure)►blue (no distress)blue (no distress)►gray (in shock)gray (in shock)

Anatomic Classification; 4 Anatomic Classification; 4 groupsgroups

► Right to Left ShuntRight to Left Shunt Tetralogy of FallotTetralogy of Fallot Transposition of Transposition of

the Great Arteriesthe Great Arteries Tricuspid AtresiaTricuspid Atresia

► Left to Right ShuntLeft to Right Shunt ASDASD VSDVSD PDAPDA

► StenoticStenotic Aortic valve Aortic valve

stenosisstenosis Pulmonic valve Pulmonic valve

stenosisstenosis Aortic coarctation  Aortic coarctation  

► MixingMixing TruncusTruncus Total Anomalous Total Anomalous

Pulmonary Venous Pulmonary Venous ReturnReturn

Hypoplastic left heart Hypoplastic left heart syndromesyndrome

CHD Classified as Cyanotic vs. CHD Classified as Cyanotic vs. AcyanoticAcyanotic

►Cyanotic (R to L shunt and mixing Cyanotic (R to L shunt and mixing lesions)lesions) tetralogy of Fallottetralogy of Fallot transposition of great vesselstransposition of great vessels tricuspid atresiatricuspid atresia total anomalous pulmonary venous returntotal anomalous pulmonary venous return truncus arteriosustruncus arteriosus hypoplastic left heart syndromehypoplastic left heart syndrome

CHD Classified as Cyanotic vs. CHD Classified as Cyanotic vs. AcyanoticAcyanotic

►Acyanotic (L to R shunts, Acyanotic (L to R shunts, stenotic lesions)stenotic lesions) ASDASD VSDVSD PDAPDA aortic valve stenosisaortic valve stenosis pulmonic valve stenosispulmonic valve stenosis aortic coarctationaortic coarctation

CyanosisCyanosis

►Classified as central or peripheralClassified as central or peripheral►Central cyanosis (always abnormal)Central cyanosis (always abnormal)

mucous membranes, trunk, extremitiesmucous membranes, trunk, extremities classified as cardiac (R to L shunt) or pulmonaryclassified as cardiac (R to L shunt) or pulmonary

►Peripheral cyanosis (acrocyanosis)Peripheral cyanosis (acrocyanosis) no involvement of mucous membranesno involvement of mucous membranes involves hands, feet, circumoral areainvolves hands, feet, circumoral area common in neonates from vasomotor instabilitycommon in neonates from vasomotor instability CHF, PVD, shock, cold extremitiesCHF, PVD, shock, cold extremities

Congenital Heart DiseaseCongenital Heart Disease

►HistoryHistory feeding difficultiesfeeding difficulties tachypneatachypnea diaphoresisdiaphoresis syncopesyncope cyanotic episodescyanotic episodes failure to thrivefailure to thrive

Congenital Heart DiseaseCongenital Heart Disease

►Physical ExaminationPhysical Examination colour: pink, blue, graycolour: pink, blue, gray vitals: tachypnea, tachycardia, BPvitals: tachypnea, tachycardia, BP symptoms suggestive of infection symptoms suggestive of infection palpation and auscultation of precordiumpalpation and auscultation of precordium chest auscultationchest auscultation survey for organomegalysurvey for organomegaly pulses in all extremitiespulses in all extremities

Cyanotic Congenital Cyanotic Congenital Heart DiseaseHeart Disease

►R to L shuntsR to L shunts

►mixing lesionsmixing lesions

Tetralogy of Fallot – the classic Tetralogy of Fallot – the classic cyanotic lesioncyanotic lesion

► RV outflow RV outflow obstructionobstruction

► RVHRVH► VSD VSD ► overriding aortaoverriding aorta

► CXR reveals boot CXR reveals boot shaped heart with shaped heart with decreased pulmonary decreased pulmonary blood flowblood flow

►2 month old female with known 2 month old female with known tetralogy of Fallot brought in with 24 tetralogy of Fallot brought in with 24 hour history of vomiting and diarrheahour history of vomiting and diarrhea

►On exam: moderate dehydrationOn exam: moderate dehydration►during IV attempts patient becomes during IV attempts patient becomes

irritable and cyanoticirritable and cyanotic

Treatment of Tet SpellTreatment of Tet Spell

► quiet, calm environmentquiet, calm environment► knee-chest or squatting position knee-chest or squatting position

increases afterload thus decreasing R to L shuntingincreases afterload thus decreasing R to L shunting► OxygenOxygen► Morphine Morphine

to treat hyperpnea and decrease systemic catecholamines to treat hyperpnea and decrease systemic catecholamines ► Phenylephrine Phenylephrine

increases afterload thereby decreasing R to L shuntincreases afterload thereby decreasing R to L shunt► Manual external aortic compression below level of Manual external aortic compression below level of

renal arteriesrenal arteries► Propranolol Propranolol

to block beta receptors in infundibulum therefore lessening to block beta receptors in infundibulum therefore lessening RV outflow obstructionRV outflow obstruction

ConsiderConsider

►consider small volume challenge (5-10 consider small volume challenge (5-10 cc/kg) to increase preload and reduce cc/kg) to increase preload and reduce dynamic outflow obstructiondynamic outflow obstruction

►?NaHCO3 for correction of acidosis?NaHCO3 for correction of acidosis►may need general anesthesia if severe may need general anesthesia if severe

and/or prolonged spelland/or prolonged spell► interim prophylactic treatment with interim prophylactic treatment with

propranolol while awaiting surgerypropranolol while awaiting surgery

Acyanotic Acyanotic Congenital Heart Congenital Heart

DiseaseDisease►L to R shuntsL to R shunts

►stenotic lesionsstenotic lesions

VSDVSD

•Most common congenital lesion•Large VSD’s may be silent and become symptomatic in first few weeks as pulmonary resistance •SOB and diaphoresis w feeds•Poor weight gain

•Systolic murmur•CXR demonstrates CHF

►2 week old infant brought in by 2 week old infant brought in by parents with difficulty breathingparents with difficulty breathing

►HR 180, BP 50/P, RR 80, T 37.5HR 180, BP 50/P, RR 80, T 37.5►history and physicalhistory and physical► investigationsinvestigations►repeat vitals: HR 30, no BP, RR 12repeat vitals: HR 30, no BP, RR 12►““definitive treatment”:definitive treatment”:

Differential Dx of Infant Differential Dx of Infant ShockShock

► infection (septic shock/ meningitis) infection (septic shock/ meningitis) bacterial: GBS, E. coli, S. aureus bacterial: GBS, E. coli, S. aureus virus: enteroviruses, H. simplex virus: enteroviruses, H. simplex

►metabolic: amino/organic metabolic: amino/organic acidopathies, urea cycle defectacidopathies, urea cycle defect

► ‘‘hypoxic shock’: eg. RSV, C.N.S. hypoxic shock’: eg. RSV, C.N.S. depression depression

►heart disease: congenital or acquiredheart disease: congenital or acquired

LV Outflow LV Outflow ObstructionObstruction

LV Outflow ObstructionLV Outflow Obstruction

► Aortic coarctationAortic coarctation►Hypoplastic left heart syndromeHypoplastic left heart syndrome► Aortic stenosis (presents later)Aortic stenosis (presents later)

► Rosen: “any neonate in shock that does not Rosen: “any neonate in shock that does not respond to fluids or pressors has LV outflow respond to fluids or pressors has LV outflow obstruction until proven otherwise”obstruction until proven otherwise”

► complete obstruction incompatible with life complete obstruction incompatible with life unless there is shuntingunless there is shunting

Coarctation of the aortaCoarctation of the aorta

•Most often distal to L subclavian•Can be diagnosed anytime•Neonates present as acutely ill, gray shocky (from DA closure)•Systolic murmur at the back•Hepatomegaly•Diminished femoral pulses•BP difference b/t arms and legs•CXR demonstrates CHF

•Treatment of CHF•Prostaglandin E1

Duct Dependant LesionsDuct Dependant Lesions

►Duct needed to perfuse lungs or Duct needed to perfuse lungs or peripheryperiphery

►LungsLungs Tetralogy of Fallot, transposition of great Tetralogy of Fallot, transposition of great

arteries, tricuspid or pulmonary atresiaarteries, tricuspid or pulmonary atresia►a patent ductus arteriosus results in preserved a patent ductus arteriosus results in preserved

pulmonary blood flowpulmonary blood flow

►PeripheryPeriphery Aortic coarctation (severe) and Hypoplastic Aortic coarctation (severe) and Hypoplastic

left heartleft heart

Treatment of acute decline in Treatment of acute decline in patients with ductal dependant patients with ductal dependant

lesionslesions►Open the closed ductOpen the closed duct►Prostaglandin E1 0.1 ug/kg/min infusionProstaglandin E1 0.1 ug/kg/min infusion►reduce dosage as perfusion and colour reduce dosage as perfusion and colour

returnreturn

►Rosen: “any infant in the first week of life Rosen: “any infant in the first week of life with decreased perfusion, hypotension, with decreased perfusion, hypotension, or acidosis should be considered a or acidosis should be considered a candidate for PGE1 administration”candidate for PGE1 administration”

What do you need to know What do you need to know about PGE ?about PGE ?

► it functions by dilating vascular it functions by dilating vascular smooth muscle, both systemically and smooth muscle, both systemically and in the pulmonary vascular bed in the pulmonary vascular bed

► it’s use in CHD pts’ is to maintain it’s use in CHD pts’ is to maintain patency of the PDA, whether to patency of the PDA, whether to maintain PBF or to maintain systemic maintain PBF or to maintain systemic blood flow past ablood flow past a

Classification ReviewClassification Review

►pink child in respiratory distress pink child in respiratory distress suggests acyanotic chd (L to R shunt, suggests acyanotic chd (L to R shunt, coarct, aortic stenosis)coarct, aortic stenosis)

►blue cyanotic child in little respiratory blue cyanotic child in little respiratory distress suggests R to L shunt or distress suggests R to L shunt or mixing lesionsmixing lesions

►gray, shocky baby suggests outflow gray, shocky baby suggests outflow tract obstruction tract obstruction

BradyarrhythmiasBradyarrhythmias

►EtiologyEtiology hypoxia, acidosis, hypoglycemiahypoxia, acidosis, hypoglycemia excess vagal stimulation (ex. intubation)excess vagal stimulation (ex. intubation)

  ►TreatmentTreatment

EpinephrineEpinephrine Atropine if known vagally mediated or Atropine if known vagally mediated or

heart blockheart block

Congenital BradyarrhythmiasCongenital Bradyarrhythmias

►complete AV blockcomplete AV block autoimmune injury to fetal conduction autoimmune injury to fetal conduction

system secondary to maternal system secondary to maternal autoimmune diseaseautoimmune disease

atropine, isoproteronol, epinephrine may atropine, isoproteronol, epinephrine may be tried temporarily prior to pacingbe tried temporarily prior to pacing

TachyarrhythmiasTachyarrhythmias

►Supraventricular TachycardiaSupraventricular Tachycardia re-entrant with accessory pathway (AV re-entrant with accessory pathway (AV

nodal or WPW)nodal or WPW) re-entrant without accessory pathway (re-re-entrant without accessory pathway (re-

entry occurs within sinus node or within entry occurs within sinus node or within atrium)atrium)

ectopicectopic

►nonspecific presentations in infantsnonspecific presentations in infants

MurmursMurmurs

►AreasAreas aortic: R 2aortic: R 2ndnd intercostal space intercostal space pulmonic: L 2pulmonic: L 2ndnd intercostal space intercostal space mitral: apexmitral: apex tricuspid and VSD: L lower sternal bordertricuspid and VSD: L lower sternal border

►PathologicPathologic diastolic, holosystolic, late systolic, diastolic, holosystolic, late systolic,

continuouscontinuous

Innocent Heart MurmursInnocent Heart Murmurs

►HistoryHistory normal growth and development, normal growth and development, normal normal

exercise toleranceexercise tolerance no history of cyanosisno history of cyanosis

► Physical ExaminationPhysical Examination Grade II or less, localizedGrade II or less, localized varies with position (decreased with upright varies with position (decreased with upright

posture)posture) normal precordium normal precordium normal pulsesnormal pulses

► LabLab normal EKG, normal CXRnormal EKG, normal CXR

3 innocent murmurs3 innocent murmurs

►Still’sStill’s short ejection systolic murmur short ejection systolic murmur musical or vibratory qualitymusical or vibratory quality heard best between apex and left sternal heard best between apex and left sternal

borderborder►physiologic pulmonary flow murmurphysiologic pulmonary flow murmur

harsh, located at pulmonic areaharsh, located at pulmonic area►peripheral arterial stenosisperipheral arterial stenosis

low-intensity systolic ejection murmur best low-intensity systolic ejection murmur best heard in axilla and backheard in axilla and back

►8 year old male presents with fever, 8 year old male presents with fever, arthralgiasarthralgias

►mother mentions that he had a sore mother mentions that he had a sore throat 3 weeks ago for a few days with throat 3 weeks ago for a few days with spontaneous resolutionspontaneous resolution

►a throat swab was done and positive a throat swab was done and positive for GAS but patient better so did not for GAS but patient better so did not take the prescribed antibioticstake the prescribed antibiotics

Acute Rheumatic FeverAcute Rheumatic Fever

► school aged childrenschool aged children► associated with certain strains of Group A associated with certain strains of Group A

beta-hemolytic streptococcal infectionsbeta-hemolytic streptococcal infections► the streptococcal organism stimulated the streptococcal organism stimulated

antibody production to host tissuesantibody production to host tissues CT of heart, joints, CNS, subcutaneous tissues, CT of heart, joints, CNS, subcutaneous tissues,

skinskin

► carditis is an endomyocarditis with valvulitis carditis is an endomyocarditis with valvulitis involving mitral and aortic valvesinvolving mitral and aortic valves

► 2 to 6 weeks post streptococcal pharyngitis2 to 6 weeks post streptococcal pharyngitis

Jones CriteriaJones Criteria

►MajorMajor carditiscarditis

►new or changing new or changing murmurmurmur

►cardiomegaly, CHFcardiomegaly, CHF►pericarditispericarditis

migratory polyarthritismigratory polyarthritis choreachorea erythema marginatumerythema marginatum subcutaneous nodulessubcutaneous nodules

►MinorMinor feverfever arthralgiaarthralgia history of previous history of previous

ARFARF elevated ESR, CRPelevated ESR, CRP prolonged PR on EKGprolonged PR on EKG Rising titer of Rising titer of

antistreptococcal antistreptococcal antibodies antibodies

Erythema MarginatumErythema Marginatum

ER TreatmentER Treatment

►management of complicating features management of complicating features of carditis (CHF)of carditis (CHF) significant carditis or CHF managed with significant carditis or CHF managed with

glucocorticoidsglucocorticoids

►high-dose ASA 75-100 mg/kg/dayhigh-dose ASA 75-100 mg/kg/day►pencillinpencillin► long term management of rheumatic long term management of rheumatic

heart diseaseheart disease

Pediatric EKG’s General Pediatric EKG’s General PrinciplesPrinciples

►RV Dominance at birth; gradually RV Dominance at birth; gradually changes to LV dominance changes to LV dominance

►axis up to +180 in normal newbornaxis up to +180 in normal newborn►T waves negative in right precordial T waves negative in right precordial

leads until adolescence (except they leads until adolescence (except they are upright in first week of life)are upright in first week of life)