2. Objectives
Present the clinical features and
emergency management of
cardiovascular disorders, including:
– Diagnose and treat rhythm disturbances.
– Detect and treat cardiomyopathy.
– Treat shock.
– Create differential diagnosis and
management plan for syncope.
Continuing Education Modules 2
3. Case Study 1: “Not Breathing”
10-day-old boy brought to ED for not
breathing and color change.
3 weeks premature, discharged from
hospital 3 days ago with apnea monitor
Decreased activity since discharge
Poor feeding today
Continuing Education Modules 3
4. Initial Assessment (1 of 2)
PAT:
– Abnormal appearance, abnormal breathing,
abnormal circulation
Vital signs:
– HR 220, RR 14, BP 55/36, Wt 3.5 kg (birth
weight 3.7 kg), O2 sat 88% on room air
Continuing Education Modules 4
5. Initial Assessment (2 of 2)
A: Patent without evidence of obstruction
B: Nonlabored but diminished respiratory rate
C: Mottled, cool, distal cyanosis,
tachycardic and weak pulse
D: Weak cry, nonfocal exam
E: Normothermic, no evidence of trauma,
fontanel flat
Continuing Education Modules 5
7. Question
What is your general impression of this
patient?
Continuing Education Modules 7
8. General Impression
Cardiopulmonary failure
– Lethargic but responsive, inadequate
respirations and tachycardia; mottling with
distal cyanosis
What are your initial management priorities?
Continuing Education Modules 8
9. Management Priorities
ABCs
Open airway.
Give 100% O2 by BMV, or perform endotracheal
intubation.
Check rhythm on cardiac monitor.
Obtain vascular access.
Obtain blood glucose prn.
Check rectal temperature.
Continuing Education Modules 9
11. Case Discussion (2 of 2)
Clinical features can be varied:
– Palpitations in verbal children
– Shock in any age
– Generalized symptoms of malaise and weakness
Diagnostic studies:
– Cardiac monitor, ECG, sepsis evaluation if young
infant who has signs and symptoms suggestive
of infection
– CXR, echocardiogram
Management: ABCs, stabilize
Continuing Education Modules 11
13. Clinical Features: Your First Clue
Intermittent, paroxysmal presence of
symptoms
Sudden onset of symptoms with little or
no prodrome
Presentation of dysrhythmias can range
from stable to cardiopulmonary arrest.
Continuing Education Modules 13
14. Distinguishing SVT from ST
ST SVT
History Fever, sepsis, Intermittent,
dehydration, paroxysmal in onset
hemorrhage,
hypovolemia, precedes
ECG ST rate is less than 2x SVT rate at or
normal rate for age. greater than 2x
Rate varies with normal rate for age.
activity. Minimal or no rate
change with activity.
Continuing Education Modules 14
20. The Bottom Line: Dysrhythmias
Management is driven by presence or
absence of poor perfusion.
Sinus tachycardia is not an arrhythmia but
its etiology must be determined.
Provide ventilation and oxygenation for all
patients in cardiopulmonary arrest, as the
primary etiology is often respiratory
failure.
Continuing Education Modules 20
21. Other Considerations (1 of 2)
Interface with EMS/Transport:
– Transport issues: Case such as this should be
transported to pediatric referral center after
stabilization.
ALS transport with monitoring and IV access
Treatment plan for possible en route for
recurrence – including potential for cardioversion
Consult accepting pediatric cardiologist
Continuing Education Modules 21
22. Other Considerations (2 of 2)
Documentation:
– Always try to get baseline 12-lead ECG before
and after cardioversion.
– Treatment record from prehospital and ED care
– EMTALA compliance
Risk management:
– Always check blood glucose.
– Assure rapid triage of infants in distress.
– Do not hesitate to cardiovert when child is
unstable.
Continuing Education Modules 22
23. Reversible Non-Cardiac
Causes of Dysrhythmias
Four H’s: • Four T’s:
– Hypoxemia – Tamponade
– Hypovolemia (cardiac)
– Hypothermia – Tension
pneumothorax
– Hyper/Hypokalemia
and metabolic – Toxins/poisons/
disorders drugs
– Thromboembolism
Continuing Education Modules 23
24. Case Progression/Outcome
ECG reveals SVT.
Infant receives BMV ventilation.
Preparations are made to cardiovert as IV access
is obtained.
Adenosine 100 mcg/kg IV push is given followed
by NS bolus (flush).
ECG shows return of sinus rhythm.
BMV is discontinued as infant’s condition
stabilized. 100% oxygen NRB mask is placed.
Continuing Education Modules 24
25. Case Study 2:
“Unresponsive Episodes”
2-year-old girl passed out eating cereal;
awoke after 5 min.
She was stiff with eyes rolled back ~
approx. 5 min.
Minimal period of sleepiness, now
awake and alert; no retractions; skin
color is normal
Continuing Education Modules 25
26. Initial Assessment and
Focused History
PAT:
– Normal appearance, normal breathing, normal
circulation
ABCDEs:
– Normal
– Vital signs: HR 120; RR 24; BP 80/60; T 37.7° C Wt
12 kg; O2 sat 99%
Focused History:
– Three similar episodes; two associated with “temper
tantrums.”
– PMH and FH: Negative
Continuing Education Modules 26
27. Question
What is your general impression of this
patient?
Continuing Education Modules 27
28. General Impression
Stable
– Patient with syncope
– In no distress; normal exam
– Concerning/ominous history
What are your initial management priorities?
Continuing Education Modules 28
29. Case Discussion
Syncope in young children is a serious
symptom.
Must attempt to exclude life-threatening
causes
Differential diagnosis is critical:
– Seizure
– Cardiac
– Breath-holding spell
Continuing Education Modules 29
30. Clinical Features: Your First Clue
Loss of consciousness
Lasted only a few minutes
Minimal or no postictal state
No stigmata of seizure: Urinary
incontinence, bitten tongue, witnessed
tonic-clonic activity
Continuing Education Modules 30
31. Diagnostic Studies
Radiology:
– CXR offers little.
– CT or MRI may be indicated if considering seizures.
Laboratory is often normal but may include:
– Electrolytes
– CBC with differential
– Ca++, Mg++, PO4
Continuing Education Modules 31
33. Prolonged QT
10% present with seizures.
15% of patients with prolonged QTc die
during their first episode of arrhythmia.
– 30% of these deaths occur during the first
year of life.
Continuing Education Modules 33
34. What Else?
Cardiac Causes of Syncope
Hypertrophic cardiomyopathy
– Syncope with exercise
– At risk for sudden death; positive family history
– Non-specific murmur; ECG can show non-specific
findings.
– CXR is non-diagnostic
– Echocardiogram is diagnostic.
Chronic cardiomyopathy
– Chronic CHF
Dysrhythmias
Continuing Education Modules 34
35. Critical Concepts (1 of 2)
Consider cardiac arrhythmias in all
patients presenting with brief, nonspecific
changes in level of consciousness:
– Fainting, syncope, seizures, breath-holding,
apparent life-threatening events
Continuing Education Modules 35
36. Critical Concepts (2 of 2)
Family history may be positive for sudden,
unexplained deaths prior to 55, fainting
episodes, or unexplained accidents.
Episodes associated with exercise are
particularly concerning.
– Patient instructed not to exercise until cleared
by a cardiologist.
Continuing Education Modules 36
37. Pulseless Arrest*
VF/VT Not VF/VT
Shock x 3 Vasopressor
Vasopressor CPR x 3 min
(Drug - Shock)
Shock
*CPR and seek reversible
causes throughout
Anti-arrhythmic
Continuing Education Modules 37
38. Case Progression
This patient has prolonged QT syndrome.
She is at risk for fatal dysrhythmia
(ventricular tachycardia or ventricular
fibrillation).
She needs to be admitted/transferred to a
pediatric cardiology center for cardiology
evaluation.
Continuing Education Modules 38
39. Case Outcome
This child is hospitalized.
Monitored and confirmed to be at risk for
dangerous dysrhythmia
Discharged on medications shown to
decrease her risk of VT/VF (e.g., ß
blockers)
She is a candidate to receive an AICD
when she gets older.
Continuing Education Modules 39
40. Case Study 3: “Chicken Pox”
6-month-old with chicken pox lesions
that began 3 days ago. Lesions are
spreading. More scabs today.
Fever since yesterday, higher today.
Today, his skin appears to be red.
He is fussy and not feeding well.
Continuing Education Modules 40
41. Initial Assessment (1 of 2)
PAT:
– Normal/abnormal appearance, normal
breathing, normal circulation
Vital signs:
– HR 160, RR 40, BP 79/56, T 39°C, Wt 8.1 kg,
O2 sat 98% on room air
Continuing Education Modules 41
42. Initial Assessment (2 of 2)
A: Patent without evidence of obstruction
B: Normal
C: Generalized red erythroderma, warm,
tachycardic (febrile)
D: Nonfocal exam, irritable
E: Many impetiginous scabs, pustules and
vesicles; some with surrounding cellulitis
Continuing Education Modules 42
43. Detailed Physical Exam
Head/Neck: No abnormalities except for skin
Heart: Tachycardic, no murmurs heard
Lungs: Clear breath sounds
Abdomen: Normal except for skin
Neuro: Alert, subdued, no meningismus
Skin: Many vesicles, scabs, pustules; some with
surrounding cellulitis. Generalized warm
erythroderma. Capillary refill 2 seconds.
Continuing Education Modules 43
44. Question
What is your general impression of this
patient?
Continuing Education Modules 44
45. General Impression
Compensated shock
– Tachycardia and mild change in appearance (fussy)
– Possible septic shock as varicella lesions with signs of
secondary infection (Staph aureus, group A strep)
– Erythroderma: Scarlet fever versus toxic shock
What are your initial management priorities?
Continuing Education Modules 45
46. Management Priorities
Provide supplemental oxygen.
Obtain vascular access.
Determine rapid glucose.
Begin fluid resuscitation at 20 mL/kg – 160
mL NS.
CBC, blood culture, other optional labs
IV antibiotics
Repeated assessment for signs of shock
Continuing Education Modules 46
47. Shock
Inadequate tissue perfusion (delivery of
oxygen and nutrients) to meet the
metabolic demands of the body.
– Hypovolemic
– Cardiogenic
– Distributive
– Septic
Continuing Education Modules 47
48. Background: Shock
Compensated:
– Vital organs continue to be perfused by compensatory
mechanisms.
– Blood pressure is normal.
Decompensated:
– Compensatory mechanisms are overwhelmed and
inadequate.
– Hypotension, high mortality risk
Aggressive treatment of early shock:
– Halts progression to decompensated shock
Continuing Education Modules 48
53. Septic Shock
Elements of distributive shock and cardiogenic
shock:
– Inappropriate vasodilation with a maldistribution of
blood flow
– Myocardial depression
Resuscitation:
– Fluid bolus
– Pressors and inotropes
– Antibiotics (expect possible deterioration initially due
to toxin release)
Continuing Education Modules 53
54. Case Progression/Outcome
Labs drawn
IV fluids given with decrease in HR to
120
IV antibiotics given
Patient admitted and discharged 4
days later
Continuing Education Modules 54
55. The Bottom Line: Shock
Early recognition and treatment of
compensated shock may prevent
progression to decompensated shock.
Decompensated shock has a poor
prognosis.
Continuing Education Modules 55
56. EIF
Available
from ACEP,
AAP
Updated by
PCP and
specialists
Very helpful
Medical ID
bracelet
Continuing Education Modules 56
57. The Bottom Line
Obtain rapid history and assess children
in shock or respiratory distress for
cardiac disease.
Utilize the EIF to gather information,
contact specialists, and guide therapy.
Echocardiography and cardiology
consultation for definitive diagnosis and
cardiac function determination.
Continuing Education Modules 57
Present the clinical features and emergency management of cardiovascular disorders, including: Diagnose and treat rhythm disturbances. Detect and treat cardiomyopathy. Treat shock. Create differential diagnosis and management plan for syncope.
A 10-day-old male infant is brought to ED for not breathing and color change. The child was 3 weeks premature, and was discharged from hospital 3 days ago with an apnea monitor. Decreased activity since discharge Poor feeding today
The PAT is as follows: A: Appearance: Abnormal B: Work of Breathing: Abnormal C: Circulation to the Skin: Abnormal Vital signs include: Heart rate: 220 bpm Respiratory rate: 14 breaths/min Blood pressure: 55/36 mm Hg Weight: 3.5 kg (birth weight 3.7 kg) Oxygen saturation: 88% on room air
A: Airway: Patent without evidence of obstruction B: Breathing: Nonlabored but diminished respiratory rate C: Circulation: Mottled, cool, distal cyanosis, tachycardic and weak pulse D: Disability: Weak cry, nonfocal exam E: Exposure: Normothermic, no evidence of trauma, fontanel flat
Head/Neck: No abnormalities Heart: Tachycardia, no murmurs heard Lungs: Decreased breath sounds Abdomen: Liver 2 finger breadths below RCM Neurologic: Weak cry, lethargic, poor interaction, responsive to pain and contact Extremities: Cyanotic, cool upper and lower extremities
Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
Cardiopulmonary failure because all arms of the PAT are abnormal. Patient appearance is lethargic but responsive, with inadequate respirations and tachycardia; mottling with distal cyanosis. What are your initial management priorities?
Check ABCs. Open airway. Give 100% O 2 by BMV, or perform endotracheal intubation. Check rhythm on cardiac monitor. Obtain vascular access. Obtain blood glucose prn. Check rectal temperature.
Tachyarrhythmias: Wide complex Ventricular tachycardia (rare rhythm in children but if wide need to consider of ventricular origin) SVT with aberrancy Narrow complex Sinus tachycardia (rates usually < 220) SVT (Rates usually > 220)
Clinical features can be varied: Palpitations in verbal children Shock in any age Generalized symptoms of malaise and weakness Diagnostic studies may include: Cardiac monitor, ECG, sepsis evaluation if young infant who has signs and symptoms suggestive of infection Chest radiograph, echocardiogram Management includes ABCs and stabilization.
The pediatric patient has 3 basic types of pathologic rhythm disturbances, which include fast pulse (tachyarrhythmia), slow pulse (bradyarrhythmia), and absent pulse (pulseless) (Table 4-3). These can be further divided into 7 classifications based on their anatomic function. Dysrhythmias may be the cause of impaired cardiac function leading to cardiac arrest. Occult dysrhythmias (e.g., prolonged QT syndrome, Wolf-Parkinson-White syndrome, etc.) may present with intermittent severe symptoms (e.g., palpitations or sudden death).
Consider the following symptoms: Intermittent, paroxysmal presence of symptoms Dramatic onset and change in condition Sudden onset of symptoms with little or no prodrome Presentation of dysrhythmias can range from stable to cardiopulmonary arrest. Infant or child may show subtle signs of major physiological derangement.
Supraventricular tachycardia (SVT) history is intermittent, paroxysmal, with sudden onset. Sinus tachycardia (ST) history suggests sepsis, dehydration, hemorrhage, hypovolemia. SVT ECG steady rate at or greater than 2x normal rate for age. ST rate is less than 2x normal rate for age. Minimal or no rate change with activity with SVT.
SVT characteristics (versus sinus tachycardia): Heart rate is >2 times normal rate for age. Rhythm is steady. P waves are absent. History is not suggestive of volume depletion or sepsis.
Radiology studies include chest radiographs; it is important to look for signs of structural congenital heart disease, congestive heart failure (due to a prolonged dysrhythmia), or signs of infection (pneumonia). Laboratory tests should ALWAYS include a blood glucose check to exclude hypoglycemia in any child with abnormal mental status.
Differential diagnoses may include: Hypoglycemia Sepsis Hyperthyroidism Volume depletion Catastrophic illness, e.g., CNS, GI trauma (abuse) Metabolic disease
Manage ABCs. Get baseline ECG. Obtain vascular access. For SVT (see AHA algorithm): Vagal maneuvers for stable SVT Adenosine: 100 mcg/kg bolus, increase to 200 mcg/kg (maximum first dose is 6 mg, maximum second and subsequent doses 12 mg) – given for stable SVT if unresponsive to vagal maneuvers or for unstable SVT if IV access is immediately available. Cardioversion for unstable SVT (poor perfusion) Procainamide or amiodarone to be considered if possible of ventricular origin; that is QRS >0.08 sec Digoxin to slow rate if cardioversion unsuccessful Cardiology consultation
This slide shows the PALS algorithm for tachycardia (sinus tachycardia, SVT, and ventricular tachycardia) with POOR PERFUSION.
Management is driven by presence or absence of poor perfusion. Sinus tachycardia is not an arrhythmia but its etiology must be determined. Provide ventilation and oxygenation for all patients in cardiopulmonary arrest, as the primary etiology is often respiratory failure.
Patients such as this should be transported to a pediatric referral center after stabilization. Transport issues include: ALS transport with monitoring and IV access Treatment plan for possible en route for recurrence – including potential for cardioversion Consult the accepting pediatric cardiologist
Documentation considerations include: Always try to get baseline 12-lead ECG before and after cardioversion. Treatment record from prehospital and ED care Emergency Medical Treatment and Active Labor Act (EMTALA) compliance Risk management considerations include: Always check blood glucose. Assure rapid triage of infants in distress. Do not hesitate to cardiovert when child is unstable.
Four H’s: Hypoxemia Hypovolemia Hypothermia Hyper/Hypokalemia and metabolic disorders Four T’s: Tamponade (cardiac) Tension pneumothorax Toxins/poisons/drugs Thromboembolism
ECG reveals SVT. Infant receives BMV ventilation. Preparations made to cardiovert but rapid IV access is obtained. Adenosine 100 mcg/kg IV push is given followed by normal saline bolus (flush). Return of sinus rhythm. BMV is discontinued as infant’s condition stabilized. 100% oxygen nonrebreather mask is placed. Return of sinus rhythm. ECG does not show early repolarization (e.g., WPW).
2-year-old girl passed out eating cereal; awoke after 5 minutes. She was stiff with eyes rolled back for approximately 5 minutes. Minimal period of sleepiness, now awake and alert; no retractions; skin color is normal
The PAT is as follows: A: Appearance: Normal B: Work of Breathing: Normal C: Circulation to the Skin: Normal ABCDEs: Normal. Vital signs include: Heart rate: 120 bpm Respiratory rate: 24 breaths/min Blood pressure: 80/60 mm Hg Temperature: 37.7°C Weight: 12 kg Oxygen saturation: 99% Focused history: Three similar episodes; two associated with “temper tantrums.” PMH: Negative FH: Negative for sudden death
Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
The patient presents with syncope and normal appearance on exam. She is in no distress and the exam is normal. Her history, however, is concerning and ominous. What are your initial management priorities?
Syncope in young children is a serious symptom. Life-threatening causes must be eliminated. A differential diagnosis is critical: Seizure Cardiac Breath-holding spell
Clinical features include: Loss of consciousness Lasted only a few minutes Minimal or no postictal state No stigmata of seizure: Urinary incontinence, bitten tongue, witnessed tonic-clonic activity.
Radiology studies may include: Chest radiograph offers little. CT or MRI may be indicated if seizures are considered. Laboratory studies often are normal, but if patient has abnormal mental status or concerning history, may include: Electrolytes CBC with differential Ca++, Mg++, PO 4
Obtain an ECG as this will assist the physician in determining potential life threatening cardiac causes of syncope. In this case the ECG shows prolonged QT. This shows a markedly prolonged QT interval (corrected QTc interval is 0.75 seconds [750 ms]) with T-wave alternans. Courtesy of Dr. Bob Hickey.
Ten percent present with seizures. Fifteen percent of patients with prolonged QTc die during their first episode of arrhythmia and 30% of these deaths occur during the first year of life.
Also consider in differential: Hypertrophic cardiomyopathy Formerly called IHSS (idiopathic hypertrophic subaortic stenosis) Syncope with exercise At risk for sudden death Positive family history Non-specific murmur ECG can show non-specific findings. CXR is non-diagnostic. Echocardiogram is diagnostic. Chronic cardiomyopathy Chronic CHF Dysrhythmias
Cardiac arrhythmias should be considered in all patients presenting with brief, nonspecific changes in level of consciousness: Fainting, syncope, seizures, breath-holding, apparent life-threatening events
Family history may be positive for sudden, unexplained deaths prior to 55, fainting episodes, or unexplained accidents. Episodes associated with exercise are particularly concerning. No further exercise until cleared by a cardiologist.
Review the above flowchart with the students. On this slide, “vasopressor” = epinephrine Epinephrine 0.01 mg/kg (0.1 mL/kg 1:10,000) IV or IO 0.1 mg/kg (0.1 mL/kg 1:1000) tracheal tube Anti-arrhythmic includes amiodarone, lidocaine and magnesium. Reversible causes include the 4 H’s (hypoxemia, hypovolemia, hypothermia, Hyper-/hypokalemia) and the 4 T’s (tamponade, tension pneumothorax, toxins, thromboembolism).
This patient has prolonged QT syndrome. She is at risk for fatal dysrhythmia (ventricular tachycardia or ventricular fibrillation). She needs to be admitted/transferred to a pediatric cardiology center for cardiology evaluation.
This child is hospitalized. She is monitored and confirmed to be at risk for dangerous dysrhythmia. She is discharged on medications shown to decrease her risk of ventricular tachycardia/ventricular fibrillation (e.g., ß blockers). She is a candidate to receive an AICD (automatic implantable cardiac defibrillator) when she gets older.
A 6-month-old boy present with chicken pox lesions that began 3 days ago. The lesions are spreading and there are more scabs today. Fever since yesterday, higher today. Today, his skin appears to be red. He is fussy and not feeding well.
The PAT is as follows: A: Appearance: Normal/Abnormal – he is fussy, which may be an early sign of shock or CNS condition. B: Work of Breathing: Normal. C: Circulation to the Skin: Normal. Vital signs include: Heart rate: 160 bpm – tachycardia is seen in many conditions, but there is concern in a patient with infection that it could be a sign of shock Respiratory rate: 40 breaths/min – without retractions, may indicate metabolic acidosis Blood pressure: 79/56 mm Hg – blood pressure is normal, so this is not decompensated shock Temperature: 39°C Weight: 8.1 kg Oxygen saturation: 98% on room air
A: Patent without evidence of obstruction B: Normal C: Generalized red erythroderma, warm, tachycardic (febrile) D: Nonfocal exam, irritable E: Many impetiginous scabs, pustules and vesicles; some with surrounding cellulitis
Head/Neck: No abnormalities except for skin Heart: Tachycardic, no murmurs heard Lungs: Clear breath sounds Abdomen: Normal except for skin Neuro: Alert, subdued, no meningismus Skin: Many vesicles, scabs, pustules; some with surrounding cellulitis. Generalized warm erythroderma. Capillary refill 2 seconds.
Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest
Compensated shock Tachycardia and mild change in appearance (fussy) Possible septic shock as varicella lesions with signs of secondary infection ( Staph aureus , group A strep) Erythroderma: Scarlet fever versus toxic shock What are your initial management priorities?
Provide supplemental oxygen. Obtain vascular access. Determine rapid glucose. Begin fluid resuscitation at 20 mL/kg – 160 mL normal saline. CBC, blood culture, other optional labs IV antibiotics Repeated assessment for signs of shock Also important to continue assessment to determine if scarlet fever or toxic shock For toxic shock: IV fluid infusion Start infusion of dopamine. Consider dobutamine infusion.
Shock is inadequate tissue perfusion (delivery of oxygen and nutrients) to meet the metabolic demands of the body. Types of shock include: Hypovolemic Cardiogenic Distributive Septic
Compensated: Vital organs continue to be perfused by compensatory mechanisms. Blood pressure is normal. Decompensated: Compensatory mechanisms are overwhelmed and inadequate - hypotension, high mortality risk. Aggressive treatment of early shock: Halts progression to decompensated shock
Inappropriate vasodilation with a maldistribution of blood flow: Anaphylactic shock, spinal cord injury, septic shock “ Warm shock” Resuscitation: Vasoconstrictors (e.g., epinephrine) Anaphylaxis treatment Spinal cord injury treatment Sepsis treatment
Elements of distributive shock and cardiogenic shock: Inappropriate vasodilation with a maldistribution of blood flow Myocardial depression Resuscitation: Fluid bolus Pressors and inotropes Antibiotics (expect possible deterioration initially due to toxin release)
Labs drawn IV fluids given with decrease in heart rate to 120 bpm IV antibiotics given Patient admitted and discharged 4 days later Option for prolonged observation in ED monitoring for deterioration in vital signs and clinical status. Benign observation period suggests scarlet fever. Worsening suggests possible toxic shock. Toxic shock: Similar to septic shock requiring fluids, pressors, inotropes, ICU monitoring
Early recognition and treatment of compensated shock may prevent progression to decompensated shock. Identifying early compensated shock is difficult. Decompensated shock has a poor prognosis.
Overall, parents of patients with underlying cardiac disease should receive information about their child’s disease, treatment, and how to reach primary care (PCP) and specialty physicians. Ideally parents of children with cardiac disease should carry an updated emergency information form (EIF) when seeking emergency care. This form provides immediate pertinent medical information. A medical ID bracelet is also useful. Available from ACEP and AAP. The EIF should be updated by the patient’s primary care physician and specialists.
Obtain rapid history and assess children in shock or respiratory distress for cardiac disease including postsurgical complications. Utilize the EIF to gather information, contact specialists, and guide therapy. Echocardiography and cardiology consultation for definitive diagnosis and cardiac function determination.