Pediatric emergency medicine trisk 1741 1741
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Initial testing for of CHF includes CXR, EKG, and BNP. Do not ignore mild
cardiomegaly and increased pulmonary vascular markings on CXR. EKG may
show arrhythmia or changes consistent with myocarditis or cardiac ischemia.
BNP aids in differentiating CHF from lung disease and can be trended after
initiation of treatment. Echocardiogram is the definitive test to assess cardiac
function but emergency ultrasound is increasingly used in pediatric EM to screen
for abnormal left ventricular systolic function. Additional evaluation is case
dependent and geared toward suspected etiologies (i.e., CBC, thyroid function,
metabolic evaluation, etc.).
Management. The priority is to restore hemodynamic stability. To initiate proper
therapy heart failure should be categorized ( Fig. 86.12 ). Diuretics are the
mainstay of management of CHF with volume overload. Administration of
diuretics should not be delayed in these patients. Inotropic therapy, such as
dopamine, epinephrine, norepinephrine, milrinone, or dobutamine may be
necessary in patients with poor perfusion. Milrinone therapy may be instituted if
blood pressure is adequate. Dopamine at 5 to 20 μg/kg/min is appropriate in
patients with poor perfusion. Epinephrine and norepinephrine support blood
pressure. Milrinone or dobutamine are used in pulmonary hypertension. Digoxin
has fallen out of favor because of time needed to reach therapeutic levels and
narrow therapeutic window and availability of better drugs now. Afterload
reduction therapy is beneficial in some cases. Patients should be admitted and
monitored in a critical care unit with continuous telemetry. It is very important to
record any arrhythmia that occurs in the ED. Cardiology should be consulted
early.
ACQUIRED HEART DISEASE
Goals of Treatment
The goal of the EM provider is the early recognition of acquired pediatric heart
disease in the setting of vague, nonspecific symptoms. This overview of acquired
heart disease in pediatrics includes cardiomyopathies (hypertrophic, dilated, and
restrictive), myocarditis, pericarditis/tamponade, endocarditis, acute rheumatic
fever (ARF), Kawasaki disease (KD), and cardiac trauma.
