Pediatric emergency medicine trisk 1708 1708
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important because the infant who is discharged from the nursery with undetected
CHD, is at increased risk for mortality and morbidity.
In the ED, history should focus on age at presentation, feeding patterns, weight
gain, breathing patterns, and color changes. When the patient presents in shock,
cardiac and noncardiac diagnoses must be considered. Cardiac lesions that
present with shock include those dependent on the DA for systemic blood flow
(LV obstructive lesions) or severe ductal dependent right ventricular outflow tract
obstruction (RVOTO). In addition, identifying a genetic syndrome may shed light
on likely cardiac diagnoses ( Table 86.4 ).
Management/Diagnostic Testing of an Infant in Shock, Suspected Ductal
Dependent Lesion. While immediate attention to airway, breathing, circulation,
and high-quality CPR are first steps in the management of a patient in shock,
initiation of prostaglandin (PGE1 ) to re-establish ductal patency is a lifesaving
therapy. The dose of PGE1 is 0.05 to 0.1 µg/kg/min via intravenous (IV) or
intraosseous (IO) line. Side effects of PGE1 include hypotension, apnea, fever,
and rash. Titrate PGE1 until femoral pulses are palpable or oxygen saturations
improve. Effect should be seen within 30 minutes.
Endotracheal intubation and mechanical ventilation decrease the work of
breathing by reducing cardiac demands and guard against apnea caused by PGE1 .
Epinephrine and other drugs for resuscitation should be prepared for
administration during endotracheal intubation, since there is a high likelihood of
cardiac arrest during this procedure. Once the airway is secured, aim to maintain
oxygen saturations at approximately 75%. Over ventilation and hyperoxygenation
may cause systemic blood pressure to drop significantly since oxygen is a potent
pulmonary vasodilator. Pulmonary vasodilation drops the PVR, thereby
increasing shunting of systemic blood flow into the lungs, and thus causing
systemic hypotension. If the blood pressure falls, check for over ventilation or
oxygen saturations above 75% to 85%. If possible, lower saturations to control
PBF and restore systemic BP.
Chest x-ray (CXR) is useful to assess heart size and pulmonary circulation or
pulmonary vascular markings. It also reveals the cardiac silhouette, thoracic and
abdominal situs, and aortic arch sidedness. Cardiac rhythm should be monitored.
EM physicians trained in emergency ultrasound may assess cardiac function.
Electrocardiogram (EKG) with rhythm strip is the gold standard for arrhythmia
diagnosis, and may also offer clues in structural heart disease. Refer to Table 86.2
for typical presenting signs and symptoms, CXR, and EKG findings on initial
