Pediatric Cardiology for the School Nurse

Transcription

1 Pediatric Cardiology for the School Nurse Stewart Mackie, MD Pediatric Cardiologist Assistant Professor of Pediatrics Associate Residency Program Director UMass - Baystate Medical Center Disclosures: I have no financial disclosures. 1

2 Further Disclosures The approach and management styles of many pediatric conditions are not evidence based, therefore different institutions/ schools may have different protocols to evaluate and work up patients with possible cardiac complaints. This is how I would triage/evaluate these type of issues as a pediatric cardiologist, your school may or may not agree.. Objectives Provide outline for routine and emergency cardiac care for school nurses to manage and treat common cardiac complaints Review pathophysiology and concerning clinical findings for hypertrophic cardiomyopathy and other conditions associated with sudden cardiac death Understand the diagnosis and implications of a diagnosis of long QT syndrome and Wolf-Parkinson-White (WPW) syndrome 2

3 Evaluation of Possible Cardiac Issues Starts with a good history: SAMPLE t Symptoms t Allergies t Medications t Past Medical History t Last Oral Intake t Events leading to issue Symptoms in evaluating Chest Pain Character How would you describe the pain? Location Exacerbating Is it worse with inspiration or palpation? Alleviating Radiation Severity/Other Symptoms Have you had recent fever/illness? Doe you have other symptoms? Timing When did it start? When does it occur? How long does it last? 3

4 History Past Medical History t Asthma t Cardiac Disease t Kawasaki Disease t Sickle Cell Disease t Marfan t Turner Syndrome t Ehlers-Danlos t Cardiac Surgery t Thoracic Surgery Family History ESSENTIAL in cardiac evaluation as often family history is positive with inherited cardiac disease May need to call parent to get details QUESTIONS TO ASK: Unexplained fainting, seizure or near drowning in a family member Premature death <50 years old due to heart disease Anyone in family with a heart problem, pacemaker or implanted defibrillator Specific knowledge of certain cardiac conditions (long- QT, other channelopathies like ARVC, CPVT or Brugada Syndrome, HOCM) Modified from American Academy of Pediatrics Prepartication Physical Evaluation Form - practice-support/pages/preparticipation-physical-evaluation- Forms.aspx 4

5 Vitals signs are vital. Exam t Weight, Heart Rate, Blood pressure, Oxygen saturation Exam t General t Neck: Jugular Venous Distension t Resp t Cardiovascular v Evaluate S1 and S2 v Assess for murmurs in multiple positions squatting, standing, lying, and sitting t Abdomen v Evaluate if soft, tender, distended Exam (cont.) t Neuro v Alert to time, place and person if not are they responsive to pain v Focal deficits v PERRL (especially if with syncope/head trauma) v Gait, coordination, speech t Skin v Bruising, rashes, abnormal chest wall shape (i.e. pectus) t Ext v Perfusion, cap refill v Evaluate for Cyanosis, clubbing, edema v Distal pulses 5

6 Vital Signs vary in Pediatrics Infant Toddler School-Age Adolescent Heart Rate Resp Rate Systolic BP Diastolic BP Remember these can be altered if patient is in pain, anxious, or after activity. Also, must use proper technique when obtaining (i.e. appropriate BP cuff size) Luma et al. Hypertension in Children and Adolescents. Am Fam Physician May 1;73(9):

7 From: Downloaded on 5/12/2017. Cardiac Exam Murmurs will usually be systolic if you hear one Murmurs in kids most commonly innocent heart murmurs t Qualities of innocent heart murmur v Vibratory, musical (not harsh) v Increase in lying position v NEVER diastolic v Do NOT increase from squatting to standing v Come and go (pathologic murmurs more likely always present) coursecaseorder=5&courseid=22 7

8 Pathologic Murmurs Typically more harsh in sound Increase from squatting to standing Do not get louder from sitting to laying Diastolic murmurs Some Emergent Cardiac Issues Severe chest pain Cyanosis (sats <94% on RA) Recurrent syncope, not c/ Persistent palpitations w vasovagal syncope Syncope without prodromal symptoms Change in level of consciousness Bradycardia/tachycardia or if HR persistently >180 bpm Shortness of Breath Poor peripheral pulses Diaphoretic Hypotensive Poor perfusion (Cap refill >2 seconds) 8

9 What to do.. Support airway, breathing, circulation Activate EMS and ask for help if available Have AED available Continue to assess student closely with repeat vital signs at least every 5 minutes Contact parent/guardian Notify school administration Urgent Cardiac Issues Moderate chest pain Vasovagal/situational syncope Non-exertional cardiac issues Anxiety Patient should have stable vital signs Family history should be reassuring There should not be red flags 9

10 What to do.. Support airway, breathing, circulation Determine need for EMS Ensure availability of AED Observe student closely with reassessment of vital signs Contact parent/guardian consider transport student to home or medical care Follow-up Less Concerning Cardiac Issues Reproducible chest pain on palpation Dizziness improved with hydration Palpitations with noted normal heart rate and regularity on your exam Fast heart rate in anxious/agitated patient that improves with calming down No red flags on history/physical exam 10

11 What to do.. Support airway, breathing, circulation likely fine Unlikely need for EMS or AED Reassess vital signs Contact parent/guardian to ensure no red flags not previously disclosed Determine need for going home with parent/guardian and seeking medical care Why do we care so much? 11

12 The Common Cardiac Causes of Sudden Death Structural/Functional t Hypertrophic Cardiomyopathy t Coronary artery anomalies t Myocarditis t ARVC (Arrhythmogenic Right Ventricular Cardiomyopathy) t Aortic aneurysm/rupture (i.e. Marfan s) t Mitral Valve Prolapse 12

13 Cardiac Causes of Cardiac Death Electrical Long QT syndrome Wolff-Parkinson White Syndrome Brugada Syndrome CPVT (Catecholaminergic Polymorphic Ventricular Tachycardia) Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes. Maron B et al. Circulation 2007;115:

14 Hypertrophic Cardiomyopathy Thickening of the left ventricle Most commonly, asymmetric septal hypertrophy but may be concentric or localized to a small segment of the septum Microscopically, disarray of hypertrophied myocardial cells and myocardial scarring Approximately 50% are Autosomal Dominant t Other 50% are sporadic Nishimura R A et al. Circulation. 2003;108:e133-e135 Red Flags concerning for HCM Chest pain with exertion, worsening fatigue, exercise tolerance, syncope with exertion, palpitations, dyspnea Family history of HCM, SUED (+ in 30-60% of px) 14

15 Physical Examination Left ventricular lift and systolic thrill on palpation of the apex of the heart Grade 1-3/6 systolic murmur which is crescendo-decrescendo usually best appreciated at MLSB or LLSB +/- systolic regurgitant murmur of mitral insufficiency PRELOAD EFFECTS DEGREE OF MURMUR Increase preload, decrease murmur t Squatting or hand-grip (more systemic venous return) Decrease preload, increase murmur t Standing or Valsalva (decreased systemic venous return) cases.aspx? coursecaseorder=7&courseid=26 15

16 Treatment Beta-blocker/ACE Inhibitor Myectomy ICD No competitive/strenous sports Anomalies Coronary Arteries Left coronary artery arising from the right sinus of valsalva (or right coronary artery) Activity -> decreased LCA flow-> Myocardial ischemia Clinical History: Chest pain with exertion, syncope with exertion, may be asymptomatic Lai et al. Echocardiography in Pediatric and Congenital Heart Disease: From Fetus to Adult. Blackwell Publishing, New Jersey, 2009;

17 Diagnoses/Treatment ECG may show signs of ischemia but often normal Echocardiography to delineate the anatomy Surgical correction depending on LCA course, or if symptomatic Myocarditis Typically a viral infection of the heart believed to be due to a cell-mediated immunologic reaction History usually significant for previous URI and may have significant fatigue, poor weight gain, activity intolerance/dyspnea, and if severe cardiogenic shock Diagnosis mainstay is echocardiography +/- cath for biopsy Treatment is supportive care,? steroids, and if severe without improvement over time possible transplant 17

18 Pericarditis Typically a viral infection History usually significant for previous URI and may have significant fatigue Chest pain often position worse laying down PE: Friction rub Diagnosis: CXR, echocardiography Treatment is NSAID,?colchicine,? drainage 18

19 Long QTc Syndrome Channelopathy that can cause lethal ventricular arrhythmia Autosomal dominant (50% inheritance) t ~60% of families have a positive family history Presentation often syncope or seizure most commonly with activity or emotion t Could present with palpitations. Treatment beta-blockade, ICD If patient with known long QTc, very low threshold for EMS, must have AED available 19

20 Wolff Parkinson White Syndrome Abnormality in conduction system Accessory Pathway Can lead to paroxysmal supraventricular tachycardia or more concerning ventricular arrhythmias Presenting complaints: Syncope, seizures, palpitations PE: Evaluate for SVT (HR typically >180bpm) t Can try vagal maneuvers to resolve t If abnormal heart rate, ensure adequate perfusion, saturation, etc. 20

21 School Resources for Long QT and other lethal arrhythmias A Case A 13 year old girl presents to the school nurse s office with chest pain. The chest pain is midsternal, non-radiating, and rated as 5/10. It is described as a sharp, stabbing pain. Pain is worse with inspiration. She has not had chest pain with activity. She has had previous similar episodes of chest pain. No other symptoms with episode. No recent fever or viral URI symptoms. Mother states family history negative for sudden unexplained death, congenital heart defect, or arrhythmias. 21

22 You classify this as a. Emergent Chest Pain and call EMS b. Urgent Chest Pain and call parents to immediately pick up patient and bring to medical care c. Non-urgent chest pain most likely musculoskeletal in etiology Chest Pain Most chest pain in children and adolescents is NOT caused by cardiac disease Figuring out a way to differentiate cardiac vs non-cardiac chest pain can be difficult History including family history and physical exam can give you a lot of helpful information 22

23 Non-Cardiac Chest Pain Musculoskeletal t Costochondritis Pulmonary t Asthma (most common) t Infectious (PNA, empyema) t Pleurisy t Acute Chest Sickle Cell Disease: An emergency Gastrointestinal t Acid Reflux t Esophageal Spasm Other stuff t Panic Disorder Anxiety Attack t Conversion Disorder Cardiac Chest Pain Causes Structural t Cardiomyopathy t LVOT obstruction v Aortic Stenosis v Subaortic Stenosis v Supravalvular stenosis t Mitral Valve Prolapse Dysrhythmias Inflammatory t Pericarditis t Myocarditis Drugs Coronary Arteries t ALCAPA t ALCARCS t Kawasaki t Transplant related t CAD Other t Aortic aneurysm or dissection t Pulm HTN t Intracardiac Mass 23

24 Structural Causes of Cardiac Chest Pain LVOT obstruction t Exertional chest pain, dizziness, and/or syncope t Fatigue t Harsh ejection murmur with radiation to carotids in AS Cardiomyopathy t Chest pain with exercise intolerance and fatigue Mitral Valve Prolapse t Barlow Syndrome v Pain v Palpitations v Dizziness v Panic Attacks Other Cardiac Related Causes Aortic Dissection t Tearing pain t Radiation to back t Risk Factors? v Marfan v Turner Syndrome v Ehlers-Danlos (IV) v Homocystinuria Dysrhythmia t Re-entry dysrhythmias in Fontan patients Pulmonary HTN t Chest pain with exertion t Syncope Drugs t Cocaine, Meth 24

25 A 14-year-old girl with type 1 diabetes drops suddenly when walking to the door. She had LoC for seconds and was alert upon waking. She had no palpitations, chest pain, or tonic-clonic movements. She had a blood sugar of 35mg/dL when seen in the ED. Is this syncope? Semantics of Syncope Transient loss of consciousness t Transient with rapid onset, short duration, and spontaneous recovery Syncope t T-LOC secondary to GLOBAL CEREBRAL HYPOPERFUSION 25

26 Transient Loss of Consciousness Non-Traumatic Traumatic Syncope Seizure Metabolic Disorder Psychogenic Adapted from: The Task Force for The Diagnosis and Management of Syncope of ESC, (2009) EHJ -Hypoglycemia -Hypoxemia -Hyperventilation with hypocapnia Syncope Neurally-Mediated Syncope Orthostatic Hypotension Reflex Primary Autonomic Vasovagal Failure Situational Secondary Autonomic - micturition, post-exercise, Failure post-prandial, GI stimuation Drug-induced Carotid Sinus Syncope Autonomic Failure Atypical Forms Volume Depletion Cardiac Syncope Arrhythmia Structural Disease -Cardiac valvular disease -hypertrophic cardiomyopathy -cardiac masses -pericardial disease/ tamponade -congenital anomalies of coronary arteries -pulmonary emboli -acute aortic dissection pulmonary hypertension 26

27 A 16 year old girl is running a cross-country race. She finishes the run and is standing when she becomes dizzy and has LoC for approximately 5 seconds. No other prodromal symptoms and no convulsive activity. Her symptoms are most likely secondary to. a. Hypertrophic cardiomyopathy b. Anomalous left coronary artery from the right sinus of valsalva c. Neural Mediated Syncope d. Prolonged QTc leading to Torsades 27

28 Most commonly it is. Neural Mediated Syncope Alterations in Autonomic function by changes in the sympathetic/ parasympathetic pathways NMS (cont.) t Can be due to low heart rate (increased parasympathetic activity) Cardioinhibitory: 12-35% t Can be due to decreased blood pressure (decreased sympathetic response) - Vasodepressor 5-15% t Can be both - Mixed response % v NMS Variants Postural Orthostatic Tachycardia Syndrome 28

29 Diagnosing Neural Mediated Syncope Vasovagal Syncope t Mediated by emotion or by orthostatic stress t Preceded by prodromal symptoms (sweating, pallor, nausea) Situational Syncope t Reflex syncope which occurs in certain circumstances t i.e. post exercise syncope in young Carotid Sinus Syncope t Caused by mechanical manipulation of carotid sinus Postural Orthostatic Tachycardia Syndrome (POTS) Orthostatic intolerance associated with an increase in HR of 30 bpm or more Non-specific complaints common of fatigue, light-headedness, palpitations, nausea, decreased concentration May or may not have syncope Symptoms have been present for >3 months Grubb, B.P. (2008) Circ. 117,

30 Cardiac Causes of Syncope Arrhythmia Structural Disease -Cardiac valvular disease -Hypertrophic cardiomyopathy -Cardiac masses -Pericardial disease/tamponade -Congenital anomalies of coronary arteries Acute Aortic Dissection (not common in pediatrics) Pulmonary Hypertension Syncope Red Flags Syncope with exertion No prodromal symptoms prior to syncope Poor perfusion upon nurse evaluation Abnormal vital signs Altered mental status and/or focal deficits on neurologic exam Palpitations with syncope or irregular heart rate noted on nurse evaluation Past Medical History of previous cardiac issues 30

31 What to do.. Support airway, breathing, circulation Activate EMS and ask for help if available Have AED available Continue to assess student closely with repeat vital signs at least every 5 minutes Contact parent/guardian Notify school administration Supraventricular Tachycardia Fast heart rate secondary to an origin above the ventricle that is not the normal pacemaker Heart rate usually >180 bpm 31

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33 History: Quick onset, offset. Heart rate persistently the same. May have chest discomfort, dizziness. Syncope unusual. PE: Vitals. Check perfusion, mental status, etc. Management: t Try vagal maneuvers these reset pacemaker. v Bearing down, blowing through a straw, cold water/ ice on face t If persistent, poor perfusion, or with other symptoms - call EMS. Long-term Management t May be controlled on oral medication (betablocker such as propranolol) or ablated t Medication decreases rate and ideally will stop episodes of SVT t If SVT infrequent, may not be on medication and not have ablation. 33

34 SVT Pill in pocket method t These patient may have pill in pocket method v Try vagal maneuvers, not successful take propranolol, retry vagal maneuvers 15 minutes later v If with continued SVT for >20 minutes or if with any concerns of hemodynamic compromise call EMS ->ED Summary History is very important t Including details of event, family history, and past medical history Vital signs are Vital t These vary by age Chest pain and syncope aren t usually going to be cardiac t But need to think about them 34

35 Summary (cont) If concerned ensure you get help, assess ABCs (CPR if necessary), and have AED If with underlying cardiac issues, low threshold for EMS Come up with protocols for these issues at your institution ahead of time We made it! 35

36 References 1. American Academy of Pediatrics. Prepartication Physical Evaluation Form. Obtained from: Preparticipation-Physical-Evaluation-Forms.aspx 2. Lai et al. Echocardiography in Pediatric and Congenital Heart Disease: From Fetus to Adult. Blackwell Publishing, New Jersey, 2009; Luma et al. Hypertension in Children and Adolescents. Am Fam Physician May 1;73(9): Maron et al. Profile and frequency of sudden death in 1463 young competitive athletes:analysis of 1866 deaths in the United States. Circulation. 2009;119(8) Maron B, Thompson P, Ackerman M et al. Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes:2007 Update. A Scientific Statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007; 115: Park, Myung. The Pediatric Cardiology Handbook, 3 rd Ed. Elsevier Publishing, Pennsylvania;