Cardiovascular Emergency

Normal pediatric HR:

  • Neonate: 150-180
  • Infant: 145-150


Normal pediatric BP:

(In pediatrics, we worry more about hypotension than hypertension)

  • Neonate -> anything below 60 is hypotensive
  • Infant -> anything below 70 is hypotensive
  • 1-9 yo -> Minimum SBP = 70 + (2 x age)
  • > 9 yo -> like “adults”


Presentation of cardiac problems:Cardiovascular emergency 1

  • ↓ feeding
  • ↓ feeding
  • ↓ activity
  • SOB


Normal closure of PDA:

  • Functional: 48 hrs
  • Anatomical: 4-6 wks


Types of cardiac diseases in pediatrics:

  • Congenital
  • Acquired
  • Electrophysiology

Cardiovascular emergency 2

a. Congenital Heart Diseases

1) Cyanotic CHD:

  • (present usually on the 2nd – 3rd week)

Tetralogy of fallot: (right -> left shunt)

  1. RVH
  2. Pulmonary\infundibular stenosis
  3. VSD
  4. Overriding aorta
  • RV outflow obstruction
  • Paroxysmal hyper-cyanotic attacks (tet spells)
  • Auscultation: harsh systolic ejection murmur + thrill {upper sternal border}, single S2
  • CXR: heart = boot, dark lungs bc ↓ pulmonary blood flow
  • Tx: PGE, definitive surgery after 4 mo
Cardiovascular emergency 3
Boot-shaped heart in TOF


Tricuspid atresia: (right -> left shunt)

  • No blood flow from RA to RV -> flows through ASD, PDA, VSD
  • Auscultation: no significant murmur, single S2
  • Tx: PGE, surgery
    • SE of PGE? Hypotension and apnea


Ebstein anomaly:

  • Downward placement of tricuspid valve
  • Auscultation: holocystolic murmur, gallop rhythm
  • ECG: WPW


Transposition of the great arteries: (mixing)

  • Aorta arises from RV, pulmonary A arises from LV -> 2 parallel circuits -> need ASD, VSD, PDA
  • Seen in IODM
  • Auscultation: single S2
  • CXR: heart = egg on string
  • Tx: PGE, definitive arterial switch in the first 2 wks of life
Cardiovascular emergency 4
Egg-shaped heart in TGA


Truncus arteriosus: (mixing)

  • Single arterial trunk + VSD (always)
  • Seen in DiGeorge syndrome
  • Auscultation: systolic murmur, loud single S2


Total anomalous pulmonary venous return: 

  • Usually pulmonary venous returns into the left atrium, if it goes to the right -> mix -> cyanosis
  • CXR: heart = snowman
Cardiovascular emergency 5
Snowman-shaped heath in TAPVR



2) Stenotic CHD:

Pulmonary stenosis: 

  • Obstruction to RV outflow -> RVH
  • Auscultation: ejection systolic murmur + thrill {left 2nd-3rd ICS}
  • Tx: balloon valvulopolasty, surgery


Aortic stenosis: 

  • Mostly caused by bicuspid valve -> obstruction to LV outflow
  • Auscultation: ejection systolic murmur + thrill {right 2nd-3rd ICS}
  • Tx: balloon valvulopolasty, surgery


Coarctation of the aorta:

  • Infantile: preductal
    • Differential cyanosis
    • Tx: PGE, surgery
  • Adult: juxtaductal\just below
    • Seen in Turner syndrome
    • Presentation: lag of femoral pulses, BP of UL > LL
    • CXR: rib-notching
    • Tx: treat HTN, surgery
Cardiovascular emergency 6
Rib-notching in CoA


3) Non-cyanotic CHD:

VSD: (left -> right shunt)

  • Most common congenital heart lesion
  • Large defect -> ↑ pulmonary flow -> ↑ PVR -> medial hypertrophy -> Eisnmenger (when PVR > SVR)
  • Subtypes: small\large, muscular\membranous (more common)
  • Auscultation: pansystolic\holosystolic murmur + thrill {lower left sternal border}
  • CXR: large heart
  • Tx: most small muscular (less membranous) close in the first 1-2 yrs
  • When to operate? FTT, failure of medical correction of HF, infants w\ large defects
  • Complication: HF, pulmonary HTN, endocarditis


ASD: (left -> right shunt)

  • Most commonly ostium secundum defect (region of fossa ovalis)
  • Auscultation: systolic ejection murmur + fixed slit of S2
  • Tx: usually close on their own, but if persists after 5 yrs -> close it surgically before puberty (why? If becomes pregnant -> increases the workload on the heart)


AVSD: (left -> right shunt)

  • Defect in the endocardial cushion -> defective AV valves
  • Seen in Down syndrome


PDA: (left -> right shunt)

  • A duct still being present 1 mo after birth
  • More in girls, preterm, maternal rubella infection
  • Presentation: wide pulse pressure, bounding peripheral pulses
  • Auscultation: continuous machinery murmur
  • Tx: indomethacin (PG inhibitor) (better results w\ preterm), surgical ligation (better results w\ term)


b. Aquired Heart Disease:


  • Organism: Coxsackie B virus
  • Presentation: fever, HF, arrhythmias
  • Dx: biopsy
  • Tx: HF and arrhythmias



  • Same presentation as myocarditis except + distant and muffled HS
  • Organism: GAS (S. agalactiae), staph
  • Tx: underlying cause, pericardiocentesis if effusion
  • ECG:
Cardiovascular emergency 7
ECG changes in pericarditis


Infective endocarditis:

  • Organism: strept viridians, staph aureus
  • High risk pts? On central line, high outflow CHD (VSD, aortic stenosis), cardiac surgery, dental procedure, artificial valve
  • Presentation: prolonged fever, splenomegaly, new murmur, splinter hemorrhage, Osler nodes, Janeway lesions, Roth spots
  • Dx: Duke’s criteria (2 major OR 1 major + 3 minor OR 5 minor)
  • Tx: organism specific for 4-6 wks, HF meds, surgery (interactable failure, abscess, recurrent emboli, increased size of vegetations, worsening regurg)
  • Prophylaxis: amoxicillin to high risk pts
  • Complications: HF from valve lesions (aortic\mitral), emboli (bc of vegetation)

Cardiovascular emergency 8


Acute rheumatic fever:

  • Organism: GAS
  • Associated w\ strept pharyngitis
  • Dx: Jone’s criteria
  • Tx:
    • For GAS eradication: oral penicillin for 10 days (erythromycin if allergic)
    • For the arthritis\carditis: anti-inflammatory (aspirin if no HF, prednisone if w\ HF)
    • Phenobarbital (only if chorea)
  • Prophylaxis: continuous abx (single IM benzathine penicillin G every mo)

Cardiovascular emergency 9



  • Medium vessels vasculitis (mainly coronary)
  • Complications: aneurysm
  • Tx: aspirin (to prevent MI) and immunoglobulin

Cardiovascular emergency 10


c. Arrhythmias:

Sinus tachycardia:

  • Caused by something external, either fever, crying, hypovolemia



  • If more than 1 yr > 180
  • If less than 1 yr > 220
  • ECG: no P wave (very close QRS), constant R-R (means the HR is constant regardless of the environment, bc the origin is in the heart, where in sinus tachycardia, the origin is from outside, so the R-R will change according to the causative agent either fever, crying, hypovolemia)
  • Tx:
    • Stable -> adenosine (first dose = 0.1 mg\kg, max is 6 mg\kg) -> not improving -> adenosine (second dose – 0.2 mg\kg, max is 12 mg\kg) -> not improving -> amiodarone -> not improving -> cardioversion
    • If unstable (↓BP, perfusion, consciousness) -> cardioversion then adenosine

Cardiovascular emergency 11


V tach: (wide complex)

  • Pulse -> amiodarone -> cardioversion
  • No pulse -> CPR -> epinephrine -> DC shock


V fib:

  • CPR -> epinephrine -> DC shock



  • CPR only!


Innocent murmur:

  • Systolic
  • Grade 2\6 or less
  • Intensifies w\ increased cardiac output (exercise\fever)
  • Change in intensity w\ posture or head position
  • No thrill, no heave, no abnormal HS, no radiation, no Sx
  • Types: peripheral pulmonic stenosis, still’s murmur, venous hum, aortic outflow murmur


Download the PDF version: here


  • Dr Alhammad’s clinical notes
  • Kaplan step 2 lecture notes

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