5 Hypoxic Spells

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Tips and Tricks in Pediatric Emergency

Prakul Chanthong MDDivision of CardiologyDepartment of Pediatrics

Faculty of Medicine, Siriraj Hospital

Hypoxic spells


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Case 1

A 1 year old child came with severecyanosis with respiratory distress withbreathing at 40/min this morning. His

mother noted these symptoms for 2months. He was diagnosed Tetralogy of

Fallot since 6 months of age.


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Case 1

Physical examination showed:

T 37 C, HR = 150/min,

RR = 40/min, BP 80/50 mmHg.

Oxygen saturation = 60%

GA: Irritability, severe cyanosis,

dyspnea CVS: Normal S1 and single S2

No murmur


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Case 1


Chest: Normal breath sound withoutadventitious sound

Abdomen: liver 1 cm below right costalmargin

Other exam was unremarkable


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Questions

What is the most likely diagnosis?

What are the appropriate management?

Can we prevent these symptoms?


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Hypoxic spells

Paroxysmal hypoxemic spells Hypercyanotic spells

Tetralogy spells

Paroxysmal dyspnea


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Signs and symptoms

Increase cyanosis

Increase rate and depth of respiration

systolic murmur

Softer

Disappear

Hypotension


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Initial Presentation

Episode of loss of consciousness

Convulsion

Episode of going pale of floppy

Deeply cyanosis then loss ofconsciousness or sleep

Rapid deep respiration or hyperpnea

High pitch abnormal cry


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Hypoxic spells

Common seen - infants and young children

Usually self-limited

Less than 15-30 min. in length

Occur in the infant mild to moderatedesaturation


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Hypoxic spells

More common and severe CyanoticCHD with iron def. anemia

Spontaneous improvement 18-24

months


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Hypoxic spells

Occur spontaneously

More frequently

In the morning

After feeding


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Hypoxic spells

May be precipitated by

Crying

Defecation

Exercise

Sudden fright

Injury Hot weather


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Hypoxic spells

Cardiac conditions PA flow depends onthe ratio of pulmonary-systemic resistance

Decrease SVR

Increase right to left shunt

Decrease aortic saturation


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Hypoxic spells

Tetralogy of Fallot

Pulmonary atresia/ VSD

Transposition of great arteries

Tricuspid atresia

Eisenmenger syndrome


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Mechanisms

Infundibular spasm

Decreased SVR

Tachycardia

Hyperpnea


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Sympathetic NS or circulating

catecholamine

Infundibular spasm

Pulmonary blood flow

right to left shunt

hypoxia

Systemic vasodilatation


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Oxygen saturation

Poor delivery of oxygen to tissue

Metabolic acidosis

Hyperventilation


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Mechanisms

Infundibular spasm

Decreased SVR

Tachycardia

Hyperpnea


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Differential diagnosis

Breath holding spells

Seizure

CNS disorder

Colic


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Treatment

Decrease RVOT obstruction

Increase SVR

T


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Treatment

Knee-chest position

Increase PVR in lower extremities

Oxygen

IV line

T t t


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Treatment

Medication

Morphine

0.1 mg/kg IM, IV or SC

Ketamine 0.5-1 mg/kg

T t t


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Treatment

NaHCO3 Beta blocker

Propranolol

Esmolol

Volume expansion

Peripheral vasoconstrictor Phenylephrine

T t t


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Treatment

General anesthesia

Systemic to pulmonary artery shunt

h l i


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Prophylaxis

Propranolol

1-4 mg/kg

3-4 divided doses

C 1


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Case 1

A 1 year old child came with severecyanosis with respiratory distress withbreathing at 40/min this morning. His

mother noted these symptoms for 2months. He was diagnosed Tetralogy ofFallot since 6 months of age.

Case 1


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Case 1


T 37 C, HR = 150/min,

RR = 40/min, BP 80/50 mmHg.

Oxygen saturation = 60% GA: Irritability, severe cyanosis,

dyspnea CVS: Normal S1 and single S2

No murmur

Case 1


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Case 1


Chest: Normal breath sound withoutadventitious sound

Abdomen: liver 1 cm below right costalmargin

Other exam was unremarkable

Questions


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Questions

What is the most likely diagnosis?

What are the appropriate management?

Can we prevent these symptoms?


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5 Hypoxic Spells

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