Nelson Club PresentationBy

Dr. Eke Eghosasere Paul15th September, 2014

Outline Introduction

Epidemiology

Aetiology

Pathophysiology

Clinical Features: Signs and Symptoms

Diagnosis

Treatment

Prognosis

Conclusion

References

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IntroductionDEFINITION OF TERMS

Cardiac Output: the amount of blood the heart pumps through the circulatory system in a minute

Stroke Volume: the amount of blood put out by the left ventricle in one contraction

Cardiac Ouput = Stroke Volume X Heart Rate

Preload: the magnitude of the maximal (end-diastolic) ventricular volume or the end-diastolic pressure stretching the ventricles

Afterload: the resistance against which the left ventricle must eject its volume of blood during contraction 3

Introduction Contd.

Heart failure occurs when the heart cannot deliver adequate cardiac output to meet the metabolic needs of the body

In the early stages of heart failure, various compensatory mechanisms are evoked to maintain normal metabolic function

When these mechanisms become ineffective, increasingly severe clinical manifestations result

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Epidemiology Accurately estimating the incidence in children is

problematic

In USA, incidence of heart failure due to congenital defects is between 1-2 per 1000 live births

Cardiomyopathy contributes significantly to pediatric cases that present with heart failure (0.87 per 100,000 in the UK)

Data from Nigeria suggests that 7.02% of emergency paediatric admissions to a tertiary hospital are for cardiac failure

Over 90% of those cases are from lower socio-economic groups

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FETAL

Severe anemia (hemolysis, fetal-maternal transfusion,

parvovirus B19-induced anemia, hypoplastic anemia)

Supraventricular tachycardia

Ventricular tachycardia

Complete heart block

PREMATURE NEONATE

Fluid overload

Patent ductus arteriosus

Ventricular septal defect

Cor pulmonale (bronchopulmonary dysplasia)

Hypertension

FULL-TERM NEONATE

Asphyxial cardiomyopathy

Arteriovenous malformation (vein of Galen, hepatic)

Left-sided obstructive lesions (coarctation of aorta,

hypoplastic left heart syndrome)

Large mixing cardiac defects (single ventricle, truncus

arteriosus)

Viral myocarditis

INFANT-TODDLER

Left-to-right cardiac shunts (ventricular septal defect)

Hemangioma (arteriovenous malformation)

Anomalous left coronary artery

Metabolic cardiomyopathy

Acute hypertension (hemolytic-uremic syndrome)

Supraventricular tachycardia

Kawasaki disease

Viral myocarditis

CHILD-ADOLESCENT

Rheumatic fever

Acute hypertension (glomerulonephritis)

Viral myocarditis

Thyrotoxicosis

Hemochromatosis-hemosiderosis

Cancer therapy (radiation, doxorubicin)

Sickle cell anemia

Endocarditis

Cor pulmonale (cystic fibrosis)

Cardiomyopathy (hypertrophic, dilated)

AETIOLOGY

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Pathophysiology Cardiac output in a normal heart is directly

proportional to preload, inversely proportional to afterload

↑Preload → ↑ Cardiac Output, until a maximum is reached and cardiac output can no longer be augmented (the Frank-Starling principle)

Stretching of myocardial fibres→ ↑ Stroke Volume

↓

↑ Increased wall tension → ↑myocardial O2 consumption

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Left Ventricular End-Diastolic Pressure (mmHg)

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Clinical Features

Right Heart Failure Left Heart Failure

Oedema Dyspnoea (on exertion, at rest, orthopnoea, PND)

Right hypochondrial pain (enlarging liver)

Cough (initially dry, later mucoid,mucopurulent, frothy, blood-stained)

Abdomial distension (liver, ascites)

Anorexia

Fullness after small helpings of food

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Symptoms:

Infants may present with poor feeding/refusal of feeds, FTT, irritability and weak cry, noisy respirations, interccostal and subcostal recessions, flaring of ala nasa

Right Heart Failure Left Heart Failure

Ankle oedema Dyspnoea

Tender hepatomegaly Basal crepititions + rhonchi

Ascites S3 or S4 gallop rhythm

Raised JVP, pulsatile Pulsus alternans

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Signs:

• Tachycardia• Tachypnoea with respiratory distress• Weak peripheral pulses and/or delayed capillary refill• Muffled heart sounds• Murmurs of the original disease• Arrhythmias may be present

DIAGNOSISA. SPECIFIC

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• Chest X-Ray

• Echocardiography

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A. Normal Echocardiograph B. Echocardiograph showing VSD

Other Investigations Full blood count

Serum electrolyte, urea and creatinine

Random blood sugar

ASO titre, CRP

B-Type natriuretic peptide

Urinalysis

Electrocardiograph

Doppler

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Treatment APPROACH CONSIDERATIONS:

Understanding the aetiology

Reducing the preload

Enhancing cardiac contractility

Reducing the afterload

Improving oxygen delivery

Enhancing nutrition

MANAGING TEAM:

Paediatric Cardiologist, Paediatric Surgeon, Nutritionist, Anaesthetist, Welfare Worker,

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TreatmentEMERGENCY MANAGEMENT

ABC, oxygen inhalation

Connect to a cardiac monitor

Secure an IV line

If in shock, intubate and ventilate

Keep fluid input/output chart

Fluid restriction 70% ml/kg/day

If baby is tachypnoeic, consider NG tube feeding

Monitor serum electrolytes frequently (especially potassium)

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General ManagementBed rest, restriction of activities

Diet: salt and water restriction (older children), increased caloric intake, NG tube feeding

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TherapeuticsDIGITALIS: Digoxin

Half the total digitalizing dose is given immediately and the succeeding two one-quarter doses at 12 hrintervals later

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Age (Years) Digitalization (mg/kg/24hr)

Maintenance (mg/kg/24hr)

< 1 month 0.04 — 0.06 0.01

1 month – 2years 0.04 — 0.08 0.01 — 0.02

> 2 years 0.04 — 0.06 0.01

Adult 0.5 — 1.0(mg/24hrs)

0.25 — 0.5(mg/24hrs)

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Prognosis Depends on the underlying cause, stage of

presentation at the hospital, early/accurate diagnosis, speed of instituting correct therapy, socioeconomic factor, availability of specialized treatment centres for surgeries

Follow-up

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Conclusion Heart failure is a common clinical condition in

children which can present at any age

Cases of heart failure should be thoroughly assessed and investigated for underlying cause for appropriate diagnosis/treatment

Management is usually multifaceted involving several departments

Follow up is essential to monitor progress, and ensure proper development of the child

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References Nelson Textbook of Paediatrics, 19th Edition; Heart

Failure

Paediatrics and Child Health in a Tropical Region 2nd

Edition, by Azubuike and Nkanginieme; Heart Failure in Childhood

Medscape Article: Paediatric Congestive Heart Failure

Approach to Paediatric Emergency, by JaydeepChoudhury and Jayanta Bandyopadhyay

A Compendium of Clinical Medicine by A.O. Falaseand O.O. Akinkugbe

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