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Paediatrics: Cardiovascular system difficulty - therapy - 1
Initial therapy includes the following.
Cardiovascular system difficulty: therapy - 1
Shock
Initial therapy includes the following.
- Oxygen: provide supplemental oxygen, FiO2100%. Intubate if required.
- Position: in shock, elevate the legs to improve venous return. In congestive heart failure elevate the head.
- IV access: central access may be required, particularly when using inotropes.
- Temperature: control fever with antipyretics (paracetamol 15mg/kg).
- Metabolic state: correct hypoglycaemia and hypocalcaemia. Acidosis of respiratory cause should be controlled with ventilation.
Fluid volumes for shock
- Hypovolaemia: IV 20mL/kg of normal saline. In severe volume, depletion gives 40–60mL/kg of normal saline, with additional increments of 10mL/kg to restore volume if small heart size on CXR, and CVP <5–10mmHg.
- Stop resuscitation with volume:
when clinical improvement is achieved;
when clinical signs of improvement fail to appear;
if there are signs of volume overload: hepatosplenomegaly, JVP distension, gallop rhythm, wheeze and crackles.
Inotropes for shock
- Start inotropes:
when circulation remains unsatisfactory and CXR shows large heart, pulmonary vascular congestion, pulmonary oedema, or pleural effusion;
when CVP >10–15mmHg; once initiated, titrate dose upward to produce the effect required.
- Hypotension with tachycardia:
dopamine—1–20microgram/kg/min (start at 5microgram/kg/min).
dobutamine—2–20microgram/kg/min (start at 5microgram/kg/min). Can use peripheral IV.
Dysrhythmias
Sinus bradycardia and heart block
- Do not treat if haemodynamically stable (i.e. BP and perfusion).
- Consider other treatable causes of bradycardia, such as raised ICP, acidosis, or hypercapnia.
- Atropine: 0.02mg/kg IV (min 0.1mg; max 1mg).
Intensive care treatments for shock
Hypotension with normal or low HR
- Adrenaline: 0.05–1microgram/kg/min (start at 0.05–0.10 microgram/kg/min)
- Noradrenaline: 0.05–1microgram/kg/min (start at 0.05–0.10microgram/kg/min)
- Amrinone: load 0.75mg/kg IV over 3min, then give 5–10microgram/kg/min
Hypotension refractory to volume and single inotrope
- Seek intensive care advice as these patients will usually need intubation and ventilation, and steroids
- Combinations of inotropes are used in this instance
- Afterload reduction may be required with sodium nitroprusside: 0.5–7micrograms/kg/min (start 0.5microgram/kg/min)
Diuresis for volume overload
- Start diuretics: after circulation is restored expected urine volume is1mL/kg/hr
- If oliguria or anuria use furosemide 0.5–1mg/kg IV or mannitol 0.5–1g/kg IV
Tachydysrhythmia—SVT
Treatment will require consultation with a cardiac specialist. If haemodynamically stable, consider the following:
- Vagal manoeuvres: ice bag to face for 15–20s or unilateral carotid massage or Valsalva manoeuvre. Do not compress orbits.
- Adenosine: 50–100micrograms/kg initially, as rapid IV push.
- DC shock: synchronized countershock 1J/kg should be reserved for the haemodynamically unstable. Intubation and appropriate analgesia and sedation are required.
- Other drugs: amiodarone, procainamide, flecainide.
Ventricular tachycardia
If haemodynamically stable and pulse, consider the following after advice from the cardiac specialist:
- If pulse present: amiodarone 5mg/kg; synchronized shock.
- Pulseless.