Episode 84 – Congenital Heart Disease Emergencies

This is Congenital Heart Disease Emergencies on EM cases with Gary Joubert and Ashley Strobel. You might be surprised to learn that the prevalence of critical cardiac disease in infants is almost as high as the prevalence of infant sepsis. And if you’re like me, you don’t feel quite as confident managing sick infants with critical heart disease as you do managing sepsis. Critical congenital heart defects are often missed in the ED. For a variety of reasons, there are currently more children with congenital heart disease presenting to the ED than ever before and these numbers will continue to grow in the future. When I was in medical school I vaguely remember learning the complex physiology and long lists of congenital heart diseases, which I’ve now all but forgotten. What we really need to know about congenital heart disease emergencies is what actions to take in the ED when we have a cyanotic or shocky baby in front of us in the resuscitation room. So with the goal of learning a practical approach to congenital heart disease emergencies using the child’s age, colour and few simple tests, Dr. Strobel and Dr. Joubert will discuss some key actions, pearls and pitfalls so that the next time you’re faced with that crashing baby in the resuscitation room, you’ll know exactly what to do. This podcast topic was chosen based on a Canada-wide needs assessment by TREKK – translating emergency knowledge for kids, and after a lengthy search for just the right expert to blow your mind with their knowledge, they found the brilliant Dr. Gary Joubert, pediatric emergency physician and cardiologist. And when I started researching this topic I came across a fantastic review article from the Emergency Medicine Clinics of North America who’s lead author was kind enough to join us for this podcast - Dr. Ashley Strobel. Written Summary and blog post by Keerat Grewal and Anton Helman Aug 2016, background research by Anton Nikouline Cite this podcast as: Helman, A, Joubert, G, Strobel, A. Congenital Heart Disease Emergencies. Emergency Medicine Cases. https://emergencymedicinecases.com/congenital-heart-disease-emergencies-2/. Accessed [date]. General Approach to Congenital Heart Disease Emergencies: Age, Colour & Tests Rather than learning all the complicated details of every congenital heart lesion, this simple approach let's you focus on time-sensitive life-saving treatments and practical management of the child. 1. Age: Less than one month or greater than one month? Any infant < 1 month of age with cyanosis or shock should be considered to have duct-dependent critical congenital cardiac disease until proven otherwise. This is almost always a left heart lesion/ductal dependent lesion such as Tetralogy of Fallot, which almost always benefit from prostaglandins. Shunting or mixing lesions such as VSD or PDA and heart failure typically present later during infancy, usually after 1-6 months of age. 2. Colour: Are they Pink, Grey or Blue? Infants with congenital cardiac conditions usually appear on observation to the clinician in one of three ways: Pink: think heart failure (adequate pulmonary blood flow, relatively well-perfused and oxygenated; usually due to a shunting lesion) Grey: think shock/circulatory collapse (not enough systemic flow, not oxygenating well; usually left-sided obstructive, ductal-dependent lesion). These patients are very sick with hypotension, tachypena and poor capillary refill. They will almost always benefit from fluids and prostaglandins if less than 1 month in age. Blue: think right obstructive duct-dependent in the first month of life or mixing lesion (inadequate pulmonary blood flow: usually right-sided obstructive ductal-dependent lesion or a mixing lesion...