Arrhythmias:
Think IV, O2, monitor, then look at rhythm strip: fast or slow, narrow or wide, regular or irregular, P waves present? Is patient stable?
Fast and unstable gets shocked, Slow and unstable gets paced

Bradycardia: wide is less responsive to meds and block is below AV node, narrow is normally faster and more responsive to Atropine

Sinus(narrow) Brady DDx think “DIE”
Drugs: BB/CCB OD, med SE
Ischemia: RCA supplies SA node, sick sinus syndrome
Electrolyte abnormality: Hyperkalemia causes no response to pacer or meds due to inability to repolarize

Wide, Fast, Regular: VTach, WPW antidromic, SVT with aberrancy
Tx: Amio, Procainamide, synchronized cardioversion

Wide, Fast, Irregular: AFib w/BBB, polymorphic VTach, AFib with WPW, Torsades
Tx: Cardioversion or Block AV node depending on stability, (Torsades gets Magnesium)

Fast, Narrow, Regular: SVT, orthodromic WPW, AFlutter, Narrow complex VTach
Tx: unstable gets cardioverted, stable gets adenosine, dilt, verapamil, or metoprolol depending on rhythm

Nursing Update:
-Broselow tape in the top drawer of the Peds code carts
-2+ SIRS with suspected infection -> within 3hrs needs lactate, blood culuture, broad spectrum ABx, 30cc/kg if lactate >4.
-Monotherapy ABx in sepsis that meet bundle criteria: Ceftriaxone for PNA or urinary (Cefepime if pseudomonas concern), Zosyn, Unasyn. (Just Vanc doesn’t cut it)

(Pediatric emergency medicine playbook is good podcast for Peds EM education)
Peds congenital heart disease (CHD):
Normal baby caloric intake is 100kcal/kg/day, CHD babies can need closer to 150
QTc cutoff in peds 460
Most common CHD in bicuspid aortic valve, most common cyanotic lesion is Tetrology.
CHD is leading cause of death in babies
Risk Factors: prematurity, 1st degree relative with CHD, genetic syndrome, maternal DM, HTN, obesity, thyroid d/o, epilepsy, in-utero infection (TORCH)

Ductal Dependent Lesions:
-Ductus Arteriosus closes around 42wks gestation (~2wks old)
-Left->Right shunting seen around 6-8weeks with sweating with feeds, tachypnea/cardia, FTT
-If reliant on duct for pulmonary flow: severe cyanosis and shock when it closes (critical pulm stenosis or pulm atresia, tetralogy)
-If reliant on duct for systemic flow: tachypnea, cardiogenic shock, lactic acidosis (hypoplastic L heart, critical aortic stenosis)

CHD signs and symptoms: HR >160, ASD causes fixed S2 splitting, extra heart sounds, pathologic murmur, decreased pulses, cyanosis/pallor, sweating with feeds, tachypnic, decreased activity, increased irritability, weight loss/FTT, hepatomegaly

Workup: PE (want BP and pulse ox in all 4 extrem), CXR, EKG, CBC, CMP, iCal, Mg, vbg, consider hyperoxia test to r/o pulm cause (100%, PaO2 should be >150 if pulm path), Echo stat
Tx: Control airway PRN (likely needed), Cyanotic 75-85% is okay (over oxygenating causes vasodilation and that can cause issues and more R-side shunting) (goal is 85% if you don’t know what’s going on), ABx for r/o sepsis, PGE-1 0.05-0.1mcg/kg/min (start high and wean down, titrate to palpable femoral pulses and SpO2 improves. This can cause apnea so make sure to be ready for airway)

CXR findings: Boot-shaped heart in tetrology, Eggs on a string in Transposition (see below)

Tet Spell: AMS, LOC, and death from cyanosis
Tx: knees to chest (increase SVR to push blood to R-side of heart), 100% O2 (vasodilate pulm to push blood to R-side), Morphine .1mg/kg IM or IV (helps relax the kid), 5-10cc/kg NS bolus, phenylephrine.5-5mcg/kg/min (same effect as knees to chest), propranolol (if needed, decrease HR and increase ventricle filling), RSI with ketamine 1-2mg/kg (if needed)

Hypoplastic L Heart Emergency: Needs fluids (clot if dehydrated), heparin (break up and prevent clotting), consider pressors, Call CV-surg ASAP, ECMO

Infective Endocarditis:
Dx with Duke Criteria: diagnostic if 2 major, 1 major and 3 minor, or all 5 minor
-Major criteria: Both BCx’s positive, Endocardial involvement (vegetation, abscess, prosthetic valve dehiscence, new valve regurg)
-Minor criteria: Fever, predisposing heart condition or IVDU, Vascular Phenomena (Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s lesions), Immunologic Phenomena (Glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor), Blood culture + but not meeting major criteria

Growing more common in elderly with increase in valves and stents (higher risk of subacute). L-sided more common since mitral and aortic valve issues more common in older individuals.

Acute decompensated Heart failure is #1 COD (think valve rupture, need CV surg ASAP, can consider nitroprusside or dobutamine in the interim)

Valve Ring Abscess: needs CV surg repair or will recur and destroy heart. Also surgery for recurrent septic emboli or metastatic infection.

Increased risk in first 3months post-surgery because that’s how long endothelialization takes

STEMI Mimics:
Read “Dr Smith’s ECG blog”!!!!!! and OMI manifesto
STEMI mimics: hyperacute T waves, posterior MI, LCMA occlusion, DeWinters, wellens, sgarbossa and smith
Hyperacute T waves: occur early in MI
Posterior MI: look for ST depression in V1-V4
LMCA occlusion: aVR ST elevation predicts left main involvements
DeWinter: hyperacute T wave with broad base and low J-point/ST depression
Sgarbossa: use with BBB or paced rhythm or PVCs
Wellens: biphasic T wave (up and then down), not stemi equivalent, it represents reperfusion T waves, can be spontaneous or after cath. Has poor R wave progression