Pediatric Congestive Heart Failure

Aka: Pediatric Congestive Heart Failure, Congestive Heart Failure in Children, CHF in Children, Pediatric Cardiogenic Shock, Cardiogenic Shock in Children, Pediatric CHF

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II. Causes: General

  1. See Congenital Heart Disease Causes
  2. Left heart obstructive disease
    1. Hypoplastic Left Heart Syndrome
    2. Aortic Stenosis
    3. Aortic Coarctation
  3. Large shunt with pulmonary overflow
    1. Ventricular Septal Defect
  4. Pump Failure
    1. Myocarditis (e.g. HH6, Enterovirus, Parvovirus, Kawasaki's Disease)
    2. Cardiomyopathy

III. Causes: Age of presentation

  1. Week 1: Hypoplastic Left Heart Syndrome
  2. Week 2: Aortic Coarctation
  3. Week 4-12: Ventricular Septal Defect
  4. After Week 12: Valvular heart disease, Myocarditis

IV. Symptoms

  1. Poor feeding
  2. Diaphoresis with feeding

V. Signs

  1. See Congenital Heart Disease
  2. See Pediatric Murmur
  3. See Pediatric Vital Signs
  4. Biventricular failure is the rule
  5. S3 Heart Sound
  6. Tachypnea and other signs respiratory disease
  7. Tachycardia (out of proportion to condition)
  8. Hepatomegaly
  9. Pallor

VI. Labs

  1. Complete Blood Count (CBC)
  2. Brain Natriuretic Peptide (BNP or ntBNP)
  3. Venous Blood Gas
  4. Serum Lactate
  5. Thyroid Stimulating Hormone (TSH)
  6. Serum Troponin
    1. Increased in Myocarditis
    2. ALCAPA (Left Main Coronary Artery Disorder) can predispose to childhood Acute Coronary Syndrome

VII. Imaging

  1. Chest XRay
    1. Pulmonary Edema
    2. Cardiomegaly
  2. Bedside Echocardiogram
    1. Decreased cardiac contractility
    2. Cardiac Tamponade

VIII. Diagnostics

  1. Electrocardiogram (EKG)

IX. Differential Diagnosis

  1. Neonatal Sepsis or Pediatric Sepsis
  2. Congenital metabolic conditions
  3. Acute Respiratory Distress Syndrome

X. Management

  1. Obtain Pediatric cardiology Consultation early in presentation
    1. Discuss acute stabilization management as high risk of decompensation
    2. Initiate transport to pediatric ICU facility with ECMO capability
  2. General Measures
    1. Elevate head of bed 45 degrees
    2. Monitor Urine Output
      1. Improved Urine Output is a marker of effective Cardiogenic Shock management
    3. Specific evaluation if known cause
      1. See Congenital Heart Disease for General Measures and Complications
    4. Categorize the presentation
      1. Warm and Dry (goal, preserved perfusion without Pulmonary Edema)
      2. Warm and Wet (Preserved perfusion with Pulmonary Edema)
        1. Manageed with Diuretics and noninvasive Positive Pressure Ventilation
      3. Cold and Wet (Cardiogenic Shock with decreased perfusion and Pulmonary Edema)
        1. Requires additional inotropes and Vasopressors
      4. Cold and Dry (Severe Cardiogenic Shock)
        1. Requires Endotracheal Intubation and emergent cardiology evaluation and management
      5. References
        1. Claudius and Strobel (2024) EM:Rap, 9/9/2024
  3. Supplemental Oxygen
    1. High Flow Oxygen indicated in non-Congenital Heart Disease cases
    2. Avoid hyperoxygenation in Congenital Heart Disease (risk of increased Pulmonary Edema)
      1. Adjust FIO2 to achieve Oxygen Saturation >90%
      2. Do not increase FiO2 in hypertrophic left heart
        1. Keep the ductus arteriosus patent
  4. Airway and Respiratory Support
    1. Non-Invasive Positive-pressure ventilation
      1. BiPap is first-line management of CHF
      2. Decreases work of breathing, Tachypnea and negative chest pressures that impede LV function
    2. Endotracheal Intubation
      1. Early intubation for increasing respiratory distress, refractory to NIPPV (e.g. BiPap)
      2. Resolve Hypotension prior to Endotracheal Intubation (see below)
      3. Induction with Etomidate
        1. Avoid Ketamine due to risk of Dysrhythmia and increased Systemic Vascular Resistance
  5. Hypotension
    1. Vasopressors (Norepinephrine, Epinephrine, Dopamine)
      1. Start with small fluid boluses (if flat Jugular Vein or IVC Ultrasound for Volume Status)
      2. Epinephrine is a first line Vasopressor in Hypotension
      3. Vasopressors are contraindicated in ductal dependent systemic Blood Flow (i.e. Aortic Coarctation) as above
    2. Inotrope support (consult pediatric intensivist)
      1. Milrinone (preferred)
      2. Dobutamine (second-line alternative)
  6. Fluid Overload
    1. Furosemide (Lasix) 1-2 mg/kg IV
    2. Exercise caution with Nitroglycerin (discuss first with cardiology)
      1. Many CHD patients are Preload dependent and may have catastrophic drop in Blood Pressure with nitrates
  7. Analgesia and sedation
    1. Sedation with Morphine Sulfate 0.05 to 0.1 mg/kg IV
  8. Fluid maintenance
    1. Fluids to 66% of expected fluid maintenance requirement

XI. References

  1. Herndon (2003) AAFP Board Review, Seattle
  2. Claudius, Behar, Salway and Kearl in Herbert (2018) EM:Rap 18(5): 1-3
  3. Claudius and Kallay in Swadron (2023) EM:Rap 23(2): 6-7

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