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Neonatal Cardiology - Part 2

Paul Checchia, MD, Andrew Sloas, DO RDMS FAAEM, and Rob Orman, MD
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No me gusta!

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The ill appearing wee ones in the ED are always a challenge. Are they septic or is it cardiac? Fret not EM:RAP-ers we are here to help with Part 2. 

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Jennifer M. -

I will put this lecture to use during my peds em month. Wish I had it for my previous peds em rotations. In part 2 after PGE, if pt develops hypotension, it was discussed to use epi or dopamine as a push dose pressor. However, in part one, we talked about using milrinone or dobutamine for pts with coarctation who become hypotensive after PGE as epi or levophed can make that kid worse and be potentially life-threatening. Can you please clarify? Thank you!!!!

Hi Jennifer- Here is the response from Andy Sloas....

When you first meet the child with CoArc in extremis their PDA is closing pulling on the CoArc and further obstructing the LVOT. Any addition in afterload could be bad. Milrinone is probably the best choice because you get increased kick from the heart with some peripheral arterial dilation. Once you give the PGE, you not only get the ductus to open, but you also get a systemic arterial dilation. That systemic arterial dilation can be detrimental and lead to hypotension which reflexively increases heart rate and causes pseudo high-output failure. A push dose of epi or phenyl should fix that problem while you find the sweet spot (titrate down) with the milrinone.

Scott W., M.D. -

When you do intubate these infants what vent setting do you use? What if the vents in the ED are only able to provide 100% oxygen?

Jennifer M. -

Thanks Dr. Sloas. So, I would give PGE first even before milrinone, correct? Then, Milrinone and once the PGE starts taking affect, start epi and titrate down the milriinone? Thanks again for your help and thanks for an awesome lecture.

Jennifer-
You are correct with all of the above.
-Rob O

Anthony M. -

Great discussion guys. Very much appreciate the knowledge transfer.

Suggestions for our shop would be appreciated. I've been advocating to add PGE to our formulary. We are 35 miles to tertiary care, small volume full-service ED.

With inclement weather, limited transfer resources etc., it could occasionally be hours before we could get a sick neonate out (although, more commonly it would take approximately one hour to get a neonatal critical care team to the bedside)

Given these factors, how hard should I push to gain access to PGE - knowing of course, like everywhere, I have to pick my battles carefully?

Hi Anthony, here is the response from Andy Sloas....
Great question,

I think you said it best…"With inclement weather, limited transfer resources etc., it could occasionally be hours before we could get a sick neonate out (although, more commonly it would take approximately one hour to get a neonatal critical care team to the bedside)."

Nothing gets an administrators attention like a pediatric resuscitation followed by a lawsuit, I would approach it more gently then I just said it, but I would say it something like that combined with your phraseology above.

It's probably worth the expense of having one dose of PGE available, but I doubt you'd get two sick neonates at the same time to justify more than that.

Let me know if I can be any assistance, I'd be happy to endorse your request to get PGE with your hospital.

- Andy

NL -

Awesome lecture, high yield.

We had a young 5 weeker that presented for the first time on my PICU block with Anomalous Left Coronary Artery From the Pulmonary Artery (ALCAPA) in cardiogenic shock. He mentioned that briefly during the lecture with deep Q waves - out patient did not, however, but had signs of cardiac ischemia - ST depression and T wave inversion. I talked it over with the PICU fellow and this is common occurrence (EKG ischemia findings) and a common presentation of ALCAPA. Cardiogenic shock (eg, dilated CMP) after pulm vascular resistance (PVR) when the PDA closes and afterload decreases. What was also impressive, and importance to realize, is the timing for these cardiac lesions (eg, Coarc presents early, etc)

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