Cardiac 101 for School Nurses DR. MARK MARTINDALE Outline: 1. Normal vs. abnormal cardiac standards 2. School cardiac emergencies 3. What physicians need school nurses to know Normal vs. abnormal cardiac standards
Heart rate Heart rate 70-120 <50 always abnormal >150 always abnormal Regular or regularly irregular rhythm Respiratory sinus arrythmia ***Always confirm manually if abnormal Blood pressure Normal Blood Pressure by Age (mm Hg) Reference: PALS Guidelines, 2015
37-56 <70 Toddler (1-2 y) 86-106 42-63 <70 + (age in years x 2)
Preschooler (3-5 y) 89-112 46-72 <70 + (age in years x 2) School-age (6-9 y) 97-115
57-76 <70 + (age in years x 2) Preadolescent (10-11 y) 102-120 61-80 <90
Adolescent (12-15 y) 110-131 64-83 <90 ***Always confirm manually if abnormal Capillary refill Less than or equal to 3 seconds
Longer can indicate shock, dehydration and decreased peripheral perfusion O2 sat >90% Usually is closer to 100% in children ***If cyanotic should include the nails and lips Auscultation Normal: separate S1, S2 (lub dub) Stills (innocent) murmur 7 key features of an innocent murmur:
1. Sensitive (changes with childs position or with respiration) 2. Short duration (not holosystolic) 3. Single (no associated clicks or gallops_
4. Small (limited to a small area and nonradiating) 5. Soft 6. Sweet (not harsh sounding)
7. Systolic Reference: Bronzetti G, Corzani A. The seven S murmurs: an alliteration about innocent murmurs in cardiac auscultation. Clin Pediatr (Phila). 2010;49(7):713. Auscultation continuedmurmurs School cardiac emergencies Sudden Cardiac Arrest
Incidence/survival rate 3 to 13 years 0.61 cases per 100,000 person-years; 40% survival 14 to 25 years 1.44 cases per 100,000 person-years; 37% survival Often have preceding symptoms- most commonly syncope, dyspnea and/or seizures Most have no known medical problems Studies show actually most commonly occurs in sleep (38%) or at rest (27%). Less commonly during exercise (11%) or after exercise (4%) Sudden Cardiac Arrest Most common causes in children: Primary arrythmia (22%)
Long QT syndrome (see upcoming slide)- SEE UPCOMING SLIDE WPW Brugada syndrome Short QT syndrome Catecholaminergic polymorphic vtach Myocarditis (7-35%) Cardiomyopathy (16-20%) Includes HCM, dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy Congenital heart disease (15%) Tetralogy of fallot, hypoplastic left heart syndrome, transposition of the great arteries, etc.
Other cardiac disease (4-8%) Includes coronary arteritis, anomalous origin of coronary arteries, aortic dissection, pulmonary hypertension, and mitral valve prolapse Unknown (7%) Sudden Cardiac Arrest Long QT
A disorder of myocardial repolarization Most often an inherited condition in children May have no previous symptoms Associated with increased risk of polymorphic vtach AKA torsades de pointes If diagnosed may have defibrillator When in doubt respiratory support and AED! Sudden Cardiac Arrest Commotio cordis
Sudden cardiac death secondary to chest wall impact 75% of cases occur in sports Treatment is standard BLS and ACLS Those who survive should undergo an extensive cardiac evaluation Syncope Differential diagnosis:
Catecholamine induced (Vtach, SVT) WPW Most structural heart diseases
Coronary artery anomalies Heat illnesses Anaphylaxis Vasovagal Hypoglycemic ***All syncope is important and should have a full work-up ***Energy drinks, supplements and stimulants put patients are higher risk NOT syncope Seizures Posterior migraine
Hyperventilation Narcolepsy Atrial Septal Defect This is a congenital condition Birth prevalence of 1-2/1000 live births Most do not cause any symptoms in infancy/childhood and are found upon auscultation of the heart Soft, systolic murmur in LUSB If symptomatic may tachypnea, rales, failure to thrive, hepatomegaly, recurrent respiratory failure or rarely embolic strokes Superventricular
Tachycardia (SVT) Heart rate >100 bpm at rest, can be up to 270 bpm Expect higher with exercise This is the most common arrythmia in kids Often due to a reentrant electrical pathway Symptoms can include palpitations, syncope or near-syncope, lightheadedness, dizziness, diaphoresis, chest pain or shortness of breath Symptoms usually start and stop abruptly Determine if they are hemodynamically stable or not If there is any hypotension, chest pain suggestive of coronary ischemia, shock, and/or decreased
level of consciousness call 911 If stable can try vagal maneuvers SVT continued Pacemakers in Students There is no difference in resuscitation in patients with pacemakers! What to do in cardiac emergencies: Stay calm! Check vitals (temperature, HR, BP, O2 sat, RR)
If vital signs are stable it is very unlikely to result in harm or death Always be prepared for BLS/AED What physicians need school nurses to know Measles Diabetes Most commonly type 1 in kids (insulin requiring) Carbohydrate counting
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