Hypoxic spells

Prakul Chanthong MD
Division of Cardiology Department of Pediatrics Faculty of Medicine, Siriraj Hospital

Tips and Tricks in Pediatric Emergency

Case 1
A 1 year old child came with severe cyanosis with respiratory distress with breathing at 40/min this morning. His mother noted these symptoms for 2 months. He was diagnosed Tetralogy of Fallot since 6 months of age.

Tips and Tricks in Pediatric Emergency

Case 1
Physical examination showed: T 37 C, HR = 150/min, RR = 40/min, BP 80/50 mmHg. Oxygen saturation = 60% GA: Irritability, severe cyanosis, dyspnea CVS: Normal S1 and single S2 No murmur
Tips and Tricks in Pediatric Emergency

Case 1
Physical examination showed: Chest: Normal breath sound without adventitious sound Abdomen: liver 1 cm below right costal margin Other exam was unremarkable

Tips and Tricks in Pediatric Emergency

Questions
What is the most likely diagnosis? What are the appropriate management? Can we prevent these symptoms?

Tips and Tricks in Pediatric Emergency

Hypoxic spells
Paroxysmal hypoxemic spells Hypercyanotic spells Tetralogy spells Paroxysmal dyspnea

Tips and Tricks in Pediatric Emergency

Signs and symptoms

Increase cyanosis Increase rate and depth of respiration systolic murmur
Softer Disappear

Hypotension

Tips and Tricks in Pediatric Emergency

Initial Presentation
Episode of loss of consciousness Convulsion Episode of going pale of floppy Deeply cyanosis then loss of consciousness or sleep Rapid deep respiration or hyperpnea High pitch abnormal cry
Tips and Tricks in Pediatric Emergency

Hypoxic spells
Common seen - infants and young children Usually self-limited Less than 15-30 min. in length Occur in the infant mild to moderate desaturation

Tips and Tricks in Pediatric Emergency

Hypoxic spells
More common and severe Cyanotic CHD with iron def. anemia Spontaneous improvement 18-24 months

Tips and Tricks in Pediatric Emergency

Hypoxic spells
Occur spontaneously More frequently
In the morning After feeding

Tips and Tricks in Pediatric Emergency

Hypoxic spells
May be precipitated by
Crying Defecation Exercise Sudden fright Injury Hot weather
Tips and Tricks in Pediatric Emergency

Hypoxic spells
Cardiac conditions PA flow depends on the ratio of pulmonary-systemic resistance Decrease SVR
Increase right to left shunt Decrease aortic saturation

Tips and Tricks in Pediatric Emergency

Hypoxic spells
Tetralogy of Fallot Pulmonary atresia/ VSD Transposition of great arteries Tricuspid atresia Eisenmenger syndrome

Tips and Tricks in Pediatric Emergency

Tips and Tricks in Pediatric Emergency

Tips and Tricks in Pediatric Emergency

Mechanisms
Infundibular spasm Decreased SVR Tachycardia Hyperpnea

Tips and Tricks in Pediatric Emergency

Sympathetic NS or circulating catecholamine Infundibular spasm Pulmonary blood flow right to left shunt hypoxia Systemic vasodilatation
Tips and Tricks in Pediatric Emergency

Oxygen saturation

Poor delivery of oxygen to tissue

Metabolic acidosis Hyperventilation

Tips and Tricks in Pediatric Emergency

Tips and Tricks in Pediatric Emergency

Mechanisms
Infundibular spasm Decreased SVR Tachycardia Hyperpnea

Tips and Tricks in Pediatric Emergency

Differential diagnosis
Breath holding spells Seizure CNS disorder Colic

Tips and Tricks in Pediatric Emergency

Treatment
Decrease RVOT obstruction Increase SVR

Tips and Tricks in Pediatric Emergency

Treatment
Knee-chest position
Increase PVR in lower extremities

Oxygen IV line

Tips and Tricks in Pediatric Emergency

Treatment
Medication
Morphine
0.1 mg/kg IM, IV or SC

Ketamine
0.5-1 mg/kg

Tips and Tricks in Pediatric Emergency

Treatment
NaHCO3 Beta blocker
Propranolol Esmolol

Volume expansion Peripheral vasoconstrictor

Phenylephrine
Tips and Tricks in Pediatric Emergency

Treatment
General anesthesia Systemic to pulmonary artery shunt

Tips and Tricks in Pediatric Emergency

Prophylaxis
Propranolol
1-4 mg/kg 3-4 divided doses

Tips and Tricks in Pediatric Emergency

Case 1
A 1 year old child came with severe cyanosis with respiratory distress with breathing at 40/min this morning. His mother noted these symptoms for 2 months. He was diagnosed Tetralogy of Fallot since 6 months of age.

Tips and Tricks in Pediatric Emergency

Case 1
Physical examination showed: T 37 C, HR = 150/min, RR = 40/min, BP 80/50 mmHg. Oxygen saturation = 60% GA: Irritability, severe cyanosis, dyspnea CVS: Normal S1 and single S2 No murmur
Tips and Tricks in Pediatric Emergency

Case 1
Physical examination showed: Chest: Normal breath sound without adventitious sound Abdomen: liver 1 cm below right costal margin Other exam was unremarkable

Tips and Tricks in Pediatric Emergency

Questions
What is the most likely diagnosis? What are the appropriate management? Can we prevent these symptoms?

Tips and Tricks in Pediatric Emergency

Tips and Tricks in Pediatric Emergency

Tips and Tricks in Pediatric Emergency

Tips and Tricks in Pediatric Emergency

Tips and Tricks in Pediatric Emergency