Meet the Consultants Pediatric Cardiology Pediatric Cardiology Section

Meet the Consultants: Pediatric Cardiology

Pediatric Cardiology Section 2

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Pediatric Cardiology Section • Pediatric Cardiology Service Staff • 1 fellow • 1 attending • Other services • Cath/EP: 1 Cath fellow • ACHD: service fellow +/- ACHD fellow 4

Service Flow • Service • PCICU rounds • NICU, PICU, ED general Pediatric Cardiology consults (home call) • ACHD patients • Cardiac Cath/EP • Cath Fellow • Echocardiography • Echo lab tech Monday – Friday 8 AM – 4: 30 PM 5

Service Flow • Expectations • Hear back: • Soon as possible if urgent consult • After echocardiogram • EPIC notes • End of the day 6

Basic Principles Cardiology consult • Have clear consult question or problem you need help with • Know about your patient when you call • Tell your patient you are consulting us or that an echocardiogram was ordered 7

• Cardiac patient • Original Anatomy • Repaired vs. Palliated • Residuals • Last cardiology follow up • Baseline status, sp. O 2 • Current meds 8

Consult questions • ED • • Arrhythmias Chest pain Syncope Known cardiac disease presenting with an intercurrent “noncardiac” illness • Transcatheter Pulmonary valve • Murmur • Abnormal ECG 9

• A 14 -year-old adolescent presents to the emergency department after an episode of syncope. The syncope occurred during lunch when she stood up from the table. She reports that, just before standing, her heart felt like it was “fluttering in [her] chest” and she felt nauseated. She then passed out and hit her arm on the table, but was otherwise unharmed. She awoke after a few seconds. No seizure activity was noted. • Of note, she reports a 5 -day history of decreased exercise tolerance and some shortness of breath with exercise that was out of proportion to her prior experience and recalls that she had a 3 day history of fever and muscle aches about a week before the current presentation. • Physical examination reveals a respiratory rate of 42 breaths/min with clear lungs, heart rate of 136 beats/min without gallop, slightly decreased (1+) distal pulses, and a normal liver span. 10

• A 14 -year-old adolescent presents to the emergency department after an episode of syncope. The syncope occurred during lunch when she stood up from the table. She reports that, just before standing, her heart felt like it was “fluttering in [her] chest” and she felt nauseated. She then passed out and hit her arm on the table, but was otherwise unharmed. She awoke after a few seconds. No seizure activity was noted. • Of note, she reports a 5 -day history of decreased exercise tolerance and some shortness of breath with exercise that was out of proportion to her prior experience and recalls that she had a 3 day history of fever and muscle aches about a week before the current presentation. • Physical examination reveals a respiratory rate of 42 breaths/min with clear lungs, heart rate of 136 beats/min without gallop, slightly decreased (1+) distal pulses, and a normal liver span. 11

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• Positive family history: • cardiomyopathy or relatives who died suddenly before the age of 50 years. • Exercise intolerance • Exertional chest pain/syncope • History of Kawasaki disease • Cardiac surgery or heart transplant • Systemic arteriopathy (Williams syndrome) • Severe familial hypercholesterolemia • Drug use: cocaine, sympathomimetics • Association with palpitations • Fever • Positional chest pain (pericarditis) if + predisposing factors: Rheumatologic conditions, Malignancy, Mediastinal radiation, Infection (HIV, tuberculosis, viral) , Renal failure, Recent cardiac surgery • Fever / Viral prodrome • Personal or family history of bicuspid aortic valve or connective tissue disorders (Marfan, Loey-Dietz, Ehlers. Danlos type IV, others) • Acute onset sharp or tearing type of pain 13

15 year old female teenager with Tetralogy of Fallot s/p repair with trans-annular patch, developed right ventricular enlargement and underwent Melody valve placement 3 years ago, presenting in the ED with fever and chills. - Obtain blood culture x 2!, CBC, CRP, Sed Rate - Make cardiology aware 14

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15 year old female teenager with Tetralogy of Fallot s/p repair with trans-annular patch, developed right ventricular enlargement and underwent Melody valve placement 3 years ago, presenting in the ED with fever and chills. - Obtain blood culture x 2!, CBC, CRP, Sed Rate - Make cardiology aware 16

Consult questions • Neonatal • Follow-up Evaluations of Fetal Diagnoses • Mom’s chart: Dr. Karnik, Dr. Ferdman • • Cyanosis Pulmonary hypertension Murmur Abnormal ECG/Telemetry 17

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Consult questions • Inpatient • • Kawasaki Function check Endocarditis concern Abnormal ECG/Tele FTT BRUE work up Murmur 19

Curbside Question List • What doesn’t require a formal consult? • ECG non urgent questions • Function check pre-chemo patients • Pulmonary hypertension screen with normal echocardiogram to determine follow up 20

Pulmonary Hypertension

Clinical change: First PHTN screen at 36 weeks CGA IVS flat or RVH or TR Jet >25 m/sec but < or = ½ Systemic BP Completely Normal initial screening echo F/up in 6 months or at 1 year of age which ever comes first 6 months after initial echo on diuretics or O 2 Yes Echo 6 months after initial echo No Echo 1 year when 1 year old Increase in O 2 requirement Increase in diuretic requirement Prior to tracheostomy Decline in growth velocity IVS flat & TR jet > ½ systemic F/up in 3 months of clinically improving and stable Cath if clinically worsening & weight > 2 Kg Treat if clinically worsening and weight < 2 Kg Echo irrespective of guidelines

Consult Example • ED/Floor • • • PMH HPI VS Interventions so far and prelim results Question for us 23

Consult example • NICU • Maternal history • If there was a fetal echocardiogram or followed by MFM • VS • 4 ext BP • ECG • Pre/post ductal sp. O 2 • Murmur assessment • Discharge planning 24

Consult List for Outpatient • Murmur • Concern Cardiac Family history • ? Non-cardiac chest pain • ? Vaso-vagal syncope 25

Dont’s • “We just want an echo” • Consult the day of discharge • Hypertension Nephrology • Hyperlipidemia Endocrine 26

Take home points • Best way to reach us: service fellow on Amion • Best time to reach us: • If urgent: ANY TIME! • If likely patient will need an echo: early text. • Congenital Heart disease • Fetus to Adult • Remember your red flags 27

Questions? 28

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