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Free MOCA-Peds 2021 eBook and more!

Solomon Behar, MD and Ameer Mody, MD
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Check out Hippo Education’s brand new, easily searchable, free eBook detailing all of the 45 MOCA-Peds learning objectives to help you confidently pass your 2021 MOCA-Peds.  The MOCA-Peds 2021 eBook is available to anyone with a paid or free Peds RAP account.  So sign in or sign up for an account today. To access the eBook, simply click on the “Download eBook” button on the banner at the top of the Peds RAP webpage, www.pedsrap.com/episode. And be sure to tell your friends! To celebrate this release, we’re re-releasing a segment from 2020 on CHF in Kids, which is one of the MOCA-Peds 2021 Objectives. Happy listening!

  • CHF can be divided into 3 categories:
    • Ventricular dysfunction (e.g. myocarditis or cardiomyopathy)
    • Volume overload (e.g. VSD or ASD)
    • Pressure overload (e.g. from severe hypertension or aortic stenosis) 
  • CHF is a layered diagnosis - one has to make the diagnosis of CHF and then figure out the underlying etiology.
  • In infancy, CHF is most commonly associated with myocarditis or structural heart disease.
    • For infants with a large VSD may present from 6 weeks - 2 or 3 months, as the pulmonary vascular resistance drops and the amount of blood flow across the VSD increases causing volume overload.
      • A classic presentation in infancy is poor feeding, fussiness +/- respiratory symptoms 
  • Myocarditis can occur from infancy to adolescents and generally presents in a child with a structurally normal heart.  
  • In older children, CHF may develop from acquired cardiomyopathy or myocarditis.
    • These children have symptoms consistent with congestion and/or volume overload, but often more peripherally than infants.  
      • For example, fatigue/exercise intolerance, GI symptoms, coughing, or wheezing.
      • The exam would show tachycardia and poor peripheral perfusion. 
  • Work up for CHF includes:
    • CXR - assessing for cardiomegaly and pulmonary venous congestion
    • EKGs may not initially be helpful but may be useful to detect underlying etiology
      • Tachycardia will be present in most cases of CHF (e.g. SVT that has been going on for a long time leading to CHF or decreased QRS voltage in myocarditis)
        • Anomalous Left Coronary  Artery from the Pulmonary Artery (ALCAPA)- while extremely rare,  may also have findings of myocardial damage/ischemia on EKG
    • Echocardiogram (ECHO) - required as soon as possible after the diagnosis of CHF
      • ECHO help with etiology and severity
        • Ejection fraction less than 55% and shortening fraction less than 30% are categories used for diagnosis
    • Labs:  CBC (may show anemia and be a sign of high output failure), chemistry panel (assessing for renal perfusion and baseline electrolyte, anticipating the use of a diuretic), troponins (can be elevated in the context of myocarditis and/or ALCAPA) and BNP (has multiple utilities in diagnosis and trending to monitor response to therapy).
      • A normal BNP would either suggest no active CHF or well-controlled CHF
  • Management
    • The first step in management (outside of a patient with shock) is to assess whether the patient has volume overload or a weakened myocardium.  
      • Diuretics will help both types of these patients.
        • In the acute setting, IV furosemide (0.5-1 mg/kg X1) is the generally first line and rapid improvement should be seen.
      • For patients with a weakened myocardium, inotropic medications are used.
        • Milrinone, an afterload reducer and an inotrope, is given as an IV infusion and generally in coordination with a cardiologist.
    • Fluid management should be guided by the degree of CHF that child has; that is, the longer the child has been in CHF, the slower the fluids should be given.
      • For children in rapid decline, fluid restriction makes less of a difference.
      • In patients approaching shock, peripheral perfusion should be considered and evaluated constantly.
        • Additionally, for patients in extremis, trialing noninvasive ventilation can be a huge benefit.
          • BiPAP, for example, allows you to still communicate with the patient if developmentally appropriate, protects evaluation of mental status, eases work of breathing, and actually reduces a little bit of left ventricular return.
            • If a child needs to be intubated, ketamine is a good induction agent as it causes a catecholamine surge (as opposed to a blood pressure drop), and be prepared for the possibility of pulmonary edema.
  • A clinical pearl: pay attention to the liver and toes in a patient with CHF - a liver that does not down tell you the right side of the heart is working well and a warm toe tells you the left side of the heart is working well. 

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