Paediatric Intensive Research Articles

Bedside ultrasound in pediatric critical care: A review

Bedside ultrasound, as performed by the intensivist, is gaining in popularity and has become a powerful tool to understand the physiological state of the critically ill patient and to decrease procedural risks. This review assesses clinical applications of bedside ultrasound in the pediatric intensive care unit. A literature review was conducted to identify English language studies in Pubmed as of June, 2010, using combinations of the following search terms: 'pediatric,' 'ultrasound,' 'critical care,' and 'intensive care.' Examination of reference lists of these studies yielded additional studies. Studies were reviewed by both authors. Intensive care unit, emergency department, or operating rooms, as relevant to application of bedside ultrasound in the pediatric intensive care unit. Pediatric patients (age 0-18 yrs) with adult patients (>18 yrs) in relevant studies utilizing bedside ultrasound by the treating clinician. Bedside ultrasound by treating clinician. Variable, per individual studies. MAIN RESULTS/CONCLUSIONS: Bedside ultrasound, as practiced by the pediatric intensivist, has the potential to improve pediatric critical care medicine, but data supporting its use is limited. Further studies are needed to explore applications, with specific emphasis on the training and experience of ultrasound operators. There is a need for a standardized educational curriculum, and questions remain as to the optimal mode of education and quality assurance of ultrasound operators.

Development of a pediatric hospitalist sedation service: Training and implementation

There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There is currently no consensus regarding the training required by non-anesthesiologists to provide safe sedation. We will outline the training method developed at St. Louis Children's Hospital. In 2003, the Division of Pediatric Anesthesia at St. Louis Children's Hospital approached the Division of Pediatric Hospitalist Medicine as a resource to provide pediatric sedation outside of the operating room. Over the last seven years, Pediatric Hospitalist Sedation services have evolved into a three-tiered system of sedation providers. The first tier provides sedation services in the emergency unit (EU) and the Center for After Hours Referral for Emergency Services (CARES). The second tier provides sedation throughout the hospital including the EU, CARES, inpatient units, Ambulatory Procedure Center (APC), and Pediatric Acute Wound Service (PAWS); it also provides night/weekend sedation call for urgent needs. The third tier provides sedation in all of the second-tier locations, as well as utilizing propofol in the APC. This training program has resulted in a successful pediatric hospitalist sedation service. Based on fiscal year 2009 billing data, the division performed 2,471 sedations. We currently have 43 hospitalists providing Tier-One sedation, 18 Tier-Two providers, and six Tier-Three providers. A pediatric hospitalist sedation service with proper training and oversight can successfully augment sedation provided by anesthesiologists.

Influence of In-house Pediatric Intensivist Supervision on Complications of Emergent Intubations

PURPOSE: In adult populations, implementation of in-house, full-time (24 hour/day, 7 day/week) supervision by intensivists is thought to reduce mortality and decrease complication rates. Little is known about the impact of in-house intensivist supervision in children's hospitals. We recently began providing such coverage in our children's hospital, and have evaluated its relationship to patient outcomes. Specifically, we sought to determine the influence of in-house intensivist supervision on the incidence of complications in children requiring emergent intubations.

Variability in usual care mechanical ventilation for pediatric acute lung injury: the potential benefit of a lung protective computer protocol.

Although pediatric intensivists claim to embrace lung protective ventilation for acute lung injury (ALI), ventilator management is variable. We describe ventilator changes clinicians made for children with hypoxemic respiratory failure, and evaluate the potential acceptability of a pediatric ventilation protocol. This was a retrospective cohort study performed in a tertiary care pediatric intensive care unit (PICU). The study period was from January 2000 to July 2007. We included mechanically ventilated children with PaO(2)/FiO(2) (P/F) ratio less than 300. We assessed variability in ventilator management by evaluating actual changes to ventilator settings after an arterial blood gas (ABG). We evaluated the potential acceptability of a pediatric mechanical ventilation protocol we adapted from National Institutes of Health/National Heart, Lung, and Blood Institute (NIH/NHLBI) Acute Respiratory Distress Syndrome (ARDS) Network protocols by comparing actual practice changes in ventilator settings to changes that would have been recommended by the protocol. A total of 2,719 ABGs from 402 patients were associated with 6,017 ventilator settings. Clinicians infrequently decreased FiO(2), even when the PaO(2) was high (>68 mmHg). The protocol would have recommended more positive end expiratory pressure (PEEP) than was used in actual practice 42% of the time in the mid PaO(2) range (55-68 mmHg) and 67% of the time in the low PaO(2) range (<55 mmHg). Clinicians often made no change to either peak inspiratory pressure (PIP) or ventilator rate (VR) when the protocol would have recommended a change, even when the pH was greater than 7.45 with PIP at least 35 cmH(2)O. There may be lost opportunities to minimize potentially injurious ventilator settings for children with ALI. A reproducible pediatric mechanical ventilation protocol could prompt clinicians to make ventilator changes that are consistent with lung protective ventilation.

Demonstration of inferior vena cava compression by probe pressure during subxiphoid echocardiography

We sought to compare the inferior vena cava diameter measured by transthoracic echocardiography and by transesophageal echocardiography in human and animals. Transthoracic echocardiography yielded lower inferior vena cava diameter values than transesophageal echocardiography. Adult and pediatric intensivists should pay attention to the risk of false measurement of the inferior vena cava anterior-posterior diameter that may be due to compression of the inferior vena cava by the sonographic probe when the subxiphoid view is used.

The Role of Neurocritical Care: A Brief Report on the Survey Results of Neurosciences and Critical Care Specialists

Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences. An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training. The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care. Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.

Los cuidados intensivos pediátricos en Latinoamérica

Objective To describe the practice of pediatric intensive care in Latin America and compare it with two European countries. Design Analysis of data presented by member countries of the Sociedad Latinoamericana de Cuidado Intensivo Pediátrico (SLACIP), Spain and Portugal, in the context of a Symposium of Spanish and Portuguese – speaking pediatric intensivists during the Fifth World Congress on Pediatric Intensive Care. Setting Pediatric intensive care units (PICUs). Participants Pediatric intensivists in representation of each member country of the SLACIP, Spain and Portugal. Interventions None. Variables of interest Each country presented its data on child health, medical facilities for children, pediatric intensive care units, pediatric intensivists, certification procedures, equipment, morbidity, mortality, and issues requiring intervention in each participating country. Results Data from 11 countries was analyzed. Nine countries were from Latin America (Argentina, Colombia, Cuba, Chile, Ecuador, Honduras, México, Dominican Republic and Uruguay), and two from Europe (Spain and Portugal). Data from Bolivia and Guatemala were partially considered. Populational, institutional, and operative differences were identified. Mean PICU mortality was 13.29% in Latin America and 5% in the European countries ( P = 0.005). There was an inverse relationship between mortality and availability of pediatric intensive care units, pediatric intensivists, number of beds, and number of pediatric specialty centers. Financial and logistic limitations, as well as deficiencies in support disciplines, severity of diseases, malnutrition, late admissions, and inadequate initial treatments could be important contributors to mortality at least in some of these countries. Conclusion There are important differences in population, morbidity and mortality in critically ill children among the participating countries. Mortality shows an inverse correlation to the availability of pediatric intensive care units, intensive care beds, pediatric intensivists, and pediatric subspecialty centers.

U.S. attitudes and perceived practice for noninvasive ventilation in pediatric acute respiratory failure

Few pediatric studies exist regarding the use of noninvasive positive-pressure ventilation for acute respiratory failure; however, those that do suggest a role. This study seeks to describe attitudes and perceived practices of pediatric intensivists regarding the use of noninvasive positive-pressure ventilation in children with acute respiratory failure. Electronic survey. Medical institutions. Of the 932 physicians approached, 353 (38%) responded to the survey. Respondents included U.S. physicians practicing pediatric critical care (90%), pediatric anesthesia critical care (4%), pediatric pulmonary critical care (4%), and other disciplines (2%). Survey. The survey contained questions regarding 1) practitioner demographics, 2) patient characteristics, and 3) clinical cases designed to assess noninvasive positive-pressure ventilation use in certain patient scenarios. Noninvasive positive-pressure ventilation was used by 99% of the respondents, with 60% using noninvasive positive-pressure ventilation as initial support >10% of the time. Respondents reported use of noninvasive positive-pressure ventilation for acute respiratory failure in lower airway disease (70%), asthma (51%), acute lung injury/acute respiratory distress syndrome (43%), and upper airway obstruction (31%). In clinical scenarios, respondents reported that the factors associated with nonuse of noninvasive positive-pressure ventilation as initial support were disease process (31%), oxygenation (19%), ventilation severity (15%), expectation that the patient was likely to worsen (12%), and age or inability to cooperate (11%). Noninvasive positive-pressure ventilation is widely used and most frequently utilized in patients with acute lower airway disease. Factors such as severe defects in oxygenation and ventilation, disease progression, and patient tolerability decreased the likelihood of use. These findings may help direct further studies of noninvasive positive-pressure ventilation in children with acute respiratory failure.

Variability in the pediatric intensivists' threshold for withdrawal/limitation of life support as perceived by bedside nurses: a multicenter survey study

BackgroundWe hypothesized that bedside nurses perceive significant variability in the pediatric intensivist thresholds for approaching a family about withdrawal/limitation of life-sustaining therapy.MethodsAll nurses working in four university-affiliated medical-surgical pediatric intensive care units staffed by 11, 7, 6, and 5 intensivists with 36, 18, 10, and 8 beds were sent three mailings of a survey asking questions about intensivist decisions for withdrawal/limitation of life-sustaining therapy. Responses were tabulated; chi-square compared results among centers; a p < 0.05 after Bonferroni correction was significant.ResultsThe response rate was 205 of 415 (49%); 152 of 205 (74%) disagreed with the statement that each of the intensivists had the same threshold for approaching a family to suggest withdrawal/limitation of life-sustaining therapy, with no significant difference between centers. Also, 110 of 205 (54%) and 119 of 205 (58%) disagreed with the statement that each intensivist has the same threshold of the patient's chance for survival or projected quality of life when making a decision to withdraw/limit life-sustaining therapy with no significant difference between centers. The threshold to suggest withdraw/limit life-sustaining therapy based on chance of survival or projected quality of life differs between intensivists by at least 10% according to 113 of 184 (61%) and 121 of 184 (66%) nurses; the two larger centers had significantly higher difference among intensivists for projected quality of life. Fifty-five of 200 (27%) disagreed with the statement that they would have equal confidence in each intensivist accepting a recommendation for withdrawal/limitation of life-sustaining therapy for their own child, with no difference between centers.ConclusionsBedside pediatric intensive care unit nurses in this multicenter Canadian study perceive wide variability in intensivist thresholds for approaching a family to suggest withdrawal/limitation of life-sustaining therapy.

Cardiac Intensive Care of the Adult With Congenital Heart Disease: Basic Principles in the Management of Common Problems

Although there has been an intense interest in the care of the adult with congenital heart disease (ACHD), these guidelines are usually not focused on the concepts of immediate postoperative care. The 2 most common perioperative complications are heart failure and atrial dysrhythmias. The broad etiological categories for ACHD and heart failure include primary pump failure (systolic dysfunction) and hypertrophy (diastolic dysfunction) of the right, left, or single ventricle. Some conditions with a pressure-loaded systemic right ventricle as well as patients with a functionally single ventricle may be particularly prone to develop heart failure; in others, right heart failure may occur in patients with Ebstein anomaly or with tetralogy of Fallot after corrective repair but with varying degrees of pulmonary insufficiency, and left heart failure can be a result of mitral or aortic insufficiency. The management of postoperative atrial tachycardia in the ACHD patient actually begins prior to surgery. Assessment of arrhythmia history, complete determination of risk, inducibility and arrhythmia substrate, preoperative planning of pacing sites, and optimal pacing strategies all assist to bring about optimal postoperative outcomes. Ideal perioperative care of the ACHD involves a multidisciplinary team of pediatric and adult cardiologists, pediatric and adult intensivists, cardiac surgeons, and nursing staff along with a myriad of adult subspecialists such as pulmonology, nephrology, endocrinology, and others including psychiatry.

Lean analysis of a pediatric intensive care unit physician group rounding process to identify inefficiencies and opportunities for improvement*

A physician group in a pediatric intensive care unit faced challenges when moving to a larger unit. Challenges included increased time for rounds, nonbillable attending physician hours, poor communication with pediatric intensive care unit staff, and meeting resident physician duty hours and teaching requirements. The purpose of this analysis was to identify waste and opportunities for improvement to improve physician efficiency. Human factor (observational data collection) techniques were used to capture >60 hrs of rounding data. Twelve attending physicians and their rounding teams were shadowed to capture rounds on 130 pediatric intensive care unit patients. Rounding events, times, and patient interactions were recorded. Lean methods and scenario analysis were used to analyze the data and identify opportunities for improvement. Rounding events were categorized to determine value-added and nonvalue-added activities. Value-added activities were subclassified as essential or nonessential to morning rounds. Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation. PATIENTS OR SUBJECTS: Eight attending pediatric intensivists and their physician rounding teams. Eight attending physician-led rounding teams were observed for 12 rounding events and a total of 130 patient contacts. Large variation existed in the rounding process. Nonessential activities was highly correlated with physician preference and created a wide range in rounding time per patient. Essential activities showed the least variation and represents a "lean process." Scenario analysis was used to determine the impact of removing waste and reallocating the nonessential activities outside of rounds. Results of the analysis indicated that rounds could be reduced by 42% and that plan of care completion would be timelier (decreased from a mean of 157 to 82 mins). In a large physician group, essential activities showed the least variation. Practice variation focused on minimizing nonessential activities could have dramatic impacts on standardizing practice. Further study is indicated to determine whether standardizing rounds to focus on essential activities can lead to more effective processes that require fewer resources while improving outcomes for all stakeholders.

Survey of pharmacologic thromboprophylaxis in critically ill children*

There is lack of evidence to guide thromboprophylaxis in the pediatric intensive care unit. We aimed to assess current prescribing practice for pharmacologic thromboprophylaxis in critically ill children. Pediatric intensive care units in the United States and Canada with at least ten beds. Cross-sectional self-administered survey of pediatric intensivists using adolescent, child, and infant scenarios. Pediatric intensive care unit clinical directors or section heads. None. Physician leaders from 97 of 151 (64.2%) pediatric intensive care units or their designees responded to the survey. In mechanically ventilated children, 42.3% of the respondents would usually or always prescribe thromboprophylaxis for the adolescent but only 1.0% would prescribe it for the child and 1.1% for the infant. Considering all pediatric intensive care unit patients, 3.1%, 32.0%, and 44.2% of respondents would never prescribe thromboprophylaxis for the adolescent, child, and infant scenarios, respectively. These findings were significant (p < .001 for the adolescent vs. child and infant; p = .002 for child vs. infant). Other patient factors that increased the likelihood of prescribing prophylaxis to a critically ill child for all three scenarios were the presence of hypercoagulability, prior deep venous thrombosis, or a cavopulmonary anastomosis. Prophylaxis was less likely to be prescribed to patients with major bleeding or an anticipated invasive intervention. Low-molecular-weight heparin was the most commonly prescribed drug. In these scenarios, physician leaders in pediatric intensive care units were more likely to prescribe thromboprophylaxis to adolescents compared with children or infants, but they prescribed it less often in adolescents than is recommended by evidence-based guidelines for adults. The heterogeneity in practice we documented underscores the need for rigorous randomized trials to determine the need for thromboprophylaxis in critically ill adolescents and children.

An update and review of acute kidney injury in pediatrics

To inform the pediatric intensivist of recent advancements in acute kidney injury diagnosis and management. Studies were identified from MEDLINE (OVID), PubMed, and the Cochrane Library for topics relevant to acute kidney injury. We also reviewed bibliographies of relevant studies. DATA EXTRACTION, SYNTHESIS, AND OUTLINE REVIEW: Because of the lack of prospective trials, a majority of information is extracted from observational and retrospective data. The pathophysiology section reviews acute kidney injury mechanisms and highlights data regarding distal injury from experimental acute kidney injury. The epidemiology section focuses on incidence and outcomes of acute kidney injury, highlighting new strategies for diagnosis. The management section cites studies investigating hemodynamic optimization, nutrition, and fluid management, including the indications and impact of continuous renal replacement therapy in fluid overload. There is limited data-driven evidence in pediatrics regarding effective therapy for acute kidney injury, a significant problem in the pediatric intensive care unit extending length of stay, ventilator days, and overall mortality. Sublethal kidney injury may be contributing to overall morbidity. We conclude that prospective clinical trials are needed to evaluate specific diagnostic aids, such as biomarkers, and therapeutic strategies, such as early initiation of continuous renal replacement therapy in children with fluid overload.

The Process of End-of-Life Decision-Making in Pediatrics: A National Survey in the Netherlands

The goal of this study was to investigate how Dutch pediatric specialists reach end-of-life decisions, how they involve parents, and how they address conflicts. We conducted a national cross-sectional survey among pediatric intensivists, oncologists, neurologists, neurosurgeons, and metabolic pediatricians practicing in the 8 Dutch university hospitals. We collected information on respondents' overall opinions and their clinical practice. Of the 185 eligible pediatric specialists, 74% returned the questionnaire. All responding physicians generally discuss an end-of-life decision with colleagues before discussing it with parents. In half of the reported cases, respondents informed parents about the intended decision and asked their permission. In one-quarter of the cases, respondents informed parents without asking for their permission. In the remaining one-quarter of the cases, respondents advised parents and consequently allowed them to have the decisive voice. The chosen approach is highly influenced by type of decision and type and duration of treatment. Conflicts within medical teams arose as a result of uncertainties about prognosis and treatment options. Most conflicts with parents arose because parents had a more positive view of the prognosis or had religious objections to treatment discontinuation. All conflicts were eventually resolved by a combination of strategies. In 66% of all cases, pain and symptom management were intensified before the child's death. Within Dutch pediatrics, end-of-life decisions are team decisions. Pediatric specialists differ considerably in how they involve parents in end-of-life decision-making, ranging from benevolent paternalism to parental autonomy. Main conflict-solving strategies are taking more time and extending discussions.

Teamwork and Program Organization in Developing Countries

Establishment of congenital heart surgery programs in developing countries is often impeded by competition among providers for scarce resources and opportunities. To avoid this problem, the authors have sought to focus program development on a domestic medical team that includes a visiting North American surgeon. A leadership group was formed consisting of a domestic cardiologist and surgeon, the visiting surgeon, and leading local benefactors. Surgery was initiated beginning with closed cases, and the volume and complexity were gradually increased. The team was mentored by the visiting surgeon, and full medical brigades visited periodically. All members of the leadership group interacted with local health care providers, missionary groups, and visiting medical teams from international organizations, aiming to develop a single congenital heart surgery center. Over a period of 3 years, 185 children have been operated on and the team has progressed to do more complex open and closed cases. Overall mortality is 6.5%. Actively working with the program are 3 of the 5 local pediatric cardiologists, 2 of 4 pediatric intensivists, the only pediatric perfusionist, and the only active pediatric heart surgeon. Three additional international organizations currently participate in program development. Fundraising by the domestic nonprofit organization has increased approximately 20-fold in 5 years, and the program has been evaluated and approved by the government-based health insurance program. Focusing program development around a domestic leadership team allows coordination of patient referrals and resources, which contributes to excellent patient care and program sustainability.

A Multicenter Survey of Heparin Prophylaxis Practice in Pediatric Critical Care

Heparin prophylaxis (HP) is commonly used for prevention of central venous catheter (CVC)-related complications among pediatric intensivists, yet efficacy of this therapy is unknown. We conducted a survey of pediatric intensivists and their experiences with HP. A total of 96 responses were received. Almost half of the respondents regularly used HP in patients with CVCs, yet most were unsure of its benefit. The majority of respondents claimed to experience no adverse effects; the complications that were reported to occur were related to bleeding or suspected heparin-induced thrombocytopenia (HIT). Overall, participants felt CVC-associated HP was safe in pediatric critical illness, while acknowledging the paucity of compelling data.

The Ritual: Death Pronouncement

Death pronouncement comes infrequently for the pediatrician. The place of death for most children is in the hospital. For hospitalists and pediatric intensivists in the neonatal intensive care or pediatric intensive care units, death pronouncement is not uncommon. For hospitalist physicians, the call to attend a code or to pronounce a death may come on any given shift and from almost anywhere in the hospital. A demonstrative case is provided, followed by key concepts for practice and for educating trainees.

Effect of pediatric advanced life support course on pediatric residents' intubation success

The Pediatric Advanced Life Support Program (PALS) course very important for teaching about intubation, resuscitation, shock, trauma, respiratory failure and rhythm disturbances. The aim of the present study was to evaluate the effect of the PALS course on pediatric residents' intubation success during their rotation, daytime and night-time practice in the pediatric intensive care unit (PICU). The study was carried out from 1 March 2005 to 28 February 2007. The study period had two parts, in that the number of attempts and successful intubations performed by pediatric residents, and the pediatric intensivist successful intubation ratio were evaluated in two different periods: before the PALS course, 1 March 2005-28 February 2006, and after the PALS course, 5 March 2006-28 February 2007. The participating residents' pediatric levels (PL) were classed as PL-1, PL-2, PL-3, PL-4, and all had first experience in the PICU at the PL-1 level. The PALS instructor was a pediatric emergency or intensive care doctor. We evaluated whether the PALS course influenced intubation success or not. Sixteen residents participated in the study. The proportion of successful intubations was 110 (53.3%) and 104 (65.4%) attempts before and after the PALS course, respectively. The proportion of intubations done by intensivists decreased from 49.1% to 31.7% before and after PALS. The most frequently used endotracheal tube (ETT) internal diameter (ID) was 4.0 mm, and cuffed ETT was used 16% and 21% before and after the course, respectively. Appropriate placing of ETT tip occurred 70.4% and 82.2% of the time before and after the PALS course, respectively. Proportion of successful intubations by residents increased in all levels, except for PL-1. The most important reason for unsuccessful attempts was inappropriate patient position. Only one patient could not be intubated, and laryngeal mask airway was used in that case. During intubation, complications were broken teeth in two patients before the course, and subglottic stenosis developed in only one patient due to cuffed ETT. Successful intubation is a life-saving intervention during resuscitation, ETT revision for extubation or obstruction for extubation or obstruction during mechanical ventilation. This skill can be developed in the PALS course and by clinical study in PICU and pediatric emergency services. The PALS course must be given to pediatric residents especially within the first year. Also, cuffed ETT can be used for infants and children.

Real-time ultrasound guidance for internal jugular vein catheterization in neonates: preliminary experience

Recent studies reported that real-time ultrasound guidance for internal jugular vein catheterization is useful in infants. However, this technique is sometimes difficult even for skilled physicians. The aim of our study is therefore to evaluate the success rate and the complication rate of this technique performed by ultrasound-trained pediatric intensivists in neonates.

Pediatric cardiac emergencies: Children are not small adults

Compared with adults, cardiac emergencies are infrequent in children and clinical presentation is often quite variable. In adults, cardiac emergencies are most commonly related to complications of coronary artery disease; however, in pediatric cases, the coronaries are only rarely the underlying problem. Pediatric cardiac emergencies comprise a range of pathology including but not limited to undiagnosed congenital heart disease in the infant; complications of palliated congenital heart disease in children; arrhythmias related to underlying cardiac pathology in the teenager and acquired heart disease. The emergency room physician and pediatric intensivist will usually be the first and second lines of care for pediatric cardiac emergencies and thus it is imperative that they have knowledge of the diverse presentations of cardiac disease in order to increase the likelihood of delivering early appropriate therapy and referral. The objective of this review is to outline cardiac emergencies in the pediatric population and contrast the presentation with adults.