Recognizing, Stabilizing, and Managing Children with Heart Failure in the Emergency Department and Other Acute Care Settings

  • Matthew J. O’ConnorEmail author
  • Robert E. Shaddy
  • Robert D. Ross


Heart failure is uncommon in children, but it often initially presents in acute care settings, such as the emergency department. As a result, clinicians need to be aware of its causes and common presenting symptoms, as well as basic principles of stabilization and management. The causes of heart failure in children vary by age, and many symptoms initially attributable to other organ systems may actually indicate heart failure. Here, we review the principles of recognizing, stabilizing, and managing pediatric heart failure in the emergency department.


Heart failure Pediatric Diagnosis Treatment Emergency department 


  1. 1.
    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–327.CrossRefGoogle Scholar
  2. 2.
    Macicek SM, Macias CG, Jefferies JL, Kim JJ, Price JF. Acute heart failure syndromes in the pediatric emergency department. Pediatrics. 2009;124:e898–904.CrossRefGoogle Scholar
  3. 3.
    Kantor PF, Lougheed J, Dancea A, McGillion M, Barbosa N, Chan C, Dillenburg R, Atallah J, Buchholz H, Chant-Gambacort C, Conway J, Gardin L, George K, Greenway S, Human DG, Jeewa A, Price JF, Ross RD, Roche SL, Ryerson L, Soni R, Wilson J, Wong K, Children’s Heart Failure Study Group. Presentation, diagnosis, and medical management of heart failure in children: Canadian Cardiovascular Society guidelines. Can J Cardiol. 2013;29:1535–52.CrossRefGoogle Scholar
  4. 4.
    Kirk R, Dipchand AI, Rosenthal DN, Addonizio L, Burch M, Chrisant M, Dubin A, Everitt M, Gajarski R, Mertens L, Miyamoto S, Morales D, Pahl E, Shaddy R, Towbin J, Weintraub R. The International Society of Heart and Lung Transplantation Guidelines for the management of pediatric heart failure: executive summary. J Heart Lung Transplant. 2014;33:888–909.CrossRefGoogle Scholar
  5. 5.
    Ross RD. The Ross classification for heart failure in children after 25 years: a review and an age-stratified revision. Pediatr Cardiol. 2012;33:1295–300.CrossRefGoogle Scholar
  6. 6.
    Towbin JA, Lowe AM, Colan SD, Sleeper LA, Orav EJ, Clunie S, Messere J, Cox GF, Lurie PR, Hsu D, Canter C, Wilkinson JD, Lipshultz SE. Incidence, causes, and outcomes of dilated cardiomyopathy in children. JAMA. 2006;296:1867–76.CrossRefGoogle Scholar
  7. 7.
    Wilkinson JD, Landy DC, Colan SD, Towbin JA, Sleeper LA, Orav EJ, Cox GF, Canter CE, Hsu DT, Webber SA, Lipshultz SE. The Pediatric Cardiomyopathy Registry and heart failure: key results from the first 15 years. Heart Fail Clin. 2010;6:401–13.CrossRefGoogle Scholar
  8. 8.
    Lipshultz SE, Cochran TR, Briston DA, Brown SR, Sambatakos PJ, Miller TL, Carrillo AA, Corcia L, Sanchez JE, Diamond MB, Freundlich M, Harake D, Gayle T, Harmon WG, Rusconi PG, Sandhu SK, Wilkinson JD. Pediatric cardiomyopathies: causes, epidemiology, clinical course, preventive strategies and therapies. Futur Cardiol. 2013;9:817–48.CrossRefGoogle Scholar
  9. 9.
    Rusconi PG, Harmon W, Wilkinson JD, Lipshultz SE. Heart failure. In: McInerny TK, Adam HM, Campbell DE, DeWitt TG, Foy JM, Kamat DM, editors. American academy of pediatrics textbook of pediatric care. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017. p. 2868–77.Google Scholar
  10. 10.
    Leopold JA. Aldosterone, mineralocorticoid receptor activation, and cardiovascular remodeling. Circulation. 2011;124:e466–8.CrossRefGoogle Scholar
  11. 11.
    Eapen Z, Rogers JG. Strategies to attenuate pathological remodeling in heart failure. Curr Opin Cardiol. 2009;24:223–9.CrossRefGoogle Scholar
  12. 12.
    Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH, Stevenson LW. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41:1797–804.CrossRefGoogle Scholar
  13. 13.
    Ewer AK, Middleton LJ, Furmston AT, Bhoyar A, Daniels JP, Thangaratinam S, Deeks JJ, Khan KS, PulseOx Study Group. Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. Lancet. 2011;378:785–94.CrossRefGoogle Scholar
  14. 14.
    Thangaratinam S, Daniels J, Ewer AK, Zamora J, Khan KS. Accuracy of pulse oximetry in screening for congenital heart disease in asymptomatic newborns: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2007;92:F176–80.CrossRefGoogle Scholar
  15. 15.
    Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SH, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J. 2016;8:16.CrossRefGoogle Scholar
  16. 16.
    Gaspar HA, Morhy SS, Lianza AC, de Carvalho WB, Andrade JL, do Prado RR, Schvartsman C, Delgado AF. Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians. BMC Med Educ. 2014;14:25.CrossRefGoogle Scholar
  17. 17.
    Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23:1225–30.CrossRefGoogle Scholar
  18. 18.
    Harris TH, Gossett JG. Diagnosis and diagnostic modalities in pediatric patients with elevated troponin. Pediatr Cardiol. 2016;37:1469–74.CrossRefGoogle Scholar
  19. 19.
    Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Cardiac troponin T as a screening test for myocarditis in children. Pediatr Emerg Care. 2012;28:1173–8.CrossRefGoogle Scholar
  20. 20.
    Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA. Breathing not properly multinational study investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347:161–7.CrossRefGoogle Scholar
  21. 21.
    Januzzi JL Jr, Camargo CA, Anwaruddin S, Baggish AL, Chen AA, Krauser DG, Tung R, Cameron R, Nagurney JT, Chae CU, Lloyd-Jones DM, Brown DF, Foran-Melanson S, Sluss PM, Lee-Lewandrowski E, Lewandrowski KB. The N-terminal pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol. 2005;95:948–54.CrossRefGoogle Scholar
  22. 22.
    Cantinotti M, Storti S, Crocetti M, Assanta N, Murzi B, Clerico A. Decision levels for plasma B-type natriuretic peptide assay to diagnose significant cardiovascular disease in children. J Am Coll Cardiol. 2010;55:1166–7.CrossRefGoogle Scholar
  23. 23.
    Maher KO, Reed H, Cuadrado A, Simsic J, Mahle WT, Deguzman M, Leong T, Bandyopadhyay S. B-type natriuretic peptide in the emergency diagnosis of critical heart disease in children. Pediatrics. 2008;121:e1484–8.CrossRefGoogle Scholar
  24. 24.
    Weber M, Hamm C. Role of B-type natriuretic peptide (BNP) and NT-proBNP in clinical routine. Heart. 2006;92:843–9.CrossRefGoogle Scholar
  25. 25.
    Sarraf M, Masoumi A, Schrier RW. Cardiorenal syndrome in acute decompensated heart failure. Clin J Am Soc Nephrol. 2009;4:2013–26.CrossRefGoogle Scholar
  26. 26.
    Samsky MD, Patel CB, DeWald TA, Smith AD, Felker GM, Rogers JG, Hernandez AF. Cardiohepatic interactions in heart failure. J Am Coll Cardiol. 2013;61:2397–405.CrossRefGoogle Scholar
  27. 27.
    Yamamoto LG, Young LL. Acute-onset dysrhythmia heralding fulminant myocarditis and refractory cardiac arrest treated with ED cardiopulmonary bypass and extracorporeal membrane oxygenation. Am J Emerg Med. 2007;25:348–52.CrossRefGoogle Scholar
  28. 28.
    Posner JC, Osterhoudt KC, Mollen CJ, Jacobstein CR, Nicolson SC, Gaynor JW. Extracorporeal membrane oxygenation as a resuscitative measure in the pediatric emergency department. Pediatr Emerg Care. 2000;16:413–5.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Matthew J. O’Connor
    • 1
    Email author
  • Robert E. Shaddy
    • 1
  • Robert D. Ross
    • 2
  1. 1.Division of CardiologyThe Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  2. 2.Pediatrics, Division of CardiologyChildren’s Hospital of Michigan and Wayne State University School of MedicineDetroitUSA

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