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• Response to Molczan Cardiac Anomalies in the Neonate: High Index of Suspicion Important Article
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Dear Editor:

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Response to Molczan Cardiac Anomalies in the Neonate: High Index of Suspicion Important Article 

Kenneth Molczan's article,¹ Cardiac Anomalies in the Neonate: High Index of Suspicion Important, highlights some very pertinent insights into why emergency nurses must be knowledgeable about this patient population. However, there are two points I would like to make about the chosen references and include some additional clinical insights.

Figure 1 describes the fetal circulation. It is necessary to point out that in the fourth row the text indicates that blood returns to the placenta from the descending aorta through the two umbilical veins. The two umbilical arteries actually carry the blood back to the placenta.

The author describes the classification of congenital cardiac anomalies as either acyanotic or cyanotic defects. It is important to note that this classification system is described as inadequate and misleading and is not even supported by the authors in the outdated edition used for this article and has been discouraged with every recent edition of this classic text and others.^2., ^3., ^4. Owing to the complexity of the many defects and the variability of the clinical manifestations, the clinical presentation cannot be clearly defined as either cyanotic or acyanotic, and hemodynamic characteristics should be used to classify these defects. That classification includes four categories with examples of conditions that were mentioned in the article:

It is important that the emergency nurse understands this classification is based on hemodynamics and does not depend upon judging whether a child is cyanotic or not to determine the patient's acuity.

The author also describes treatment for conditions that are ductal-dependent lesions, such as coarctation of the aorta, tetralogy of fallot, and transposition of the great vessels. Along with knowledge about administration of prostaglandin E1 (PGE1), the emergency nurse also must be aware that lower oxygen saturations of 70% to 80% are normal for these patients (mixing defect) and administering high levels of oxygen to raise the oxygen saturation may be detrimental to the child's condition. Higher oxygen saturations could stimulate the ductus arteriosus to close and could lead to cardiovascular collapse. Common consensus is that the saturations should be below 87%, so prudent use of oxygen is necessary. Also, initiating fluids is a first priority over administering PGE1 as the child is at risk for stroke from the polycythemia owing to chronic low oxygen saturations, and increased intravascular volume could offset this risk.

Another important point is that emergency nurses must consider congenital heart defects as the cause for oxygenation/circulation problems in children of all ages. Structural defects may not show up for months or even years, with the child presenting to the emergency department when they can no longer compensate because of increased size and oxygen demands. Also, with the advanced technology and interventions, patients may have problems with internal devices that were inserted to fix the defect but are now too small owing to the child's increasing age and heart size.

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References 

1. Molczan K. Cardiac anomalies in the neonate: high index of suspicion important. J Emerg Nurs. 2006;32:94–97
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2. Hockenberry M. In: Wong's nursing care of infants and children. 7th Ed. St Louis: Mosby; 2003;
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3. Hockenberry M. In: Wong's essentials of pediatric nursing. 7th Ed. St Louis: Mosby; 2005;
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4. Wong D, Perry S, Hockenberry M, Lowdermilk D, Wilson D. In: Wong's maternal child nursing care. 3rd Ed. St Louis: Mosby; 2006;
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