40/41 - Pediatric cardiology Flashcards by Karlo Sison

Normal Fetal Circulation

PLACENTA

PLACENTA
provides Oxygen + Nutrients to fetal blood via:
UMBILICAL VEIN

How well did you know this?

Not at all

Perfectly

Normal Fetal Circulation

DUCTUS VENOSUS

Ductus Venosus

Allos umbilical venous blood to

*BYPASS LIVER** –> IVC
inferior vena cava –> right atrium*

How well did you know this?

Not at all

Perfectly

Normal Fetal Circulation

FORAMEN OVALE

Foramen Ovale

Allows blood from the right atrium
VVV
to pass into the Left Atrium

How well did you know this?

Not at all

Perfectly

Normal Fetal Circulation

DUCTUS ARTERIOSUS

Ductus Arteriosus

connect Pulmonary Artery** to the **Descending Aorta
VVV
allowing the blood to
BYPASS THE LUNGS

How well did you know this?

Not at all

Perfectly

Normal Fetal Circulation

Fetal difference in CARDIAC OUTPUT?

BP = CO x SVR

CO = STROKE VOLUME** x **HEART RATE

Fetus has a
LIMITED ability to Increase Stroke Volume
So….
CO is MORE Sensitive to HEART RATE

How well did you know this?

Not at all

Perfectly

Normal Fetal Circulation

Fetal Difference in PVR
Pulmonary Vascular Resistance

Adults:
Systemic Vascular Resistance = Pulmonary Blood Flow > PVR

Fetus:
PVR > Systemic/Pulmonary Blood flow
VVVV
↓PVR before BIRTH due to ↑# pulmonary veins
VVV
SWITCHES AROUND
Systemic/Pulmonary Blood flow > PVR

How well did you know this?

Not at all

Perfectly

CV Changes AFTER birth

What causes the:
CLOSURE OF THE FORAMEN OVALE?

Closure of foramen ovale:
RA –> LA

Due to the:
DECREASE** in **Right Atrium Pressure

How well did you know this?

Not at all

Perfectly

CV Changes AFTER birth

What causes the:
CLOSURE of DUCTUS ARTERIOSUS

Ductus Arteriosus:
Pulmonary Artery –> Descending Aorta
Bypass lungs

Constriction due to:
↑pO₂ and ↓Prostaglandin 2 (PGE2)

How well did you know this?

Not at all

Perfectly

Neonatal Cardiovascular Parameters

Neonatal HR / BP

Heart Rate:
140 - 160 bpm

BP:
70 / 50

Cardiac Output:
Neonates have a decreased cardiac reserve
cardiac fxn is CLOSE to PEAK performance @all times

How well did you know this?

Not at all

Perfectly

Congenital Heart Defects

Different Classifications

L>R Shunts
PDA / VSD / ASD

R>L Shunts
hypoplastic left heart syndrome = “ductal dependent” lesions

OBSTRUCTIVE LESIONS
Mild-moderate obstruction = stenosis
complete obstruction = atresia
ex. coarctation of the aorta

REGUGITANT LESIONS
due to an incompetent valve ex. mitral valve

How well did you know this?

Not at all

Perfectly

Congenital Heart Defects

LEFT to RIGHT Shunts

Examples / Consequence

PDA** / **VSD** / **ASD
Patent ductus arteriousus / ventricularseptal defect / artrial septal defect

Allows for:
OXYGENATED BLOOD –> RE-circulate through LUNGS
ACYONOTIC
↓CO, since blood is SHUNTED off to lungs

↓Renal Fxn / ↓Systemic Perfusion / Pulmonary Edema
can lead to right heart failure

How well did you know this?

Not at all

Perfectly

PDA = Patent Ductus Arteriosus

Etiology / Pathophysiology

PDA = Left -> Right Shunt

*Premature Infant** - 20% > Term infant
*Birth weight < 1000g** = 80%

Patho:
Blood flows from:
Aorta –> PDA –> Pulmonary Artery
directrion of flow determined by:
SVR** & **PVR
↑ blood in pulmonary circuit
↑ workload on the heart

How well did you know this?

Not at all

Perfectly

PDA = Patent Ductus Arteriosus

Diagnosis / Confirmation

PDA = L>R Shunt

Clinical Features:
Cardiac MURMUR
HYPERactive PREcordium = heart beat out of chest
Bounding Pulses + WIDE pulse pressure
TachyCardia + TachyPnea

ECHOCARDIAGRAM
used to CONFIRM –> size of PDA
Degree+Direction of shunt

How well did you know this?

Not at all

Perfectly

PDA = Patent Ductus Arteriosus

TREATMENT OPTIONS

Symptom Management:
Fluid Restriction** + **Diuretics
↓ intravascular volume -> ↓ workload of the heart
↓pulmonary edema

*PROSTAGLANDIN INHIBITORS**
*Indomethacin =** Ibuprofen

Surgical Closure
LIGATION

How well did you know this?

Not at all

Perfectly

Indomethacin** = **Ibuprofen

Class / MoA / ADR

↓PGE2 –> natural closure of Ductus Arteriosus
PRASTOGLANDIN INHIBITORS
↓PGE2 –> drug-induced closure of PDA

Indomethacin - 3 doses q12-24 hrs
Ibuprofen - 3 doses q24 hrs

ADRs:

*RENAL: dysfunction, ↑BUN/SCr,** oliguria, (indo)-hypoNatremia
*GI**:bleeding, (indo) - alterned mesenteric blood flow
*HEMATOLOGIC: bleeding, ↓platelet fxn**

How well did you know this?

Not at all

Perfectly

Indomethacin = Ibuprofen
treatment for PDA

CONTRAINDICATIONS

ADRs are
RENAL / GI / HEMATOLOGIC

Active Bleeding

THROMBOCYTOPENIA
for kids <50k platelets

*Renal Impairment**
*SCr > 1.5**

Ductal-Dependent Congenital Heart Defect

Congenital Heart Defects

RIGHT to LEFT Shunts

Examples / Consequence

*“Ductal Dependent” Lesions**
*HypoPlastic Left Heart Syndrome** + Transposition of Great Arteries
*Ttralogy of Fallot** + Coarctation of Aorta

Allows for:

UNoxygenated Blood* CIRCULATES to the body
*CYONOTIC**

PDA has to STAY OPEN so that BLOOD can reach the body

TREATMENT

“Ductal Dependent” Lesions
HypoPlastic Left Heart Syndrome + Transposition of Great Arteries
Tetralogy of Fallot + Coarctation of Aorta

*ALPROSTADIL**
*Prostaglandin E₁**

Used to temporarily maintain Patency of DA
until SURGERY can be performed

MoA:
relaxation of smooth muscle of ductus arteriosis –> vasodilation

Admin:
continuous IV infusion

ALPROSTADIL
Prostaglandin E1

Use / ADR / Monitoring

“Ductal Dependent” Lesions = R>L Shunts
HypoPlastic Left Heart Syndrome + Transposition of Great Arteries
Tetralogy of Fallot + Coarctation of Aorta

Vasodilation: ADRs”
Apnea / Flushing
HypoTension / Fever

Monitoring:
O2 saturation, blood gas, blood pressure, respiratory rate, temperature, HR

Hypertension Classifications

Children > 13yo

Diagnosis needs to be confirmed by:
3 seperate readings taken >1 week apart

same as ADULTS, stage them depending on HIGHEST classification

Normal BP
<120 / <80

Elevated BP
120-129 / <80

Stage 1 HTN
130-139 / 80-89

Stage 2 HTN
> 140 / 90

Hypertension Classifications

Children < 13yo

Diagnosis needs to be confirmed by:
3 seperate readings taken >1 week apart

Need AGE** + **GENDER** + **HEIGHT

Normal BP
<90^th %

Elevated BP
>90^th%<95^th%

Stage 1 HTN
>95^th% BUT <95^th% + 12mmhg

Stage 2 HTN
_>_95^th% + 12mmhg

When to BP Screen for Pediatrics

ANNUAL BP Screening
for ALL children 3- 17 y/o

@Every “Health Care Encounter” for 3yo+ for:
OBESE / Diabetes / RENAL disease
Coarctation of the aorta/arch abstruction
MEDICATIONS that ↑BP

MEDICATIONS that ↑BP
Requires 3yo+ to get BP SCREENED @EVERY health care encounter
Also:
Obese / Diabetes / RENAL disease
Coarctation of he aorta/arch abstruction
annual if NOT

Prescription Drugs

*OCPs** / STIMULANTS
*CorticoSteroids / TCAs**

OTC
DECONGESTANTS / Caffeine / Herbal

Recreational
Amphetamines / Cocaine / Steroids

Treatment of Ped. HTN

ELEVATED BP

Classification / Recommendation

ELEVATED BP
BP >90^th% <95^th% or 120-129 / <80 (13+)

LIFESTYLE MODS
VV
Recheck in 6 Months
VV
BP Meds if presence of:
LVH / CKD / DM / Cardiac Failure

**_Treatment of Ped. HTN_** **STAGE 1 HTN** Classification / Recommendation

STAGE 1 HTN **BP \>95^th%** BUT **\<95^th% +12mmhg** **_LIFESTYLE MODS_** VV **Recheck in _1-2 Weeks_**, *sooner if Sxs* VV if BP is PERSISTANTLY elevated in 2+ checks: **refer to nephrology / HTN clinic**

**_Treatment of Ped. HTN_** **STAGE 2 HTN** Classification / Recommendation

ELEVATED BP **BP _\>_95^th% + 12mmhg** **_REFER TO NEPHROLOGY**_ / _**HTN clinic_** **_BP Meds_**

**_Indications for Pharmacologic BP Management_**

**_FAILED \>6 mo of Lifestyle Mods_** **_Stage 2 HTN**_ or _**Symptomatic_** BP _\>_95th% + 12mmhg Presence of other comorbidities: **_HYPERlipidemia**_ / _**DM**_ / _**Renal Disease**_ / _**LVH_**

Which Anti-HTN agents are available as **_ORAL-LIQUID_**

Ped. HTN --\> weight based dosing ## Footnote **_FUROSEMIDE_** **_ENALAPRIL_**

_Treatment of Pediatric Hypertension_ **_HYPERTENSIVE EMERGENCY_**

* *_Symptomatic BP + \>99th%-ile_** * LESS COMMON in children vs adults* Usually related to: **Comorbidity = Renal Disease** often manifests as: **_Encephalopathy w/ Seizures_** treat with: **IV meds**

_Treatment of Pediatric Hypertension_ **When would we prefer to use this HTN MED?** **_ACE/ARB_**

**enalapril** available as ORAL LIQUID **_DIABETES**_ or _**Proteinuric RENAL disease_** preferred * **_African American_*** * LESS responsive* * **_Pregnancy_*** * fetal kidney dmg, CONTRAINDICATED*

_Treatment of Pediatric Hypertension_ **When would we prefer to use this HTN MED?** **_Calcium Channel Blockers_**

**_CONCURRENT MIGRAINES_** Also for BETA Blockers ## Footnote * **associated with* * _PERIPHERAL EDEMA_***

_Treatment of Pediatric Hypertension_ **When would we prefer to use this HTN MED?** **_BETA BLOCKERS_**

***_NOT RECOMMENDED for INTIAL TREATMENT_*** initial is: ACE/ARB \> CCB \> Thiazide Diuretics **_MIGRAINES_** also CCBs \> BB first use Want to avoid NON-CARDISELECTIVE if **_ASTHMA:_** ***_CARVEDILOL / PROPRANOLOL_*** * **_INSULIN-DEPENDENT DIABETIC_*** * mask symptoms of hypoglycemia*