Cardiac

Question 1

CHF etiology, P

Answer 1

1) congenital heart disease: incr pul flow (VSD, PDA, TGA, truncus arteriosus, TAPVC), obstructive lesion (valve stenosis)
2) acquired: viral myocarditis
Dysrhythmias, severe anemia (cause high OP CHG)
P: tachy, cough, wheezing rales.
CXR: pul edema
hepatomegaly- peripheral edema= systemic venous congestion
tx: cardiac glycosides (digoxin, incr myocardial func= relieve tachy)
inotropes- dop, dobutamine

Question 2

innocent heart murmur

Answer 2

still’s (2-7yo) pulmonic systolic,
venous hum: neck below clavicles, disappear when supine.
acyanotic congenital HD

Question 3

ASD

Answer 3

ostium premium- lower portion of atrial septum, in down. + mitral reg –> CHF
ostium secundum: most common. middle
sinus venosis- high at junction of RA and SVC –> right pul vein drain into RA or SVC instead of LA.
in all, LA –> RA –> incr RA/RV sie –> incr pul flow.
PE: incr right ventircle impulse bc overload, systolic ejection murmur at mid upper L sternal border (ULSB), filed split S2. diastolic rumble LLSB
ECG: RAD, RVH, RAE
CXR: right atrial and ventricular enlargement incr PVM
tx: close by open heart surgery to prevent RHF.

Question 4

ventricular septal defect

Answer 4

classify as inlet, trabecular (muscular), membranous, outlet (supracristal)
lead to pul HTN sep on size of hole and PVR. large hole leads to incr PVR which could remain after surgical closure of VSD-eisenmenger
PE: high pitched holosystolic murmur at LLSB w/wo thrill. diastolic rumble at apex if pul flow is high.
ECG: small- normal or mild LVH. mod- LVH, RVH if pul ht.
cxr: small- normal, mod- cardiomegaly and incr PVM, incr incr PVR then decr PVM

Question 5

patent ductus arteriosis

Answer 5

Blood from aorta to pul A. small-sax, large –>CHF
continuous murmur at ULSB, machine. brisk pulses
ECG: LVH, RVH if pul HTN present
CXR: cardiomegaly with incr PVM

Question 6

aortic stenosis

Answer 6

Congenital- hypoplasia of LV. asx at birth. sx at 12-24hr when ductus arteriosus closes. cause exercise intolerance, chest pain, syncope, sudden death
ejection click, systolic ejection murmur at base with radiation to URSB, apex, suprarenal notch and carotids, thrill at URSB and suprasternal notch
ECG: normal or LVH
CXR: normal or mild cardiomegaly, prominent ascending aorta- poststenotic diatation

Question 7

coarctation of aorta

Answer 7

Worse when PDA closes
narrowing of arch just below left subclavian A or proximal to ductus arteriosus
Elevated BP in right arm, decr in legs until CHF = all low BP. dampen and delayed femoral pulse, bruit left upper back. 50% have bicuspid aortic valve- aortic stenosis - systolic murmur
ECG: normal or LVH
CXR: normal size, rib notching
Tx: PGE given to open ductus arterioles
inotropic med- overcome myocardial epression. dop -max renal perfusion and func. surgery or balloon angioplasty

Question 8

pulmonary stenosis

Answer 8

IF severe but cause R to L shunt through patent foramen ovale- cyanosis.
ejection click, dystonic ejection murmur and ULSB
ECG: RVH
CXR: normal, prominent main pul A
tx: balloon valvulopasty

Question 9

Cyanotic Congenital HD

Answer 9

5T: Tof, transposition of great arteries, tricuspid atresia, trunks arteriosus, total anomalous pulmonary venous cxn,
100% O challenge- suggested when PO2 doesn’t rise despite 100% O2.

Question 10

noncardiac causes of central cyanosis

Answer 10

pulmonary disease, sepsis, hypoglycemia, polycythemia, NMD, impaired chest mV

Question 11

ToF

Answer 11

4: VSD, overriding aorta, pul stenois, RVH
actions that decr SVR (exercise, vasodilation) or incr R through RVOT incr R to L shunt - cyanosis.
blue after PDA closes
tet spells- sudden cyanosis+ decr mumur intensity –> infant cries -> incr R through RVOT –> worsen cyanosis –> alter consciousness and hyperpnea –> squat to incr venous return and incr SVR
PE: systolic ejection murmur of pul stenosis
ECG: RVH
CXR: uptured cardiac apex-boot shaped. decr PVM, right aortic arch (common)
tx: surgery at 4-8mo

Question 12

transposition of great arteries

Answer 12

cyanosis at birth cyanosis better if PFO large or other sites of mixing like ASD or VSD
PE: no murmur, single S2
ECG: normal or RVH
CXR: small heart with narrow mediastinum -egg on a string, incr PVM
Tx: iniital PGE, or emergent ballloon artrial eptostomy (rashkind)- incr size of PFO or ASD
arterial switch operation

Question 13

tricuspid atresia

Answer 13

ASD or PFO always present. whether VSD present determines flow direction and cyanosis
No VSD- ventricular septum intact, pul atresia present. flow through PDA, so when PDA gone- cyanosis
VSD- flow from LV through VSD L to R shunt into pul artery= enough
PE: no murmur and 1 S2 if no VSD. If VSD, systolic murmur.
ECG- LAD (left axis deviation!), RAE, LVH!
CXR: incr PVM, small heart, decr PVM
tx: fontan procedule- IVC to pulmonary A

Question 14

truncus arteriosus

Answer 14

aorta and PA originate from common artery. almost always have VSD. CHF signs
PE: single S2, systolic murmur LSB (sign of insufficient truncal valve), diastolic murmur at apex
ECG: CVH(combined ventricular hypertrophy)
CXR: enlarged heart, incr PVM, right aortic arch (common)

Question 15

total anomalous pulmonary venous connection

Answer 15

PV drain into systemic venous (SVC or inominant vein or RA and portal). mixed blood in all 4 chambers. cyanosis
PE: pul ejection murmur LSB
ECG: RVH, PAE
CXR: enlarge heart in older, unprepared kids with supra cardiac drainage- snowman appearance. incr PVM. if obstructed- small heart + pul edema
tx: reanastomose pV to LA and close PFO/ASD

Question 16

infective endocarditis

Answer 16

most common- strep viridian’s, staph, rarely gram neg or fungal
P: fever, nonspecific HA, wt loss, night sweats
sign: murmur, splenomegaly, hematuria from embolism, splinter hemorrhages in nails, retinal hemorrhages, osler’s nodes, janeway lesion, roth’s spots
Labs: Blood culture!ESR elevated unless polycythemia, rheumatoid factor
transthoracic ECG detects most vegetation but transesophageal is more sensitive
tx: antibiotics IV.

Question 17

pericarditis etio

Answer 17

etio: #1 is viral infection in kids (Cox, echovirus, EBV, para/influenca). purulent pericarditis (bacterial infection)- primary or disseminated from pneumonia - s aureus and strep pneumonia, often have constrictive pericarditis due to intense inflm response. collagen vascular disease, uremia, inflm response to cardiac surgery = postperiocardiotomy sundry-AI

Question 18

pericarditis P, Dx, Tx

Answer 18

P: chest pain intense when supine, relieved when upright. fever,dyspnea, malaise. PE- pericardial friction rub, distant heart sounds, pulses paradoxus (>10mmHg reduction in systolic BP on deep inspiration), hepatomegaly

dx: any kid with dyspnea and fever need r/o. percicardiocentesis, incr ESF. ECG-st change, CXR- enlarge shadow, echo- show extent and quality
tx: antibiotics, antiinflm agents, drainage

Question 19

myocarditis etio

Answer 19

celular infiltrate and myocardial cell death
can cause sudden death in young athletes.
etio: coxsackievirus, bacteria (C diphtheriae, strep, staph, TB), fungi (candida), protzoa ( chagas), Ai (SLE, rheumatic fever, sarcoidosis), kawasaki disease

Question 20

myocardidis P, Dx, Tx

Answer 20

follows flu like or vial illness. dyspnea and malaise. resting tacky, muffled heart sound, hepatomegaly, rales

dx: incr ESR, CRP, viral serology or PCR of endomyocardial bx. echo normal with global ventricular dysfunc
tx: supportive, inotropic agent, diuretics, cardiac transplant, ivig

Question 21

dilated cardiomyopathy

Answer 21

etio: idiopathic, viral, mito, carnitine def, nutritional def, hypocalcemia, chronic trachydysrhythmias, meds
CHF sx
dx: viral serologies, serum carnitine lvl
ECG- sinus tachy, low cardiac voltage, st seg and t wave changes
echo- dilated LV with port ventricular func
tx: CHF management, tx underlying prob, surgical remain of ALCAPA, cardiac transplant

Question 22

hypertrophic cardiomyopathy

Answer 22

no systemic or cardiac disease. asymmetric septal hypertrophy
etio: auto dom in 60%.
path: poor LV filling. LVOT obstruction –> MI
most common cause of sudden death in athletes
sx may be absent until syncope or SD-chest pain, exercise intolerance
PE- harsh systolic ejection murmur at apex - worse with valsalve or standing by decr LV volume.
tx: for sx. ca ch blocker. surgical myomectomy, anti arrhythmic meds, dul chamber pacing

Question 23

Dysrhythmias

Answer 23

most common: SVT, heart block, long QT

Question 24

SVT types

Answer 24

>

250. originate proximal to bifurcation of bundle of his. most common dysrhythmia
     2 types
     1) artrioventricular re-entrant tachycardia (AVRT) - retrograde indication through accessory pkwy
     2) atrioventricular node re-entrant tachy (AVNRT): abn in dif pathway within av node
     wolff-parkinson-white syndrome- anterograde conduct occur through a bypass tract btw A and V. associated with sudden cardiac death

Question 25

SVT P, Dc, tx

Answer 25

P: palpitation, chest pain dysparenea, altered loc. prolonged SVT –> CHF sx in neonate.

dx: ECG- delta wave
tx: vagal maneuver like valsalva, icepack to face, carotid massage, child upside down, orbital pressure. IV adenosine. synchronized cardioversion if hemodynamically unstable. chronic management with digoxin or propranolol. radiofreq catheter ablation to destroy accessory pathway if chronic SVT

Question 26

AV block

Answer 26

congenital 3rd degree associated with SLE mother. associate with bacterial endocarditis
P: fatigue, syncope, sudden death
management- pacemaker

Question 27

long QT

Answer 27

incr risk of lethal ventricular arrhythmias- tornadoes de points
in 50%, auto recessive (jervell-lange-Nielsen syndrome- deafness) or autodom (Romano-ward syndrome- no deafness). or drugs (phenothiazine, TCA, erythromycin), idiopathic
P: ECG,
Tx: beta blocker for sx. cardic pacing, left setllate ganglionectomy, AICD

Question 28

chest pain

Answer 28

most common cause is pericarditis. non cardiac- asthma, esophagitis, costochondritis (tenderness in one or more costochondral J)