Cardiac Abnormalities Flashcards
How can you grade murmurs?
Grading works on loudness
- Just audible with a quiet child in the room
- Quiet but easily audible
- Loud but no thrill
- Loud with thrill
- Audible even if stethoscope only just makes contact
- Audible without a stethoscope
When is it normal to hear murmurs?
Very common to hear completely innocent early systolic murmurs in children at some time usually due to fever, anxiety and exercise.
Venous hums Due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles
Still’s murmur Low-pitched sound heard at the lower left sternal edge
What features are suggestive of an innocent murmur?
Features associated with innocent murmurs:
• Grade ≤ 2
• Softer intensity when patient sitting compared with supine
• Short systolic (not holosystolic or diastolic)
• Minimal radiation
• Musical or vibratory quality
Describe the common pediatric causes of Ejection systolic murmur Pansystolic Late systolic Continuous murmur No murmur with cyanosis
Ejection Systolic – ASD or TOF Pansystolic – VSD Late Systolic – COA Continuous murmur – PDA No murmur – TGA
What is Eisenmenger’s syndrome?
Reversal of left to right shunt to right to left shunt due to increasing pulmonary resistance or failing left heart. Cyanosis will only be present if there is a right to left shunt. This occurs in: TGA, ToF, tricuspid or pulmonary atresia, total anomalous pulmonary venous return, hypoplastic left heart and truncus arteriosus
What are the risk factors for congenital cardiac abnormalities
Family History
Diabetes
Monochorionic twins
Down’s syndrome
When do congenital cardiac abnormalities usually present?
Some conditions present early (hours to days): hypoplastic left heart, transposition of the great arteries and shunt dependant circulations. Ventricular septal defect by about a month.
Some present during adulthood: atrial septal defect, and coarctation of the aorta
What are the usual clinical features of congenital cardiac abnormalities?
Decompensation and heart failure of which hepatomegaly is an important sign Cyanosis (only right to left shunt) Poor feeding Dyspnoea Tachycardia (bradycardia or inappropriately normal rate suggests immediate arrest) Cool peripheries Sweating Acidosis Pulmonary venous congestion on CXR Clubbing Thrills Breathlessness which is worse on exertion e.g. feeding
How should a child with suspected cardiac abnormality be investigated?
FBC CXR Blood gas O2 sats ECG Echocardiogram Cardiac catheter/advanced imaging
How should heart failure in a child be managed?
Sit upright and give oxygen
Calories via NG tube
Diuretics (furosemide +/- spironolactone) to reduce pre-load
Captopril – ACEi to reduce afterload
Increase contractility using Digoxin
If duct dependant and cyanotic need to maintain patency – alprostadil
What are ventricular septal defects and how do they progress?
Defect in the ventricular septum. In an otherwise normal heart this results in flow of blood from the left ventricle through the right ventricle and into the pulmonary artery. This presents at about 4-6 months after the pulmonary resistance decreases. The excess blood in the pulmonary vasculature causes pulmonary hypertension and oedema and the reduction in systemic blood flow will cause the heart to have to work harder. Eisenmenger’s syndrome can occur.
What are the risk factors for ventricular septal defects?
Rubella Drugs, tobacco and alcohol during pregnancy Diabetes and Lupus Obesity Mother with PKU
Describe how a child with a ventricular septal defect usually presents?
Usually mild and has a pansystolic murmur Poor eating and failure to thrive Tachypnoea on exertion Fatigability Tachycardia
How should a suspected ventricular septal defect be investigated?
Echo
ECG will show right heart strain
CXR will show pulmonary engorgement and cardiomegaly.
How are ventricular septal defects managed?
Treat Heart failure
Cardiac catheterisation and repair
Small or muscular defects close independently over time, but larger ones will need surgery.
What are atrial septal defects and how do they progress?
Defect in the atrial septum. These present late as the pressure difference between the two atria is slight and so overloading of the right ventricle occurs slowly. Eventually they will present with right ventricular hypertrophy which causes pulmonary hypertension and right heart failure. There is also an increased risk of stroke. Seriousness depends on its location i.e. it can be secundum (most common), primum or an AVSD. ASD is fairly common in trisomy 21. Eisenmenger’s syndrome can occur.
