Cardiac disease Flashcards
Paediatric Heart failure aims
Reduce preload: - diuretics (furosemide) or rarely venous dilators (nitroglycerin) Enhance contractility - IV dopamine (alt. digoxin, dobutamine, adrenaline) Reduce afterload - PO ACEi, IV hydralazine, nitroprusside Improving O2 delivery: -beta blockers (carvedilol) Enhance nutrition
If HF thought to be bc of cardiac malformation
If cyanotic: prostaglandin infusion (maintains PDA in duct dependent)
Echo to work out defect
Atrial septal defect
Murmur: ejection systolic heard best and LSE and fixed wide-split second HS
Significant ASD (enough to cause RV dilatation) req. treatment
Secundum ASDs managed by cardiac catheterisation w/ insertion of occlusive device (percutaneous closure)
Partial AVSD managed surgically
Treatment usually undertaken at 3-5y of age
Ventricular septal defect
Murmur: loud pansystolic murmur loudest LSE quiet pulmonary HS II
These will close spontaneously
Demonstrated by disappearance of murmur and normal echo
When present avoid bacterial endocarditis by dental hygiene
Large VSD:
- HF = diuretics +/- captopril
- Additional calories
- surgery at 3-6m:
- prevent permanent damage from pHTN and high blood flow (Eisenmenger)
- manage HF and faltering growth
PDA
Closure to remove lifelong risk of bacterial endocarditis and pulmonary dx
Closed medically using indomethacin or other NSAIDs
Can be closed using coil at 1yr age
Cyanotic dx dependent on PDA (e.g. TGA)
Keep PDA open until corrective surgery performed
start prostaglandin infusion to keep open PDA
Congenital cyanotic heart disease
Ix: O2 sats, ABG, echo, CXR, hyperoxia test
ABCDE
Start prostaglandin infusion (5ng/kg/min) , most infants w/cyanotic dx presenting in first week are duct dependent
Maintaining patency key to survival
Prostaglandin maintain patency
SE: apnoea, jitteriness, seizures, flushing, vasodilation, hypotension
IV broad spec ABx
Tetralogy of Fallot
Initially medical Mx w/surgery at 6mo
Surgery: closing VSD and relieving RV outflow obstruction
Very cyanosed: shunt
Hypercyanotic spells are usually self limiting and followed by period of sleep
Shunt in TOF
Connect tube between subclavian art and pulmonary art or by balloon dilatation of RV outflow tract
Mx of prolonged hypercyanotic spells in TOF
Sedation and pain relief - morphine
IV propranolol (peripheral vasocontrictor, relieving sub-pulmonary muscle obstruction)
IV volume administration
Bicarb to correct acidosis
Muscle paralysis and Artificial ventilation to reduce O2 demand
Transposition of the great arteries
In sick cyanosed neonate improve mixing
Prostaglandin infusion
Balloon atrial septostomy may save life
ALL pts require surgery (arterial switch in neonatal period including coronary attachment)
Balloon atrial septostomy
breaks valve of foramen ovale to causing mixing of blood
Tricuspid atresia
Early palliation to maintain blood to lungs and low pressure
- blalock-taussig shunt (subclav.+pulm. arteries)
- pulmonary banding if breathless
Complete corrective surgeryn not possible in most cases bc only one functioning ventricle
Operations can be performed to connect I/SVC to pulmonary artery
Aortic stenosis in children
regular echo monitoring
balloon valvulotomy if high resting pressure gradient or Sx on exercise
most will need replacement if significant stenosis
Pulmonary stenosis in children
If gradient across pulmonary valve >64mmHg then interene
transcatheter balloon dilatation
Coarctation of the aorta
surgical repair
Hypoplastic LH syndrome
surgery (norwood procedure)
Supraventricular tachycardia
Prompt resortation of sinus rhythm key to improvement
Circ+Resp support:
- correct tissue acidosis
- positive pressure ventilation needed
Vagal stimulation manoeuvres
IV adenosine
If fails: synchronised DC shock
Once sinus restored give maintenance therapy (fleicainide or sotalol)
90% of children will have no further attacks
Children who do relapse treated w/percutaneous radiofrequency ablation of cryoablation of accessory pathway
Rheumatic fever
Acute rheumatic fever treated w/bed rest and anti-inflammatory agents
- aspirin effective at suppressing inflammation in heart and joints HIGH dose
Anti-streptococcal Abx (penicillin V, benzathine benzylpenicilin, amoxicillin)
consider corticosteroids
Sx relief of HF w/diuretics and ACEi
Prevent recurrence
Preventing recurrence in rheumatic fever
proph. monthly benzathine penicillin
Alternative: PO penicillin OD
Most recommend prophylacis either 10y after the last episode of acute RF or until age of 21
Lifelong proph. recommended for sev. vascular disease
Surgical Mx w/valve repair or replacement may be req.
Infective endocarditis in children
Approach: MDT (cardio, surgeons, ID, neuro, micro)
50% will req. surgery
Empirical Abx - consult ID
IE of native valves
Penicillin sensitive strep viridans = beta-lactam (benzylpenicillin, ampicillin, ceftriaxone, amox) +/- gentamicin or vancomycin
Methicillin-sensitive Staph. aureus = beta-lactam or vanc or daptomycin or cotrimox AND clindamycin
Prosthetic valves IE
Penicillin sensitive Strep viridans = betalactam +/- gentamicin
Methicillin sensitive S aureus = nafcillin OR oxacillin OR cefazolin OR vanc AND rifampicin AND gentamicin
?surgery
Rx course in IE
6 weeks
Prophylaxis against IE
Good dental hygiene
avoid piercings tattoos
Abx proph. no longer recommended
Innocent murmurs
Ejection murmur: turbulent outflow
Venous hum: turbulent flow in great veins (countinuous blowing below clavicles)
Still murmur: low pitched sound at LSE
ejection murmur common features
Soft blowing in pulmonary area or short buzzing in aortic some vary w/posture localised no radiation No diastolic component No thrill No added sounds asymptomatic
