Cardiac Presentations

Question 1

Outline paediatric infective endocarditis

Answer 1

Infection of the endocardium, particularly of the heart valves

Most common MO in children are Strep viridans, Staph and Enterococci

S+S = fever, new murmur, anaemia, splenomegaly, retinal infarcts, arthritis, microscopic haematuria (Roth spots, Janeway lesions, splinter haemorrhages and Osler’s nodes are rare in children)

Blood culture, ECHO

4-6w Abx

Question 2

Outline Kawasaki Disease

Answer 2

Most common vasculitis in childhood after Henoch Schonlein purpura, the most common cause of acquired heart disease in children in developed countries causing coronary artery aneurysms (CAA).

Mainly effects <5y, B>G

S+S = fever >5d, rash, cervical lymphadenopathy, palms/soles of hands/feet turn bright red, puffy, skin can peel, bilateral conjunctivitis, lips crack, strawberry tongue, oral erythema, polymorphous exanthem

Mx = IV gamma globulin, aspirin, corticosteroids

Comp = coronary A aneurysms (ECHO)

Question 3

Outline rheumatic fever

Answer 3

Systemic illness that may occur following group A beta haemolytic streptococcal (GABHS) pharyngitis

Often between 5-15y

S+S = fever, arthralgia, chest pain, tachy, mitral regurgitation, pericardial rub, aortic regurgitation, subcutaneous nodules, sydenham chorea

Modified jones criteria, joint aspiration, ECG, ECHO, CRP/ESR

Mx = Abx, aspirin, corticosteroids

Question 4

List the types of paediatric murmurs and how they present?

Answer 4

30% children have innocent = soft, short, systolic, symptomless, softer when sitting than supine, minimal radiation, musical/vibratory quality

• aortic stenosis = ejection-systolic
• pulmonary stenosis = ejection-systolic
• atrial septal defect = mid-systolic, crescendo-decrescendo
• PDA = continuous crescendo-decrescendo
• ToF = ejection-systolic

Question 5

How should a paediatric murmur be investigated?

Answer 5

ECG
CXR
ECHO

Question 6

What causes HF in children?

Answer 6

Neonates = hypoplastic L heart syndrome, aortic valve stenosis, coarctation

Infants = VSD, AVSD, large persistent arteriosus,

Children/adolescents = cardiomyopathy, rheumatic heart disease, Eisenmenger syndrome

Question 7

Hoes does HF in children present?

Answer 7

Oedema of the feet/ankles (R sided HF), lower legs, abdomen, liver, and neck veins

Trouble breathing, breathlessness, especially with activity including rapid breathing, wheezing, or excessive coughing, tachypnoea, tachy

Poor feeding and weight gain (in infants)

Feeling tired

Excessive sweating while feeding, playing, or exercising

Irritability

Chest pain

Question 8

Outline how suspected HF in children should be Ix?

Answer 8

Bloods = bnp, CK, troponin

CXR

ECG

ECHO

Cardiac catheterization = measures pressure

Question 9

Describe the Mx for paediatric HF

Answer 9

ACEi
Beta Blockers
Diuretics
Digoxin 
Pacemaker
Heart transplant 

Nutritionist
Exercise rehab program

Question 10

What are cyanotic spells?

Answer 10

Cyanotic spells are a paediatric emergency requiring prompt recognition and Tx

Cyanotic spells are paroxysmal hypoxic events = decreased pulmonary blood flow due to increased resistance in the pulmonary circuit leading to R-L shunting across VSD

Can occur in any heart condition involving VSD and a restriction to pulmonary blood flow. Spells are often associated with ToF (commonest cyanotic congenital heart disease)

Question 11

What can cause cyanotic spells?

Answer 11

Any increase in pulmonary vascular resistance (PVR) and/or decrease in systemic resistance (SVR) will cause right to left shunting and resulting cyanosis

= crying (increased PVR), defecation (reduced SVR), fever (reduced SVR), awakening from naps, feeding, tachycardia (reduced preload) and ACEi (reduced afterload / systemic resistance)

During a spell the reducedO2 sats cause cerebral irritability leading to further crying; this increases PVR further exacerbating the problem

Question 12

How do cyanotic spells present?

Answer 12

Inconsolable crying
Cyanosis
Tachycardia
Hyperpnoea
Anoxic seizures
Gasping respiration
Apnoeas

Question 13

How should a cyanotic spell be manged?

Answer 13

Inform paediatric intensive care unit

Place child in knee-chest position with pressure on femorals

High flow O2, non-rebreathe

Morphine 50micrograms/kg SC/IV/IM (if spell resolves stop Tx)

Fluid bolus 10ml/kg NaCl IV

Oral propranolol 0.5mg/kg

IV Phenylepherine 5-10 mcg/kg

Transfer to PICU for intubation and ventilation

Question 14

What is blue baby syndrome and its causes?

Answer 14

Conditions that affect O2 transportation in the blood, resulting in blueness of the skin

Cyanotic heart disease = results in low levels of O2 in the blood, by either reduced blood flow to the lungs or mixing of oxygenated and deoxygenated blood

• Persistent (or patent) truncus arteriosus
• Transposition of the great vessels
• Tricuspid atresia
• ToF
• Anomalous pulmonary venous connection

Methemoglobinemia = high levels of methemoglobin in the blood, preventing O2 from being released into the tissues and resulting in hypoxemia

Resp = surfactant def, meconium aspiration, pulmonary hypoplasia

Question 15

How should a blue baby in Ix?

Answer 15

?cardiac = CXR, ECG, ECHO

?methemoglobinemia = co-oximeter

Question 16

Outline the Mx of a blue baby

Answer 16

Cardiac = prostaglandin E1 after birth to keep the ductus arteriosus open, O2, surgery

Methemoglobinemia = methylene blue (reduce methemoglobin in the blood)