Cardio Flashcards

1
Q

Cardiac History

A

Exercise tolerance, chest pain, syncope, family hx

Feeding difficulty

Hx of dizziness and syncope

Diaphoresis, congested cough, tachypnea

Perinatal hx

Maternal hx

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2
Q

Maternal use of NSAID and ASA

A

Increased risk of pulmonary hypertension of the newborn

Increased risk of premature closure of ductus

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3
Q

Maternal use of Lithium

A

Increased risk of Ebstein’s anomaly of the tricuspid valve

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4
Q

SLE

A

neonatal heart block

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5
Q

Diabetes

A

Cardiomyopathy

Transposition of the great arteries

Ventricular septal defect

PDA

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6
Q

Age Appropriate Hx

Infant

A

Growth

Check feeding

Color

Congested cough

Rapid deep breathing with SOB in a colicky baby suggests heart failure

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7
Q

School Aged Hx

A

Growth pattern

Chest deformity

Activity level

Difficulty in keeping up with activity

Hx of dizziness or syncope

Tires after activity

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8
Q

Family Hx

Maternal diabetes

Medications

Prenatal infection

A

Maternal diabetes: ASD, coarctation, cardiomyopathy

Prenatal Hx of medication use: Dilantin, coumadin, psychotherapeutics, antiepileptics

Prenatal infection: CMV, Coxsackie, Herpes

Family Hx

Prenatal Substance abuse

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9
Q

Physical Assessment Order

A

Inspection

Palpation

Auscultation

Percussion

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10
Q

General Physical Assessment

A
  • Vital Signs
    • Temperature
    • HR (sinus arrythmia)
    • RR (look for retractions, grunting, and nasal flaring)
    • BP
      • Pressure differential b/w right arm and lower leg
      • BP is HIGHER in leg
  • Activity level
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11
Q

Oxygen Saturation

A

75-85 is normal for children with right to left shunt

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12
Q

Faces

A

Central Cyanosis

Peripheral cyanosis

Acrocyanosis

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13
Q

Cardiac Evaluation Continued

A

Overall growth and appearance

Lungs – clear wheezing, grunting and rales

Peripheral perfusion/abdominal pain

Hepatosplenomegaly (1-2cm soft liver edge is normal, evaluate for position and size, critical indicator of cardiac output)

Extracardial anomalies

SACRAL EDEMA*****

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14
Q

Inspection (7)

A

Close observation of growth and development

Cyanosis

Look for precordial bulging, sign of right sided enlargement

Clubbing

VS

Jugular venous pulsation

Pallor, cyanosis, peripheral lymphedema

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15
Q

Pulse rate is increased by ______ for each centigrade of fever

A

10-15 bpm

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16
Q

Waterhammer or Corrigan’s pulse

A

pulse that is bounding and forceful, rapidly increasing and subsequently collapsing, as if it were the sound of a waterhammer that was causing the pulse.

PDA

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17
Q

Quincke Pulse

A

With a light held on the pad of the finger, gentle pressure is applied to the distal nail, if the pulse pressure (PP) is wide, alternating filling and blanching of the capillary bed can be seen

Aortic insufficiency

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18
Q

Premature Pulses

A

may have bounding pulses due to lack of subcutaneous fat and higher incidence of PDA

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19
Q

Assessment of pulses

A
  • Assessment of femoral and radial pulse
  • Palpate for thrill
    • Turn child to the left and feel the apex
    • Basal thrills are felt with child sitting up
    • Look for thrills at PMI and suprasternal notch
  • Pericardial friction rubs can be palpated
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20
Q

High frequency thrills along the LBD

A

Ventricular septal defect

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21
Q

Low frequency thrill in 2nd ICS suggests

A

Aortic stenosis

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22
Q

Diastolic thrill at the apex

A

mitral stenosis

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23
Q

Point of Max Impulse

A
  • Normal position of apex beat
  • 5th ICS space MCL after 7
  • Before this age, the apex best is in the 4th ICS to the left of the MCL
  • Determine ventricular overload
  • Cardiomegaly
  • Presence or absence of thrill
    • Turbulent blood flow
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24
Q

AUSCULTATE

A

Aortic

Mitral

Erb’s point

Tricuspid

Pulmonic

Infraclavicular – carotid and axillary

Posterior aspect under scapula

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25
Listen for low pitched sounds of the diastolic murmur by listening for
the absence of silence during diastole
26
Age specific hits Infants
Listen during feeding
27
Age specific hints 4months to 1 year
Listen while baby is being brough to sitting: Strain to sit up
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Age specifc TODDLER
Play with them once they have confidence in you Give them time to warm up
29
7 S's of innocent murmurs
Systolic Short duration (not holosystolic) Single (no clicks or gallops) Small (do not radiate) Sensitive (tend to change with position or respiratory effort -- louder supine) Soft Sweet (no harsh sounds)
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S1 Split S1
* Due to closure of the tricuspid and mitral valve * Best heard at the left lower sternal border or at the apex * Split s1 can be normal in children but if wide can be right bundle branch block or Ebstein anomaly
31
S2
Due to closure of pulmonic and aortic valve Aortic valve closes first
32
Distinguishing between Splitting and S3
Intensity Quality * Split s2 of equal intensity and quality * Hear at base * Occur with very interval between sounds * Splitting at base is absence in pulmonic stenosis, tetralogy of fallot, pulmonic atresia or truncus Position Heard Distance between sound
33
Murmurs
Murmurs are produced when the blood velocity becomes critically high in the presence of an irregularity or narrowing of the surface over which the blood flows.
34
The loss of laminarity
Results in turbulence which in turn produces a sound.
35
Etiology of Murmurs
* The frequency of the sound from the turbulence varies directly with velocity of the blood flow. * High sound frequencies are associated with high velocity jets as in mitral regurgitation with the flow from the high pressure left ventricle to the low pressure left atrium
36
Aids to Auscultation
Quiet patient Quiet room No distractions Good Stethoscope Good hearing
37
Types of murmurs
Systolic -- ejection, holosystolic or regurgitant Diastolic -- early decrescendo, mid-diastolic Continuous = PDA
38
Characteristics of Murmurs
Timing -- systolic, diastolic, continuous Intensity -- standard scale Quality -- frequency and pitch
39
Intensity of the murmur
The velocity of the blood The volume of blood causing the murmur The distance from the site of the origin of the murmur to the stethoscope
40
Grading of the murmur
* 1/6 Faint, not easily heard * 2/6 Faint but heard immediately * 3/6 Loud but no thrill * 4/6 Loud with a thrill * 5/6 Loud with a thrill and heard with the edge of the stethoscope on the chest * 6/6 Heard with the stethoscope 1 cm. off of the chest wall
41
Third Heart Sound
* Associated with ventricular filling * Louder in the non-compliant left ventricle * Louder with increased blood flow/cardiac output * Intermittent S3 may be a normal variant
42
Extra Cardiac Sounds
Friction rubs Bronchial sounds Rales Pleural rubs Wheezes
43
Radiation of the murmur
Direction of blood flow Site of Origin Intensity of murmur
44
Chest X-ray and Cardiac Anomalies Tetralogy of Fallot
Boot sign
45
Chest X-ray and Cardiac Anomalies Transposition of great arteries
Egg on a string sign
46
Chest X-ray and Cardiac Anomalies Total Anomalous Pulmonary Venous Connection
Snowman sign
47
Chest X-ray and Cardiac Anomalies Partial anomalous pulmonary venous return
Scimitar sign
48
Innocent murmur
Systolic Less than 4/6 (no thrill) Generally increased with fever, anemia, anxiety, excitement Sitting or standing decreases murmur due to venous pooling Several specific types
49
5 innocent murmurs of childhood
Still's murmur Pulmonary flow murmur Peripheral pulmonic stenosis murmur Supraclavicular bruit Venous hum
50
Still's murmur
Caused by uniform periodic vibration of the left heart structure First heard during sick visit in preschooler and usually disappears in puberty Most common innocent murmur
51
Still's murmur characteristics
Short, systolic Vibratory, buzzing hocking Lower left sternal border Most common 3-7 years Louder supine Decreases significantly or disappears with Valsalva
52
Pulmonary ejection murmur
* Probably from mildly turbulent flow in right side of heart * Short, systolic ejection * Upper left sternal * All ages (rare in infants) Much more common in late childhood and early adolescents * Louder with expiration * Normal S2 split
53
Pulmonic ejection murmur characteristics
* Thin body habitus * Straight back syndrome * Increase cardiac output * Increases with supine position * Increased with fever, anemia * Varies from I-III/VI * Left and right sternal border, transmit to back * Best heard in supine position with exhalation * Intensifies with exercise
54
Peripheral pulmonic branch stenosis
* Turbulence arising the acute angle at which the relatively small branch pulmonary arteries take off from the main pulmonary artery * Systolic, ejection which disappears by six months * If it does not disappear by six month, severe branch pulmonary artery stenosis is associated with Williams syndrome and congenital rubella * Chest and axillae (often loudest in axillary * New born infants and early well child check
55
Supraclavicular carotid bruit Cause
Caused by turbulence at the take off area of the brachiocephalic and carotid arteries from the aortic arch
56
Supraclavicular Carotid Bruit Characteristics
* Systolic and ejection, high pitched, harsh * Best heard in supraclavicular fossa on the right more than left * Does not radiate far * Supraclavicular region and neck * Not heard below clavicle * Not affected by sitting or lying * Decreased by hyperextension of shoulder
57
Venous Hum
* Continuous (lounder in diastole) * Supraclavicular * Right more common than left * Disappears with change in head position, digital pressure, lying spine * Loudest when sitting or standing
58
When to refer: Neonate
* Murmurs are common in neonates * Absence of murmur does not mean no heart disease * Loud or long murmur * Murmurs radiating to back * Appears ill * Any diastolic murmur * Abnormal CXR or EKG * Dysmorphic features * Abnormal cardiac sounds * Clicks, rubs, abnormally split S2 or single S2
59
Clues to Cardiac Disease in Neonates
Cyanosis Tachypnea Tachycardia Diaphoresis Gallop Abnormal splitting of S2 Abnormal precordial activity Hepatomegaly Abnormal pulses BP lower in lower extremities Mottled extremities
60
Significant Hx
* Tachypnea * Feeding intolerance * Poor weight gain * Exercise intolerance * Excessive fatigue * Frequent respiratory infections * Syncope * Persistent cough, wheezing (not associated with asthma * Chest pain with exertion * Cyanosis * Palpitations
61
When to refer over 6 weeks
Abnormal pulse or BP Abnormal S1 or S2 Displaced apical impulse Click, gallop, rumble Murmur -- diastolic, continuous (if not venous hum), loud
62
Murmurs needing Eval
Murmurs in symptomatic kids Loud murmur Diastolic murmurs Murmurs that don't fit into categories of innocent murmur
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Congenital heart disease
Presenting as an asymptomatic murmur
64
Septal
ASD, VSD
65
Obstruction to ventricular outflow
Valvar, subvalvular or supravalvar aortic or pulmonic stenosis Coarctation of aorta PDA
66
What causes systolic murmur
* Turbulence in ventricular outflow * Narrowing of aortic or pulmonary valve, aorta or pulmonary artery * Increased flow * AV valve regurgitation * Abnormal ventricular or arterial communications * VSD or PDA
67
Aortic Valve Stenosis Intro
Occurs in 5% of children with CHD May have associated defect such as coarct, VSD or PDA Non obstructive isolated bicuspid aortic valve is most common congenital defect which occurs in 1% of the population
68
Presentation of Aortic Stenosis
Most common is just a murmur If very narrow valvular opening, needs the right to left shunting available through the PDA and may present acutely with shock or CHF if ductus closes Can progress over months
69
Aortic Stenosis Presentation cont. (4)
* May be valvar, subvalvar or supravalvar * Systolic ejection murmur begins early in systole after the click * Medium to high pitched * Upper right sternal border to apex * Radiation to neck * Click helps distinguish it from pulmonary flow murmur * May have a thrill in suprasternal notch or in carotid arteries area * Valvar AS usually cases a systolic ejection click at the apex * Click is not present in the most severe cases
70
Pulmonic Stenosis
* Systolic ejection murmur * Upper left sternal border * Radiation to back * Systolic ejection click at lower left sternal border which varies with respiration * May have thrill in suprasternal notch * Harsh loud murmur
71
Patient Ductus Arteriosus
* Blood from right ventricle into descending aorta, bypasses the lungs * PDA normally closes by **48 hours** after birth * Direction of shunt depends upon the differential resistance between the aorta and pulmonary artery * Right to left ductal shunting occurs with severe left heart obstructive lesions * Severe coarctation * Hypoplastic left heart * Normally left to right shunting
72
Patent ductus arteriosus Presentation
* Prematurity * May have pulmonary overcirculation and will present early * Infants and children tend be completely asymptomatic * If infant is going to present with pulmonary overcirculation, does so when the pulmonary resistance falls at 4 to 6 weeks. * Single S2 = pulmonary hypertension
73
Patent ductus arteriosus 2
Wide pulse pressure Bounding pulses -- waterhammer pulse Quincke pulse on finger tips
74
Coarctation of Aorta
* Narrowing of aortic arch adjacent to the site of ductus * Systolic ejection murmur below left scapula * Decreases pulse and BP in lower extremities * If severe, causes shock * Often associated with bicuspid aortic valve
75
Ventricular Septal Defect
* Holosystolic murmur * Harsh, high pitched if VSD is small * Diastolic rumble at Apex * CHF is VSD is large * Increased LA pressure * Pulmonary edema * Increased work of breathing * Poor growth * Can lead to pulmonary hypertension if not found
76
Ventricular Septal Defect (2)
* At birth PVR is greater than SVR and shunt is right to left or bidirectional * As PVR falls, then left to right shunt and murmur appears * Pitch depends on whether right to left or left to right * Diastolic rumble * Caused by vibration of the mitral valve as the large volume of flow from the lungs goes into the left ventricle * Much more likely to be moderate in intensity
77
VSD (3)
Can have a normal to wide split S2 which will vary with respirations Increase volume traversing the pulmonary valve causes it to close later Loudness of murmur does not correlate with size of the defect Plateau shaped murmur with the same intensity throughout.
78
Atrial Septal Defect
* Systolic ejection murmur * Upper left sternal border * Wide fixed split S2 * Right ventricular impulse * Diastolic rumble at lower left sternal border * CHF not seen * Subtle exercise intolerance
79
What causes diastolic murmurs?
* Turbulence in ventricular inflow * Narrowing * Increased flow * Semilunar valve regurgitation
80
What causes continuous murmurs
* Abnormal systemic to pulmonary artery communications * PDA * Abnormal arteriovenous communications * AV fistula * Coronary artery fistula
81
Common murmurs in first days of life NORMAL
* PPS * Pulmonary flow murmur * Transitional murmurs * Closing PDA * Transient tricuspid regurgitation
82
Common murmurs in first days of life ABNORMAL
* Outflow obstruction * AS * PS * Coarctation * Abnormal communications * VSD * PDA
83
Transitional murmurs
ULSB or left infraclavicular area Systolic or continuous Often louder as PDA gets smaller Occasional vibratory Typically 12 to 48 hours of age
84
Transient Tricuspid Regurgitation
* LLSB * Regurgitant, systolic * Often seen with asphyxiated infants or infants with pulmonary hypertension * Takes several days to resolve
85
Complex Congenital Heart disease
* Ebstein anomaly * Common AV canal (truncus) * Tetralogy of Fallot * Hypoplastic left heart * Transposition of the great vessels
86
CHF History Child
Decreased exercise capacity Fatigability SOB Weight gain or loss
87
CHF History -- infant
Poor weight gain Cachexia Malnutrition Sweating when feeding
88
CHF Hx Adolescent
Fatigue Cold intolerance Exercise intolerance Syncope Dizziness
89
CHF physical Exam First sign = TACHYCARDIA
* Infant heart is stiffer and less distensbile so they increase rate as they cannot increase stroke volume * Tachypnea * Hepatomegaly * Edema * Ascites * Diminish perfusion * Pedal edma and neck veing distention are rare * Listen for gallop
90
Hypertrophic Cardiomyopathy
* May have biventricular outflow tract obstruction in infancy * Older children asymptomatic * May have murmur * Pulse may be diminished as ventricular ejection is impeded * Listen to murmur squatting and then have the patient stand. * MURMUR WILL greatly INCREASE IN INTENSITY as child stands
91
Hypertrophic cardiomyopathy POSITIONS
* Maneuvers that increase the intensity and duration of the murmur * Decrease preload * Strain of Valsalva * Increase contractility * Exercise * Decrease afterload * Stand suddenly * Maneuvers that will decrease the intensity and duration of the murmur (this is the opposite of what you would expect) * Increase afterload * Squat or hand grasp * Increase preload * Raise legs
92