Cardio-Respiratory Flashcards
Pulmonary Hypertension: Causes
Causes of Pulmonary Hypertension:
1. Primary: Rare
2. Secondary: mostly
= Pulmonary stenosis
= Pulmonary regurgitation
= Lung disease: CF, Bronchiectasis
= Schistosomiasis
= Vasculitis
= ASD, VSD, PDA
= High altitude
= Thromboembolism, PE
= Valve destruction due to IE
= PR caused by carcinoid effects
Patent Ductus Arteriosus
It occurs because a normal fetal connection between the aorta and the pulmonary artery does not close as it should after birth. PDA happens most often in premature infants. It often occurs with other congenital heart defects. A small PDA may close on its own as your child grows.
PDA signs:
1. Continuous machinery murmur (systolic) along 2nd ICS, left parasternal, below Left clavicle & posteriorly, 2. Thrusting apex, displaced to AA line, with collapsing nature of pulse if large PDA,
3. Toe clubbing
and
4. signs of PAH if long standing as:
= Palpable P2
= TR murmur with RV heave
= Eisenmenger syndrome & cyanosis as R-L shunt develops
= moratility 20% after 20 years
complications: Endocarditis, Ductal rupture, PAH, aneurysm, calcification
Rx: IV Indomethacin, percutaneous closure, Surgical closure
Causes of continuous MURMUR
Continuous Murmur + collapsing pulse
= MR + AR
= VSD + AR
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C-Murmur without Collapsing pulse:
= Venous hum in children - disappears on lying flat or on compressing Rt Jugular vein
= Pulmonary AV fistal or shunt (Blalock)
Mitral Regurgitation
Signs of MR
= Volume overload, displaced apex
= Thrusting apex, RV Lift(heave)
= Pallor, Inner conjunctival petechie
= Systolic murmur, radiates to axilla
= Peripheral signs of IE:
= Splinter haemorrhages@ nailbeds
= Janeway lesion, flat-macular,
= Osler nodes, tender,finger/toe pulps
= Roth’s spot in Retina
= Skin necrosis
= Spleenomegaly
Skin Petechiae Causes
Petechiae can be seen with:
= Severe thrombocytopenia
= Infective endocarditis
= Scurvy
= Renal Failure
= Bacteremia without IE (meningococcemia)
= Fat embolism in Cardiopulmonary bypass
Duke’s Criteria for Infective endocarditis
Duke’s Criteria for IE
1. Pathological Criteria
= Micro-organisms in a vegetation - demostrated by blood cultures, Histological examination of a vegetation or in intra-thoracic abscess specimen
= Pathological lesions - vegetation or intra-cardiac abscess confirmed by histologic exanination showing active endocarditis
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2. Major Clinical Criteria:
= Blood cultures positive, 2 bottles
= Single Blood cultures + for Coxiella
= Antiphase I anti-IgG antibody titre>1:800
= Evidence of Endocardial involvement: ECHO+, abscess, new partial dehiscence of Prosthetic valve, new regurgitation
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3. Minor Clinical Criteria:
= Predisposing heart condition/IV DU
= Fever
= Vascular phenomenon: Major arterial emboli, stroke, septic PE, Mycotic aneurysms, ICH, Conjunctival petechiae, Janeway lesions
= Immunological phenomenon: Acute GN, Osler nodes, Roth spots, RA Factor
= Micro-biological evidence but doesnt meet as in major criteria
Duckett- Jones Criteria for Acute Rheumatic Fever
Jones Criteria for ARF
1. Evidence of preceding Group A strep infection:
= Rising or high ASO titre
= ++ Group A strep CHO antigen test
= Positive Throat culture
= History of ARF or established Rheumatic heart disease
2. Population at risk
= Low Risk < 2 cases per 100k children
= High Risk
3. Major Criteria:
= Carditis
= Arthritis
= Chorea
= Erythema marginatum
= Subcutaneous nodules
4. Minor Criteria:
= Prolonged PR interval
= Monoarthralgia
= Fever > 38c/ 100.4F
= ESR > 30 CRP > 3 or more than upper level of normal for your Lab
Eisenmenger Syndrome
It is development of right to left shunt in congenital cardiac anomalies with development of cyanosis and usually irreversible with high mortality.
Signs:
= Central cyanosis
= Clubbing of fingers, or toes in PDA
= Large a wave in JVP
= RV heave along parasternal
= Palpable P2 heart sound
= Pulmonary Regurg with murmur
= Single Loud S2
= Pansystolic murmur of TR with PAH
Eisenmenger Syndrome, causes
Causes of ES:
= Large VSD
= Primary PAH
= ASD with severe RVH
= PDA with Leg cyanosis, Toe clubbing
= Fallot’s Tetrology
= no PS systolic murmur or thrill
Co-arctation of Aorta, signs
Signs of Co-Arctation, unrepaired
= Radio-femoral delay
= Weak Leg pulses, strong radials
= BP higher in UL > LL
= Aortic, Supra sternal systolic murmur + thrill
= Heaving apex beat but undisplaced
= Posteriorly left 4th ICS loud systolic murmur
= Right arm BP > Left arm
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Repaired co-arctation signs:
= no radio-femoral delay
= Left sided thoracotomy scar
= Ejection click with SSM in Aortic area
= Normal undisplaced apex
= Absent/Reduced Left radial pulse
= AR some times
Associations of Co-arctation
= Bicuspid Aortic valve lead to AR
= Rib notching
= Post Stenotic dilatation in CXR
= Berry aneurysm in Brain, (SAH risk)
= PDA (machinery murmur, toe clubbing)
= Turner syn: Web neck, short, carrying angle is more,
= Marfan syn: Tall, Arachnodactyly, High arch palate, Lens dislocation, AR
= Hypertension, resistant
= Early High mortality after 40s
Causes of rib notching
Causes of rib notching
= Co-arctation of aorta
= Neurofibromas of Intercostal nerves
= Nerve enlargement in amyloidosis, cong. Hypertrophic polyneuropathy
= IVC obstruction
= Blalock shunt operation
= congenital anomaly
Cannon JVP waves:
are giant a waves & occur whenever a right atrium contracts against closed TV
Causes of Regular pattern cannon waves:
= nodal rhythm (AV nodal)
= Paroxysmal nodal tachycardia
= Partial Heart block with very long PR
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Causes of Irregular Cannon waves:
= CHB
= Multiple ectopic beats
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p wave in ECG will fall between QRS/T or at end of T wave.
Tetrology of Fallot
- ventricular septal defect,
- overriding aorta,
- pulmonary stenosis and
- ## right ventricular hypertrophy.Signs of TOF:
= VSD murmur
= PS murmur, systolic with thrill
= RV Heave parasternal
= Central cyanosis + clubbing
= Rt pulse weak than left or vice versa
= ? early diastolic murmur of AR
= Large VSD has no murmur =equal pressure between RV/LV
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Most patients will present in the neonatal period with mild-to-moderate cyanosis, but typically without respiratory distress.
What is Blalock Shunt
A Blalock-Taussig (BT) shunt is a small tube that connects the arterial circulation to the pulmonary circulation in order to get more blood to the lungs. This is the first in a series of operations required to correct complex congenital heart defects.
A modified BT shunt, a Gore-Tex tube graft is placed between the subclavian artery and the ipsilateral pulmonary artery, and in the central shunt a Gore-Tex tube of a known diameter is placed between the ascending aorta and the pulmonary artery.
Dextrocardia, apex to right
About 1 in 4 people with dextrocardia also have primary ciliary dyskinesia such as Kartagener’s syndrome
= Dextrocardia with situs inversus is usually normal, alone it has cardiac anomalies.
= Turner syndrome may have it
= Listen to Lung fields to bronchiectasis associated with Kartagener
Kartagener syndrome
a primary ciliary dyskinesia + Situs
rare, autosomal recessive genetic ciliopathy, that causes defects in the action of cilia lining the upper and lower respiratory tract, sinuses, Eustachian tube, middle ear, Fallopian tube, and flagella of sperm cells. Within the first few months of life, most develop a chronic mucus-producing cough and runny nose.
= Dextrocardia
= Bronchiectasis
= Situs inversus
= Infertility
= Frontal sinus dysplasia
= Sinusitis
= Otitis media
HOCM,
Autosomal dominant
Clinical features of HOCM:
= mildly displaced forceful apex
= Double apical impulse due to atrial systole
= ESM, 4th Heart Sound
= Associated MR with radiating murmur
= Carotid pulse jerky when severe
= Atrial fibrillation possible
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All first degree relatives- screen by echo
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Fainting attacks at end of exercise in HOCM as opposed to fainting during exercise in Aortic stenosis.
HOCM Diagnosis
= Genetic studies
= echo, gradient > 40 mmHg
= Echo septal thickness > 18 mm, asym
= LVH, V3V4 tall QRS, LAD in ECG
= H/o Syncope after exercise
= Family H/o Sudden deaths
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Rx options:
= Beta blockers
= Calcium channel blockers
= Septal ablation or Myomectomy
= implantable cardiac defibrillators
JVP Waves and meanings
a-x-c-x1-v-y
A= Rt atrial contraction pushes some blood into IJV (upright wave)
x-descent = RA relaxes dropping pressure
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C= TV closes and RV contract so bulges into right atrium (upright)
X1-descent=end of RA contraction creates space when RA starts filling
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V =RA filling against closed TV pushes some blood into IJV (upright)
y-descent = opening of TV so blood goes into ventricles
High JVP Causes
= Heart failure
= Tricuspid stenosis
= Pulmonary stenosis
= Cor pulmonale, PAH
= PAH 2ry to Mitral disease
= Constrictive pericarditis
= Large pericardial effusion
= SVC obstruction, flushed face
Ebstein’s anomaly
The annulus of the T valve is still in the normal position. The valve leaflets, however, are to a varying degree, attached to the walls & septum of the right ventricle. A subsequent “atrialization” of a portion of the morphologic right ventricle (which is then contiguous with the right atrium) is seen. This causes the right atrium to be large and the anatomic right ventricle to be small in size.
= S3 heart sound
= S4 heart sound
Triple or quadruple gallop due to widely split S1 and S2 sounds plus a loud S3 and/or S4
Systolic murmur of tricuspid regurgitation = Holosystolic or early systolic murmur along the lower left sternal border depending on the severity of the regurgitation
= Right atrial hypertrophy
= Right ventricular conduction defects
= Wolff-Parkinson-White syndrome often accompanies
Ebstein’s associations
It is - tricuspid valve in the wrong position and the valve’s flaps (leaflets) are malformed.
= PFO/ ASD >50%
= VSD/PS < 5%
= Rt to Lt shunt, Cyanosis, Clubbing
= Arrhythmias: Afib, Aflut,
= Congestive hepatomegaly
= Maternal exposure to Lithium carbonate in 1st TM is risk
= ECG tall P waves,
WPW (short PR +delta waves) + LBBB - right sided accessory pathway
RBBB without accessory pathway
= TR severity decides decompensation
Pulmonary stenosis
1 mmHg = 1.35951 cm H2O
congenital or Post TOF repair
Signs:
= ESM across PV, Thrill if severe
= RVH and left parasternal heave
= TR with systolic murmur
= Signs of RT CHF, congestive
= Post stenotic PA dilatation in CXR
= Split S2
= Pulmonary murmur increases on deep inspiration as right sided valve.
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Repair if gradient across PV> 50 mmHg