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a Paediatrics by themes > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What congenital heart diseases present in the first few hours of life?

A
  • AVSD
  • Tricuspid Atresia
  • Hypoplastic left heart syndrome
  • Peripheral transient cyanosis is very common in the first 24 hours of life → assess them regularly
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2
Q

What congenital heart diseases present in the first few days of life?

A
  • Transposition of the Great Arteries (day 2-4)
  • Tetralogy of Fallot
  • Large PDA in premature contraction
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3
Q

What congenital heart diseases present in the first few weeks of life?

A
  • Aortic stenosis
  • Coarctation of the aorta
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4
Q

What congenital heart diseases present in the first few months of life?

A

Any L to R shunt → occurs as pulmonary resistance falls

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5
Q

What is the significance of the majority of paediatric murmurs?

A
  • Majority of murmurs in paediatrics are innocent - Still’s, Venous hum
    • Characteristics
      • Soft
      • Systolic
      • Asymptomatic
      • Left sternal edge
      • Sitting/Standing variation
      • Short
    • Can be due to ↑CO in illness or anaemia
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6
Q

What investigation can determining the presence of heart disease in a cyanosed neonate?

A

Hyperoxia - Nitrogen washout test

  • 1) 100% O2 for 10mins
  • 2) If right radial artery PaO2 from blood gas stays low (<15kPa, 113mmHg) = diagnose of cyanotic CHD
    • If PaO2 >20kPa then it is not cyanotic HD
  • Must have excluded persistent pulmonary HTN of the newborn
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7
Q

What are the risk factors for congenital heart disease?

A
  • Maternal
    • Rubella
    • DM
    • SLE
    • Warfarin
    • FAS
  • Chromosomal
    • Down’s
    • DiGeorge
    • Edwards
    • Patau’s
    • Turner’s
    • William’s
    • Noonan’s
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8
Q

What are the types of congenital heart disease?

A
  • Left to right shunts = Breathless Baby
    • ASD
    • VSD
    • PDA
    • CoA
    • Aortic valve stenosis
  • Right to left shunts = Blue Baby
    • Tetralogy of fallot
    • TGA
    • Tricuspid atresia
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9
Q

What are the types of atrial septal defects?

A
  • Secundum ASD – defect in atrial septum → foramen ovale does not close
    • 80% of ASDs
  • Partial AVSD – defect of AV septum
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10
Q

What are the signs and symptoms of atrial septal defects?

A
  • Asymptomatic
  • Recurrent chest infections / wheeze
  • Arrhythmias (from 40yo+)
  • Murmur:
    • Ejection-Systolic Murmur at ULSE
    • Fixed wide splitting of S2 → pulmonary valve closure occurs after aortic
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11
Q

What are the appropriate investigations for suspected atrial septal defects?

A
  • CXR
  • ECG
    • Secundum = RBBB and RAD
    • Partial AVSD = ‘superior’ QRS axis
  • Echocardiography = diagnostic
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12
Q

What is the management of atrial septal defects?

A
  • Secundum ASD = cardiac catheterisation + insertion of occlusive device (percutaneous/endovascular closure)
  • Partial AVSD = surgical correction
  • Usually at 3yo
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13
Q

How are ventricular septal defects classified?

A

Size

  • Small = <3mm → higher risk of endocarditis
  • Large = >3mm
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14
Q

What are the signs and symptoms of a small ventricular septal defect?

A
  • Asymptomatic
  • Loud Pan-Systolic Murmur at (LLSE) - louder = smaller defect
  • Soft pulmonary 2nd sound
  • Breathless 3m-old baby with normal sats, poor feeding with tiredness
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15
Q

What are the appropriate investigations for suspected small ventricular septal defects?

A

ECHO = diagnostic

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16
Q

What is the management of a small ventricular septal defect?

A
  • Self-limiting → close by themselves
    • After these close, they are no longer at a high risk of infective endocarditis
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17
Q

What are the signs and symptoms of a large ventricular septal defect?

A
  • Heart failure → SOB
  • Recurrent chest infections
  • Hepatomegaly
  • Soft Pan-Systolic Murmur with Mid-diastolic murmur (apical)
  • Loud pulmonary 2nd sound
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18
Q

What are the appropriate investigations for suspected large ventricular septal defects?

A
  • Echocardiography = diagnostic
  • CXR → heart failure ‘ABCDE’
  • ECG → heart hypertrophy R wave height >8mm
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19
Q

What is the management of large ventricular septal defects?

A
  • CDC
    • Captopril
    • Diuretics
    • Calories - additional calorie input
  • Surgery at 3-6 months to prevent permanent lung damage from pulmonary hypertension and high blood flow → prevent Eisenmenger syndrome
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20
Q

At what age should the ductus arteriosus close?

A

1 month → by 2-4 at the very latest

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21
Q

What are the signs and symptoms of a patent ductus arteriosus?

A
  • Gibson’s murmur at ULSE = continuous ‘machine-like’
  • Left sub-clavicular thrill
  • Heaving apex beat
  • Wide pulse pressure
  • Large volume, bounding, collapsing pulses
  • Respiratory symptoms → apnoea, bradycardia, high O2 need
  • Ventilatory wean difficulty if on one
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22
Q

What is the management of a patent ductus arteriosus?

A
  • Medical → indomethacin (NSAID) - will promote duct closure
  • Surgical → coil/device closure via cardiac catheter at 1yo
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23
Q

What are the signs and symptoms of an atrioventricular septal defect?

A
  • Cyanosis at weeks 2-3 of life
  • No murmur → found on routine echocardiography of Down’s
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24
Q

Which condition is associated with atrioventricular septal defects?

A

Down’s

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25
Q

What is the management of atrioventricular septal defects?

A
  • Medical management of heart failure
  • Surgery at 3 months
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26
Q

What is the most common cause of cyanotic heart disease in a neonate?

A

Tetralogy of Fallot

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27
Q

What are the 4 features of tetralogy of fallot?

A
  • VSD
  • Overriding aorta → compresses pulmonary outflow → pulmonic stenosis → RVH
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28
Q

What are the signs and symptoms of tetralogy of fallot?

A
  • Clubbing
  • Loud Ejection Systolic Murmur at LLSE - pulmonary stenosis
  • Tet spells = crying → increased pulmonary resistance → R-L shunt → cyanosis
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29
Q

What are the appropriate investigations for suspected tetralogy of fallot?

A
  • CXR → small boot-shaped heart - due to RVH
  • Echocardiography
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30
Q

What is the management of tetralogy of fallot?

A
  • 1st = Prostaglandin or Alprostadil - maintain PDA
  • Reverses severe cyanosis
    • Severe/prolonged = BT shunt from subclavian-pulmonary artery OR balloon dilation of RV outflow
      • Morphine (sedation and pain relief)
      • IV propranolol
      • IV fluids + bicarbonate - correct acidosis
      • Muscle paralysis
      • Artificial ventilation
    • Mild cyanosis = self-limiting (<15 minutes cyanosis)
  • 2nd = Surgery at 6 months
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31
Q

Define Eisenmenger Syndrome.

A

Irreversibly raised pulmonary vascular resistance from chronically raised pulmonary arterial pressure and flow leading to a right to left shunt forming

  • High pulmonary flow from large L-to-R shunt untreated → arteries thick walled → resistance increases → shunt decreases → child becomes less symptomatic
  • At 10-15y, shunt reverses → blue + cyanotic with Eisenmenger syndrome → death by right-sided heart failure (40-50yo)
32
Q

What are the main causes of Eisenmenger syndrome?

A
  • Large VSD
  • Chronic PDA
33
Q

What is the management of Eisenmenger syndrome?

A
  • Early intervention for pulmonary blood flow → surgical correction
  • Heart transplantation not easy but can be done
34
Q

What is the cause of rheumatic fever?

A

Group A β-haemolytic streptococcus (GAS)

35
Q

What is the long term consequence of rheumatic fever?

A

Mitral stenosis → opening snap is followed by a low-pitched diastolic rumble and presystolic accentuation with loud S1

36
Q

What are the signs and symptoms of rheumatic fever?

A
  • Latent interval of 2-6 weeks after pharyngeal infection = PPE
    • Polyarthritis → tender joints, swelling
    • Pericarditis → endocarditis, myocarditis, pericarditis
    • Erythema marginatum → map-like outlines
  • Sydenham’s chorea 2-6 months later – involuntary movements
37
Q

What is the diagnostic criteria for rheumatic fever?

A
  • Diagnosis = Jone’s Criteria
    • Evidence of recent strep throat and 2 majors or 1 major + 2 minors
      • Evidence of recent strep throat:
        • ↑ ISO titre
        • Other streptococcal Abs
        • Group A strep on throat culture
      • Majors - CASES
        • Carditis
        • Arthritis
        • Subcutaneous nodules
        • Erythema marginatum
        • Sydenham’s chorea
      • Minor - FRAPP
        • Fever
        • Raised ESR/CRP
        • Arthralgia
        • Prolonged PR interval
        • Previous rheumatic fever
38
Q

What is the management of rheumatic fever?

A
  • Acutely
    • Bed rest
    • Anti-inflammatory agents
    • High-dose Aspirin - suppresses the inflammatory response of the joints and heart
    • Antibiotics - Amoxicillin - if persistent infection
    • Corticosteroids - if the fever and inflammation doesn’t resolve rapidly
  • Prophylaxis → monthly injections of benzathine penicillin
    • Until 10 years after the last episode or until the age of 21 years or lifelong if severe valve disease
  • Surgical valve repair or replacement may be required
39
Q

What are the signs and symptoms of cardiac failure in a child?

A
  • SoB
  • Poor feeding / Poor weight gain
  • Recurrent chest infections
  • Fatigue
  • Increased RR
  • Increased HR
  • Murmur / Gallop rhythm
  • Signs of venous congestion
  • Enlarged heart
  • Hepatomegaly
  • Cool peripheries
  • Insufficient cardiac output
  • Respiratory distress
  • Pallor
  • FTT
40
Q

What are the causes of cardiac failure in a neonate?

A
  • Duct dependent or Obstructed systemic circulation
    • Hypoplastic L-heart
    • Aortic stenosis
    • Severe coarctation of the aorta
    • Interruption of aortic arch
  • Do not close the ductus arteriosus
  • Volume overload → anaemia, sepsis
  • Pressure overload → hypertension
41
Q

What are the causes of cardiac failure in an infant?

A
  • Defect causing high pulmonary blood flow
    • L-to-R shunt → persistent VSA, ASD, PDA
  • Volume overload → anaemia, sepsis
  • Pressure overload → hypertension
42
Q

What are the causes of cardiac failure in an older child?

A
  • R- or L-HF
    • Eisenmenger (RHF)
    • Rheumatic HD
    • Cardiomyopathy
  • Volume overload → anaemia, sepsis
  • Pressure overload → hypertension
43
Q

What are the appropriate investigations for suspected cardiac failure in a child?

A
  • Obs → O2 sats, BP,
  • Bloods → FBC, U&Es, Ca2+, BNP/ANP
  • CXR
  • ECG
  • Echocardiography
44
Q

What are the appropriate investigations for suspected cardiac failure in a child?

A
  • Obs → O2 sats, BP,
  • Bloods → FBC, U&Es, Ca2+, BNP/ANP
  • CXR
  • ECG
  • Echocardiography
45
Q

What is the management of cardiac failure in a child?

A
  • Reduce preload → Diuretics or GTN
  • Enhance cardiac contractility → Dopamine or Digoxin, Dobutamine, Adrenaline, Milrinone
  • Reduce afterload → ACE inhibitors or Hydralazine, Nitroprusside, Alprostadil
  • Improving oxygen delivery → Beta-blockers
  • Enhance nutrition
  • If cyanotic → Prostaglandin infusion (alprostadil)
46
Q

What is the most common complex cyanotic heart disease?

A

Tricuspid Atresia

47
Q

What are the signs and symptoms of tricuspid atresia?

A
  • Cyanosis and SoB
    • Presents very early (10mins)
  • Ejection Systolic Murmur at left sternal edge
  • Hypoplastic left heart
48
Q

What is the management of tricuspid atresia?

A
  • 1st = Maintain a secure supply of blood to the lungs
    • Option 1: Blalock-Taussig (BT) shunt insertion (between subclavian and pulmonary arteries)
    • Option 2: Pulmonary artery banding operation to reduce pulmonary blood flow if breathless
    • Complete corrective surgery not possible in most cases because only one functioning ventricle
  • 2nd = Glenn operation → connect SVC to pulmonary artery
  • 3rd = Fontan operation → connect IVC to pulmonary artery
49
Q

What is Ebstein’s Abnormality?

A

Malformation of TV leading to severe tricuspid regurgitation → cardiomyopathy.

50
Q

What are associated with Ebstein’s abnormality?

A
  • Maternal lithium use in pregnancy
  • Down’s
51
Q

What are the signs and symptoms of Ebstein’s abnormality?

A
  • Split 1st & 2nd heart sounds
  • Cardiomegaly
52
Q

What are the important investigations for suspected Ebstein’s abnormality?

A

ECHO

53
Q

What is the management of Ebstein’s abnormality?

A
  • Prostaglandins
  • Surgery → Cone repair of tricuspid valve
54
Q

Define Transposition of the Great Arteries..

A

The pulmonary artery and aorta are switched.

  • Aorta is connected to the right atrium and the pulmonary artery is connected to the left atrium
  • Oxygenated blood goes to the lungs and deoxygenated blood is sent to the body
  • Usually fatal immediately → often found alongside VSDs, ASDs, PDAs, etc. which aid mixing in the short-term
55
Q

What are the signs and symptoms of transposition of the great arteries?

A
  • Cyanosis within a few hours
  • Loud S2 → No murmur
56
Q

What are the appropriate investigations for transposition of the great arteries?

A
  • CXR
    • Narrow upper mediastinum (‘egg on side’)
    • Increased pulmonary markings
  • Echocardiography
57
Q

What is the management of transposition of the great arteries?

A
  • Immediate prostaglandin infusion → PDA patency
  • Balloon atrial septoplasty → tears atrial septum down to allow mixing
  • Arterial switch surgery to switch the vessels
  • Must act quickly/within hours → fatal if not
58
Q

What are the causes of outflow cardiac obstruction?

A
  • Aortic Stenosis
  • Pulmonary Stenosis
  • Coarctation of the Aorta
  • Hypoplastic Left-Heart Syndrome
59
Q

What conditions often co-exist with aortic stenosis?

A

Coarctation of aorta ± mitral valve stenosis

60
Q

What are the signs and symptoms of aortic stenosis?

A
  • Ejection Systolic Murmur
  • No Cyanosis
  • Carotid thrill
61
Q

What are the signs and symptoms of pulmonary stenosis?

A
  • Ejection Systolic Murmur - particularly harsh murmur
  • No Cyanosis
62
Q

What is the management of aortic and/or pulmonary stenosis?

A

Transcatheter balloon dilatation

63
Q

What are the signs and symptoms of coarctation of the aorta?

A
  • Asymptomatic in many
  • If symptomatic → presents in 3rd day to a few weeks of life
    • No cyanosis
    • Ejection systolic murmur
    • High BP in arms + Low BP in legs
    • ‘Rib notching’ - occurs due to large collateral intercostal arteries forming
64
Q

What are the appropriate investigations for suspected coarctation of the aorta?

A
  • ECHO
  • Magnetic Resonance Angiography
65
Q

What is the management of coarctation of the aorta?

A
  • Sick infant
    • ABC
    • Prostaglandin infusion guidelines
  • Well child / Stabilised child
    • Surgical repair OR
    • Balloon angioplasty ± stenting
66
Q

What is Hypoplastic Left-Heart Syndrome?

A

Congenital defect in which the mitral valve, left ventricle, aortic valve, and aorta fail to develop properly.

  • Very poorly developed and small left ventricle
67
Q

What is the management of Hypoplastic Left-Heart Syndrome?

A
  • 1st
    • ABC
    • Prostaglandin
  • 2nd
    • Blalock-Taussig (BK) shunt - artificial ductus arteriosus OR
    • Norwood stage 1
  • 3rd
    • BK shunt removed → Glenn or hemi-Fontan → Fontan or TCPC (Total Cavo-pulmonary Connection)
68
Q

What is the most common arrhythmia in children?

A

SVT

69
Q

What are the signs and symptoms of SVT?

A
  • HR 250-300bpm
    • Poor CO
    • Pulmonary oedema
  • Neonatal = HF, hydrops fetalis
  • Foetus = Intra-uterine death
70
Q

What are the appropriate investigations for suspected SVT?

A
  • ECG
    • Narrow complex tachycardia - delta wave in WPW
    • T wave inversion due to ischemia
  • Echocardiography
71
Q

What is the management of SVT?

A
  1. Circulatory and respiratory support → correct tissue acidosis and positive pressure ventilation if needed
  2. Vagal stimulating manoeuvres → e.g. carotid sinus massage, cold ice pack to face = 80% success
  3. IV adenosine → induces AV lock after rapid bolus infusion
  4. Electrical cardioversion with synchronised DC shock if adenosine fails
72
Q

What are the risk factors for infective endocarditis?

A

Any congenital heart defect or abnormality which gives rise to a turbulent blood flow - i.e. VSD

73
Q

What is the most common cause of infective endocarditis?

A

Streptococcus viridians

74
Q

What are the signs and symptoms of infective endocarditis?

A
  • Fever
  • Anaemia / Pallor
  • Clubbing, splinter haemorrhages
  • Necrotic skin lesions (infected emboli)
  • Changing cardiac signs
  • Splenomegaly
  • Neuro signs from cerebral infarct
  • Retinal infarcts
  • Arthritis or arthralgia
  • Microscopic haematuria
75
Q

What are the appropriate investigations for suspected infective endocarditis?

A
  • Multiple blood cultures - before Abx
  • ECHO to identify vegetations
76
Q

What is the management of infective endocarditis?

A
  • High dose penicillin in combination with aminoglycoside - (gentamicin or streptomycin) for 6w IV
  • Surgical removal of infected prosthetic material

a Paediatrics by themes (26 decks)

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