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Paediatrics > Cardiology > Flashcards

Cardiology Flashcards

1
Q

At what concentration of deoxyhemoglobin can cyanosis be detected clinically?

A

> 5g/dL

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2
Q

When does the ductus arteriosus close in a term infant?

A
  • Functional closure within the first 15 hours of life
  • Anatomic closure within the first few days of life
    » Usually around 48 hours of life
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3
Q

What is the definition of heart failure?

A

Inadequate cardiac output to meet the metabolic needs of the body

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4
Q

How can we classify congenital heart disease?

A

Cyanotic VS. Acyanotic

Acyanotic
- L>>R Shunts
   >> ASD
   >> PSD
   >> PDA
   >> AVSD/Endocardial cushion defect
- Obstruction
   >> Coarctation of the aorta
   >> Pulmonary stenosis
   >> Aortic stenosis
Cyanotic
- R>>L Shunts
   >> Tetralogy of Fallot
   >> Ebstein's anomaly
- Others
   >> Truncus arteriosus
   >> Transposition of the great vessels
   >> Tricuspid atresia
   >> Pulmonary atresia
   >> Total anomalous pulmonary venous drainage
   >> Hypoplastic left heart syndrome
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5
Q

What conduction defect is Ebstein’s anomaly associated with?

A

Wolff-Parkinson-White disease

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6
Q

What is the most common cause of CHD death in the first month of life?

A

Hypoplastic left heart syndrome

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7
Q

What is shunt volume dependent upon?

A
  1. Size of the defect
  2. Pressure gradient between the two connected chambers or vessels
  3. Peripheral outflow resistance
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8
Q

What are the complications of acyanotic congenital heart disease, mainly the left-to-right shunts?

A
  • Eisenmenger syndrome (pulmonary hypertension&raquo_space; right-to-left shunt)
  • Congestive heart failure
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9
Q

What are the three types of atrial septal defect?

A
  • Ostium primum (endocardial cushion defect)
  • Ostium secundum
  • Sinus venosus
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10
Q

What is the most common type of atrial septal defect?

A

Ostium secundum

  • Enlarged foramen ovale
  • Inadequate growth of the septum secundum
  • Excessive absorption of septum primum
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11
Q

What is the natural clinical course of ASD?

A
  • Congenital heart disease
  • 80-100% spontaneous closure if ASD diameter > Congestive heart failure
    &raquo_space; Pulmonary hypertension
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12
Q

Name 3 diagnostic studies for ASD.

A
  1. ECG: right axis deviation, mild RVH, RBBB
  2. Echocardiogram
  3. Cardiac catheterization
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13
Q

What is the treatment for ASD?

A
  1. Conservative: 80-100% spontaneous closure if <8mm
  2. Treat heart failure
    • Diuretics: frusemide, spironolactone
    • Vasodilators: captopril, hydralazine
    • Digoxin
  3. Surgical/catheter closure – elective at 2-5 years
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14
Q

What are the complications of ASD closure?

A
  • Arrhythmias

- Pericardial effusion

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15
Q

What is the most common congenital heart defect?

A

Ventricular septal defect (30-50%)

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16
Q

What is the management for VSDs?

A

Dependent on the size of VSD

  1. Conservative
    • Most small VSDs close spontaneously
  2. Treat heart failure
    • Diuretics
    • Vasodilators: captopril, hydralazine
    • Digoxin
  3. Surgical closure by 1 year of age
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17
Q

What is the likelihood of developing congestive heart failure in a VSD?

A

By 2 months in moderate-to-large VSD

|&raquo_space; Late secondary pulmonary hypertension if left untreated

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18
Q

What are the presenting features of CHF in a child?

A
  • Poor feeding
  • Delayed growth
  • Decreased exercise tolerance
  • Recurrent URTIs/asthma episodes
  • Tachycardia
  • Tachypnoea
  • Hepatomegaly
  • Cardiomegaly

> > Look for murmurs upon auscultation for congenital heart diseases

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19
Q

What are the four types of VSDs?

A
  1. Muscular
  2. Perimembranous
  3. Supracristal
  4. Inlet (related to AVSD)
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20
Q

What are the complications of surgical repair of VSD?

A
  • Residual VSD
  • Aortic insufficiency
  • Complete heart block
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21
Q

What are the physical findings of a patent ductus arteriosus?

A
  • Tachycardia
  • Bounding pulse
  • Widened pulse pressure
  • Hyperactive precordium
  • Continuous machinery murmur best heard over the left infraclavicular region
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22
Q

What are the possible causes of a hyperactive precordium?

A
  • Tachycardia
  • Ventricular hypertrophy
  • Aortic coarctation
  • Patent ductus arteriosus
  • Hyperthyroidism
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23
Q

What is the natural clinical course of PDA?

A
  • Delayed closure of ductus is common in premature infants (1/3rd in infants > If a PDA persists beyond the first week of life, it is unlikely to close spontaneously
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24
Q

What are the presenting features of a PDA?

A
  • Asymptomatic
  • Poor feeding
  • Apneic or bradycardic spells
  • Use of accessory muscles for breathing
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25
Q

What is the management of PDA?

A
  1. Conservative: spontaneous closure is common in premature infants
  2. Medical: indomethacin/ibuprofen for premature infants
  3. Surgical/catheter closure
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26
Q

What are the indications for surgical/catheter closure of PDA?

A
  • Respiratory distress
  • Failure to thrive
  • Persistence beyond 3 months of age
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27
Q

What are the complications of PDA repair?

A

Residual shunt

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28
Q

What are the presenting features of obstructive heart lesions?

A
  • Decreased urine output
  • Pallor
  • Cold extremities
  • Weak pulses
  • Shock or sudden collapse
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29
Q

What are the common ductal-dependent heart lesions?

A

Pulmonary flow

  • Critical pulmonary stenosis
  • Pulmonary atresia
  • Tricuspid atresia
  • Tetralogy of Fallot
  • Transposition of great vessels
  • Truncus arteriosus
  • Total anomalous pulmonary venous return

Systemic flow

  • Coarctation of the aorta
  • Hypoplastic left heart syndrome
30
Q

When does congestive heart failure typically present?

A

At birth
- Large volume overload lesions
&raquo_space; Tricuspid regurgitation
&raquo_space; Pulmonary regurgitation

First week of life

  • Ductal dependent lesions
  • The ductus usually closes within the first 15 hours functionally and anatomically closes within the first week of life
First-Second months of life
- Significant left-to-right shunts
   >> ASD
   >> VSD
   >> AVSD
   >> PDA
- When increased pulmonary vascular resistance starts to develop
31
Q

What is coarctation of aorta?

A

Narrowing of the aorta, almost always at the level/slightly distal to the ductus arteriosus

32
Q

What are the CXR findings of coarctation of aorta?

A
  • Dilated ascending aorta
  • Coarctation segment
  • Dilated descending aorta
  • Rib notching from dilated intercostal vessels in older children
33
Q

What are the presenting features of coarctation of aorta?

A
  • Upper extremity systolic pressures elevated
  • Decreased blood pressure in lower extremities
  • Weak/absent pulses in the lower extremities
  • Radial-femoral delay in older children
  • Shock in the neonatal period when the ductus closes if obstruction is severe
34
Q

What is the management of coarctation of aorta?

A
  • Keep ductus patent with prostaglandins
  • Surgical correction in neonates: extended end-to-end antastomosis via thoracotomy
  • Catheterization in older children
    &raquo_space; Balloon angioplasty
    &raquo_space; Stent placement
35
Q

What are the 4 types of aortic stenosis?

A
  • Valvular
  • Subvalvular
  • Supravalvular
  • Idiopathic hypertrophic subalrtic stenosis (IHSS) = HOCM
36
Q

What is the management of aortic stenosis?

A

Depends on the type of AS

  • Valvular: balloon valvuloplasty
  • Subvalvular/Supravalvular: surgical repair, exercise restriction required (esp. for HOCM)
37
Q

What are the 3 types of pulmonary stenosis?

A
  1. Supravalvular
  2. Valvular
  3. Subvalvular
38
Q

What is the definition of critical pulmonary stenosis?

A
  • Inadequate pulmonary blood flow
  • Ductus-dependent
  • Progessive hypoxia and cyanosis
39
Q

What is the management for pulmonary stenosis?

A
  1. Conservative
  2. Surgical
    • Critically ill
    • Symptomatic older children
40
Q

What are the four features defining the Tetralogy of Fallot?

A
  1. Pulmonary stenosis
  2. Right ventricular hypertrophy
  3. Ventricular septal defect
  4. Overriding aorta
41
Q

What are “tet spells”?

A

Increased pulmonary vascular resistance with decreased systemic vascular resistance during exertional stage increases the right-to-left shunt of TOF

  • Rapid deep breathing
  • Irritability
  • Increasing cyanosis
  • Decreased intensity of the murmur

> > If severe: seizures and death

42
Q

What are the characteristic CXR finding of the Tetralogy of Fallot?

A

Boot-shaped heart

43
Q

What are the common causes of a right aortic arch?

A
  • Tetralogy of Fallot + pulmonary atresia
  • Classical Tetralogy of Fallot
  • Truncus arteriosus
  • Double outlet right ventricle
  • Single ventricle
44
Q

What is the management of a “tet spell”?

A
  • Knee-chest position
  • Oxygen supplement
  • Fluid bolus
  • Morphine
  • Propanolol
45
Q

What is the management of Tetralogy of Fallot?

A
  • Blalock-Taussig repair/shunt: palliative OT

- Surgical repair at 4-6 months of age

46
Q

What is the management of congestive heart failure in children?

A
  • Sit up
  • Oxygen supplement
  • Diuretics
  • Vasodilators: captopril, hydralazine
  • Digoxin

> > Surgical repair of underlying problem

47
Q

What is the most common cyanotic congenital heart disease in a neonate? What are the associated presenting features

A

Transposition of the Great Arteries (TGA)
» Big blue baby
» Ductus arteriosus closure within the first week causes rapidly progressive hypoxemia that is UNRESPONSIVE TO OXYGEN THERAPY

48
Q

What is the classical CXR finding for transposition of the great arteries?

A

Egg-on-a-string

49
Q

What is the management for transposition of the great arteries?

A
  1. Keep ductus open by PGE1 infusion + balloon atrial septostomy
  2. Surgical repair within the first 2 weeks of life in those without an ASD
50
Q

What is the management for total anomalous pulmonary venous circulation/return?

A

Surgical repair in ALL cases

- Urgently for severe cyanosis

51
Q

What lesion must be present in a child with tricuspid atresia?

A

Atrial septal defect

52
Q

What is the management for truncus arteriosus?

A

Surgical repair within the first 6 weeks of life

53
Q

What are the features of hypoplastic left heart syndrome? Name 4.

A
  • Hypoplastic left ventricle
  • Narrow mitral/aortic valves
  • Small ascending aorta
  • Contracted aorta

> > Culminates to systemic hypoperfusion
DUCTAL-DEPENDENT SYSTEMIC CIRCULATION

54
Q

What is the management for hypoplastic left heart syndrome?

A
  1. Supportive treatment
    » Resuscitate
    » Intubate
    » Correct metabolic acidosis/ electrolyte anomalies
  2. IV infusion of PGE1 to keep ductus open
  3. Surgical
    &raquo_space; Palliative OT
    &raquo_space; Heart transplant
55
Q

What are the features of congestive heart failure in children?

A

Infants

  • Poor feeding with failure to thrive
  • Early fatigability
  • Lethargy
  • Signs of respiratory distress

Children

  • Decreased exercise tolerance
  • Fatigue
  • Decreased appetite
  • Failure to thrive
  • Signs of respiratory distress
  • Recurrent URTIs/asthma episodes
56
Q

What are the four cardinal features of congestive heart failure in children?

A
  • Tachycardia
  • Tachypnea
  • Cardiomegaly
  • Hepatomegaly

+ Failure to thrive

57
Q

What are the causes of congestive heart failure in children?

A

Congenital

  • Congenital heart diseases
  • Arteriovenous malformation
  • Congenital arrhythmias
  • Congenital cardiomyopathies

Acquired

  • Myocarditis
  • Cardiomyopathy
  • Arrhythmias
  • Acute hypertension
  • Cor pulmonale
  • Anemia
58
Q

What are some ECG changes for hyperkalemia?

A
  • Tented T-wave
  • Increased PR interval
  • Widened QRS
  • Absent P-wave
  • Sinusoidal wave in late cases
59
Q

What are some ECG changes for hypokalemia?

A
  • Decrease ST segment
  • Diphasic T-wave
  • Decreased PR interval
  • Shortened QRS
  • U-wave
60
Q

What are some ECG changes for hypocalcemia?

A

Prolonged QT interval

61
Q

What are some ECG changes for hypercalcemia?

A

Shortened QT interval

62
Q

What are the most common mechanisms for supraventricular tachycardia in children?

A

AV re-entry lesions

  • Wolff-Parksinson-White syndrome (Ebstein’s anomaly)
  • HOCM/Dilated myopathy
  • Hyperthyroidism

AV nodal re-entry lesions

63
Q

What is the most frequent sustained dysarrhythmia in children?

A

Supraventricular tachycardia

64
Q

What is the management for SVT?

A 
1. Conservative maneuvres
    >> Ice bag on forehead
    >> Valsalva maneuvre
    >> Carotid massage
2. Electrocardioversion
3. Pharmacotherapy
    >> Adenosine
    >> Verapamil - rarely used
65
Q

What is a benign premature ventricular complex?

A
  • Single
  • Uniform
  • Disappears with exercise
  • No structural lesions
66
Q

What are the common causes of congenital heart block?

A

Maternal anti-Ro or anti-La antibodies (SLE)

  • Often diagnosed in utero
  • May lead to fetal hydrops
67
Q

What are the characteristics of an innocent murmur?

A
  • Systolic
  • Soft and musical in nature
  • Equal or less than grade 2/6
  • Best heard over the left lower sternal border
68
Q

What is the most common complication of PDA in childhood?

A

Infective endocarditis

69
Q

What are the criteria for diagnosing infective endocarditis?

A 
Modified Duke's criteria
1. Major criteria
- Positive blood culture of atypical IE microorganism
   >> Viridans
   >> Strep bovis
   >> Staph aureus
   >> HACEK group
- Evidence of endocardial involvement on ECHO
  1. Minor criteria
    - Any predisposing factors: known cardiac lesions
    - Fever >38C
    - New murmur
    - Any embolic phenomenon
    » Osler nodes
    » Janeway lesions
    » Finger splinter hemorrhages
    » Roth spots on the retina
    » Pulmonary infarcts
    - Immunological problems
    » Glomerulonephritis
    » Rheumatoid factor

> > 1 major + 1 minor
3 minors

70
Q

What is the diagnostic criteria for rheumatic fever?

A 
JONES's criteria
J: Joints (polyarthritis)
O: Heart murmurs
N: Subcutaneous nodules
E: Erythema marginatum
S: Sydenham's chorea

Minor criteria:
Fever 38.2-38.9C
- Raised ESR/CRP
- Leukocytosis
- ECG: features of a heart block (e.g. prolonged PR)
- Previous episodes of rheumatic fever or inactive heart disease

> > 2 major
1 major + 2 minor

71
Q

What is the most appropriate specific treatment for rheumatic fever?

A

Benzathine benzylpenicillin

|&raquo_space; Look out for congestive heart failure

Paediatrics (16 decks)

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