Cardiology Flashcards
differentiate ausculatory findings for innocent vs pathologic heart mumur
if murmur diminishes/resolves as you move patient from supine to sitting→ likely innocent (BENIGN)
whooshing sounds (turbulent flow from high pressure area to low pressure across a defect) that does not dimish with change output changes→ **PATHOLOGIC **
will radiate in direction of blood flow from initial constriction
physiology of an innocent murmur
LAMINAR flow produces musical, single-frequency sound that is louder with increased cardiac output (fever, anemia, exercise, hyperthyroidism)
History questions to evaluate for congenital heart disease:
-
Feeding difficulties
- feeding for only short periods of time
- “How long to finish a bottle?”
- Often cannot tolerate breastfeeding
- Ashen color/sweating during feeds
- 1st degree relative with cardiac problems
- poor growth (d/t poor feeding & increased metabolic rate)
- Delayed gross motor skills
- Rapid breathing/ neonate with cough
- cyanosis with exercise/exercise intolerance
Name 4 genetic syndromes assoc with cardiac defects:
- Down syndrome: 50% have ASD, VSD, or AVSD
- cardiology eval needed in 1st month of life
- Turner syndrome: 20-40% have coarctation of the aorta
- Edward syndrome: 99% have VSD
- Marfan syndrome: 90% have mitral valve prolapse, aortic root ectasia, predisposed to aortic dissection and sudden cardiac death
PE findings that indicate the possibility of pediatric cardiac defects:
cyanosis of oral mucosa
pulse ox→ R hand & either foot (normal if >95% and <3% difference between UE and LE)
thrills, femoral pulse lag, clubbing of fingers/toes, edema (esp in face or sacrum on infant)
differentiate the cardiac ausculatory findings in children with innocent murmurs
(Still’s, Peripheral pulmonary stenosis, venous hum, pulnary ejection murmur)
MC= Still’s→ vibratory sound, between apex and LSB (2+yo)
*no need to differentiate Still’s and Pulmonary ejection murmur
Peripheral pulmonary stenosis→ axilla, radiating to back (0-18mo)
Venous hum→ L & R infraclavicular region, diminishes when turning pt’s head away from side you are auscultating. The only innocent diastolic murmur!
differentiate cardiac x-ray in pediatric pt with that of an adult in congestive heart failure:
PEDS:
- most of heart silhouette is the RV d/t fetal circulation
- heart size of 50% of chest cavity is normal <2yo
- (vs 1/3 of chest cavity in adults)
- thymus will make mediastimum appear enlarged
explain the physiology of fetal circulation
Fetal circulation:
- foramen ovale shunts blood from RA→LA→LV→Aorta→umbilical arteries
- ductus arteriosus shunts blood from Pulmonary artery→ aorta d/t high pulmonary vascular resistance (physiologic)→ umbilical arteries
- remains open d/t prostaglandin E
- low systemic vascular resistance shunts blood to umbilical arteries
explain the physiology of neonatal cardiac transition:
At Birth:
- Foramen ovale closes d/t increased L-sided pressure at birth
- increased systemic vascular resistance d/t clamping cord
- not NET mov’t of blood across ductus arteriosus
First week of Life:
- 48hrs→ ductus arteriosus closes on pulmonary side
- 4-7 days→ ductus fully closes
4-6 weeks of life:
- Increased pulmonary vascular flow
explain the management approach of pediatric patients with cardiac murmurs in primary care setting
if murmur is 3/6 or greater→refer to peds cardiology (let them order the echo)
if <2mo and any pos Hx or exam findings→ consult peds cardio ASAP
older and stable child→ screen with EKG, refer if abnormal
grade 1-2 murmur and <3weeks old with neg history and physical exam→ likley PFO⇒ recheck weekly (consult peds cardio if concerning s/sx or persists after week 4)
what conditions warrant bacterial endocarditis prophalaxis
Prophalaxis for:
- prosthetic valve
- previous bacterial endocarditis
- congential heart disease
- unrepaired cyanotic CHD
- repaired with prosthetic device (first 6mo post surgery)
- repaired, with residual effects
- cardiac transplant pts who develop valve abnormality
which types of procedures warrant bacterial endocarditis prophalaxis
- dental procedures involoving gingival tissues, oral mucosa, periapical region of teeth (NOT for rountine fillings)
- procedures on respiratory tract, infected skin or MSK tissue
- NOT recommended for GI/GU procedures including hysterectomy
Recommended antibiotic for bacterial endocarditis prophalaxis (given 1 hour before procedure)?
Peds:
Adult:
if allergy to 1st line:
Peds: amoxicillin, 50mg/kg
Adults: 2g amoxicillin
if allergy to PCNs: clindamycin 20mg/kg or cephalexin 50mg/kg
What are highest risk sports for teen risk of sudden cardiac death?
What are most common conditions leading to sudden cardiac death?
basketball and football
MCC: hypertrophic cardiomyopathy- thickened septum (MC in AA males)
- history of near or complete syncopal episodes
Other causes: Arrthymias (esp prolonged QT), aortic stenosis, anomalous coronary arteries
approach to teen pre-sport eval (what to look for, who cannot be cleared and what needs to be referred on):
Concerning Hx: syncope, near syncope (not vaso-vagal), chest pain with exercise)
Look for evidence of cardiac pathology, neuro risk factors, MSK disorders
NEVER clear for sport if murmur or personal or FHx of cardiac pathology
refer to CARDIOLOGY for above or if seen previously by cardiology for a murmur
