cardiology

Question 1

what are the presentations of CHD

Answer 1

CHF
cyanosis
murmur
rhythm disturbances
other (i.e family hx, screening)

Question 2

what are the causes of CHF

Answer 2

1. volume overload–preload
2. pressure load–afterload
3. myocardial causes
   - -inotropy/contractility
   - -chronotropy/heart rate
   - -lusitropy/relaxation

Question 3

what affects pressure load/afterload in the heart

Answer 3

1. outlet obstruction
   - -coarctation of the aorta
   - -aortic stenosis
   - -interruption of the aorta
   - -HLHS
   - -pulmonary stenosis
2. inlet obstruction
   - -mitral stenosis
   - -TAPVC

Question 4

what causes increased volume load/preload in the heart

Answer 4

1. shunts
   - -ASD, AVSD, VSD, PDA, TAPVC
2. anemia
3. AV valve regurg
4. AV malformation
5. sepsis
6. complex

Question 5

what causes myocardial problems in the heart

Answer 5

1. arrhythmias
2. sepsis
3. viral
4. metabolic
5. asphyxia
6. cardiomyopathy
7. coronary arteries
8. kawasaki disease
9. rheumatic fever
10. adriamycin
11. post-op

Question 6

if all pulses are poor, you think…

Answer 6

myocardial problem

Question 7

if there is a palpable paradox pulse, you think…

Answer 7

pericardial fluid

Question 8

if there are bounding pulses, you think…

Answer 8

run off lesion or sepsis

i.e PDA, truncus arteriosus, aortic interruption, AVM

Question 9

if femoral pulses are weaker than radials, you think…

Answer 9

coarctation of the aorta with or without other lesions

Question 10

if right brachial pulse is the only palpable pulse you think…

Answer 10

aortic interruption

Question 11

if all pulses are decreased, with left brachial more than right, you think…

Answer 11

HLHS (hypoplastic left heart syndrome)

Question 12

what are important points on history of the child with suspected CHD

Answer 12

FEEDING DIFFICULTIES

breathing difficulties
sweating
syncope
family hx

Question 13

when should you worry about syncope

Answer 13

if the patient has….

no typical prodrome

abnormal cardiac exam

abnormal ECG

it is exertional syncope

family history of sudden death

Question 14

what are the key points on physical exam for a murmur

Answer 14

growth parameters
femoral pulses
saturations
second heart sound
axillae

Question 15

what features suggest a normal murmur

Answer 15

normal history
normal peripheral exam
not diastolic 
no thrill
normal S2
usually low pitched, ejection

Question 16

what % of kids have a murmur at some point

Answer 16

80%

Question 17

will you always have a murmur when you have CHD

Answer 17

no

significant CHD can exist without murmur i.e large VSD or coarctation

Question 18

is a murmur a diagnosis

Answer 18

NO

it is a physical sign

Question 19

should you reassure or should you refer?

Answer 19

false reassurance is more dangerous than a “soft referral”

Question 20

what are shunt lesions? in what pattern do symptoms of shunt lesions appear?

Answer 20

communications between systemic and pulmonary circulations

intracardiac shunts require pulmonary vascular resistance to FALL to become symptomatic

usually a GRADUAL onset of symptoms

Question 21

how do rate and rhythm differ between pediatric and adult ecgs

Answer 21

in paeds–
rates are variable with wide range of normal

sinus arrhythmia is common

Question 22

is the right side or left side of the heart dominant in babies?

Answer 22

right side

see this on ecg

right sided dominance regresses over the first decade, particularly over the first few months –> T WAVES INVERTED IN PRECORDIAL LEADS

prominent mid precordial voltages common

Question 23

do you worry as much about ST elevation in paedatric ECGS

Answer 23

no–ST elevation is common

Question 24

what leads do you use to check axis

Answer 24

I and aVF

Question 25

R wave is mostly positive in I and aVF—this means…

Answer 25

normal axis

lies between 0 and +90 degrees

Question 26

R wave is positive in I and negative in aVF–this means…

Answer 26

unclear, need more info

lies between 0 and -90 degrees… could be normal or could be left axis deviation

• -look at lead 2
• -if positive…normal
• -if negative…left axis deviation

Question 27

R wave is negative in I and positive in aVF–this means…

Answer 27

right axis deviation

Question 28

R wave is negative in both I and aVF

Answer 28

either far right or far left axis deviation

Question 29

what is a “superior axis” on ECG

Answer 29

means leftward/left axis deviation

Question 30

on ECG, if you have left axis deviation plus RVH, you think…

Answer 30

AVSD or complex

Question 31

on ECG, if you have left axis deviation and LVH, you think…

Answer 31

tricuspid atresia

Question 32

on ECG, if you have Q waves in I, aVL, V4-6 with left axis, LVH, you think…

Answer 32

anomalous left coronary

Question 33

on ECG, if you have decreased RV forces, you think…

Answer 33

hypoplastic right side

*ebsteins if giant P wave in II

Question 34

on ECG, if you have normal ECG but cyanosis clinically, you think…

Answer 34

transposition of the great arteries

Question 35

on ECG, if you have RVH plus poor femorals, you think…

Answer 35

coarctation of the aorta

Question 36

on ECG, if you have LVH plus poor pulses, you think…

Answer 36

aortic stenosis

Question 37

on ECG, if you have ST changes or low voltages, you think…

Answer 37

myocardial problem

Question 38

reading rate on ECG, what is the trick?

Answer 38

large lines… 300–150–100–75–60–50.

Question 39

how do you assess rhythm on the ECG

Answer 39

regular or irregular

if irregular, how irregular

relationship of P waves to QRS complexes

Question 40

how do you assess P waves in the ECG (what are you looking for?)

Answer 40

large upright P wave in II or V1 suggests right atrial enlargement

broad P wave in II or prominent negative in V1 suggests LAE

Question 41

what are you looking at with the QRS complex?

Answer 41

width

R/S progression

Q, R and S