Cardiology Flashcards
1
Q
Pulsus Paradoxus
A
decrease BP > 8-10mmHg in inspiration
DDX: tamponade, asthma, constrictive pericarditis, pericardial effusion
2
Q
Pulsus Bigeminus
A
= two heartbeats close together followed by pause
DDX: HOCM, dig toxicity, low thyroid
3
Q
Atrial Fibrillation DDX
A
PIRATES PE Ischemia MR Anemia Thyrotoxicosis Toxins Electrolytes Sepsis, Stimulants
4
Q
Name 3 Cyanotic CHD + Low pul blood flow
A
"To-Tri" TOF Tricuspid Atresia TR Ebstein Anomaly TAVPR w/ obstruction
5
Q
IDM Hypertrophic Cardiomyopathy Tx
A
Spontaneous resolution.
If symptomatic (Resp, CO, HF) then support (i.e. propranolol).
6
Q
Fetal pO2
A
25-30 mmHg
7
Q
% Asymptomatic PFO in Adults
A
15-25
8
Q
LVH Findings on ECG
A
LAD V1= S Deep Big + wide V6= (R'R= R big) V5-V7= Deep Q waves V5-V7= ST depression, T wave inversion
9
Q
RVH Findings on ECG
A
RAD
V1= rSR’ (big R’)
V1-V3= abnormal T orientation (upright)
V6= S wave Deep + Big
Remember R big first (V1) given ‘R’ in RVH.
10
Q
T21 with previous CHD repair. 2 considerations for diff Sx:
A
R/O pul HTN
R/O undx/residual heart dx
R/O other T21: cervical spine instability, upper airway obstruction, heme imbalance, CBC (Fe) etc.
11
Q
Familial Hypercholesterolemia Mngmt
A
- HMG-CoA reductase inhibitors (Statins)
- Ezetimibe (block cholesterol absorption from gut)
- LDL aphaeresis from blood
- Liver transplant
12
Q
Indomethacin/Indocid AE
A
- Low plt function (GI bleed, IVH)
- NEC
- Transient renal insufficiency
- Spontaneous GI perforation
13
Q
First line med for HF
A
Diuretics; Furosemide most commonly used.
14
Q
Cyanotic Heart Disease: Murmur or not?
A
NOT. Most have murmur and no distress.
15
Q
Name 3 Cyanotic with increased pulmonary volume
A
“The Great-Trunk”
TGA
Truncus Arteriosus
Single Ventricle
TAPVR w/o obstruction
16
Q
Name cyanotic heart lesions
A
- Truncus arteriosus
- Tricuspid Atresia
- Total anomalous pulmonary venous return
- TOF
- TGA
Other: 2 A’s
- Pulmonary Atresia
- Ebstein Anomaly
Other: Critical PS/ AS, Critical Coarc., Hypoplastic L Heart Syn
17
Q
CXR: Egg on String
A
TGA
18
Q
to-and-fro murmur (systole + diastole)
A
Truncus Arteriosus
19
Q
CXR: Boot Shaped
A
TOF
20
Q
CXR: small heart with pulmonary venous congestion (snowman)
A
TAPVR
21
Q
4 Parts of TOF
A
PROV
- Pulmonary atresia/RV outflow tract obstruction
- RVH
- Overriding Aorta
- Large VSD
22
Q
What is a truncus arteriosus
A
dilated aorta overriding a large VSD
23
Q
CXR for TAPVR
A
Snowman
24
Q
How does Hypoplastic Left Heart Syn (HLHS) present?
A
Cardiogenic shock (i.e. 3 d old when PDA closed)
25
Cardiac Assoc. W/ Williams Syn
Supravalvular AS
Williams: elfin, friendly, DD, high Ca2+
26
Cardiac Assoc. W/ Marfan
Mitral Valve Proplapse
| Aortic Root Dilation
27
Tricuspid atresia has normal CXR.
Sorta true +/- decreased pulmonary vasculature (dependent on if associated PS)
28
Prolonged RV Ejection in ASD Causes...
Fixed split S2.
29
TGA vs. Trun Arter. P/E difference.
"The Great Trunk"
Both single S2
TGA: no murmur
Trunc Art: (+) murmur
30
4 Complications PGE1
1. Fever
2. Apnea
3. Hypotension
4. Tachycardia
5. Flushing
31
Vibratory Murmur =
Still's Murmur
- 2-6 yr commonly
- vibratory
- LLSB to apex; NO back
- loud supine, quiet standing
32
Peripheral Pul Stenosis Murmur =
high pitched grade 1-2, base of heart and radiate to axillae and back
33
Supraclavicular Bruit=
low pitch brief SEM at clavicle and radiate to neck. Gone with hyperextending shoulders. No click (which is why not AS)
34
Venous Hum
3-8 y.o.
Roaring Continuous murmur
By clavicles
Loud when sitting
35
Pt with ASD have fixed split S2 due to:
prolonged RV ejection
36
For Fun: Split S2 DDX
ASD
Severe PS
TAPVR
RBBB
37
Still vs. Venous Hum
Still: LLSB, vibratory
Venous: Clavicular, Continuous, gone supine
38
4 Flags for Cardiac Syncope
1. No prodrome
2. Mid-exertion
3. prolonged LOC (>5 min)
4. Fright/startle induced
5. Associated CP, palpitation
6. (+) Hx heart dx
7. New med with potential cardiotoxicity
8. Fhx sudden death, long QT
9. AbN cardiac P/E
39
Viral, Disproportionate Tachy, HF symptoms +/- Rash =
Viral myocarditis
40
Friction Rub=
Pericardial Effusion (i.e. Think Pericarditis)
41
Gallop=
Myocarditis
42
Cardiac Tamponade Beck Triad
1. JVP distension
2. Muffled Heart Sounds
3. HYPOtn for age
43
Diffuse ST elevation
Pericarditis
44
Myocarditis ECG
non specific
- sinus tachy
- ventricular hypertrophy
- low QRS voltage
- inverted T waves
45
Abx Prophylaxis for Infective Endocarditis (IE)
1. Previous IE
2. Unprepared cyanotic congenital heart dx (including palliative shunt and conduit)
3. Prosthetic valve
4. Within 6 mo. of completely repaired congenital heart defect w/ prosthetic material or device
5. Repaired congenital heart dx w/ residual defect at or adjacent to site of prosthetic patch
6. Cardiac transplant w/ valvulopathy
7. Rhematic heart dx (if prosthetic material used in repair)
46
What Abx Prophylaxis for IE to Give
Amox single dose 1h before (to 2h after) procedure
47
Dental prophylaxis needed for what dental procedures
1. Gingival tissue manipulation
| 2. Oral mucosa perforation
48
True or False: You do not need GI/GU IE ABX prophylaxis
TRUE
49
Common Bacterial IE (list w/e you know)
1. Strep viridians
2. Staph aureus
3. Enterococcus (Strep bovis or faecalis)
4. HACEK= Haemophilus influenzae, Acetinobacillus, Cardiobacterium hominis, Eikenella corrodens, Kingella species
5. IVDU= pseudomonas aeurginosa, Serratia marcescens
6. Immunosuppressed, Neo= fungal
50
Infect. Endo. Pathological Dx
Microorganism (Cx or Histology)
| OR pathologic lesion via histology showing active IE
51
Name of Clinical Diagnosis Criteria for Infect. Endo
Duke Criteria.
2 major
OR 1 major + 3 minor
OR 5 minor
52
Name the Duke Criteria. What Does it Dx.
Dx: Infective Endocarditis
Major:
1. (+) BCX for typical bug in 2 sep. Cx.
2. (+) Endocardial involvement on echo.
Minor:
- predisposing PMHX (i.e. cardiac dx, IVDU)
- fever
- vascular: conjunctival hemm, intracranial hemm, arterial emboli, septic pul infarct, janeway lesion
- immunologic: Roth spots, Osler nodes, GN, (+) RF
- bugs (single Cx)
- echo (not major criteria)
53
List four clinical signs of Endocarditis
1. Fever
2. New or change in murmur
3. Conjunctival hemorrhage
4. Janeway Lesion (painless on finger + soles)
5. Roth spot (hemm w/ pale centre)
6. Osler nodes (painful + pad on finger or soles)
7. Splinter hemorrhages
8. Petechiae
9. Signs of HF (rales, edema)
9. Hematuria
54
Most common IE complication
Congestive Heart Failure
55
List diagnostic criteria for KD
"Crash and Burn"
Fever for min. 5 d
+ 4 of 5
1. Conjunctiva
- b/l non purulent injection
2. Rash (NOT vesicle, bullae, petechial)
3. Adenopathy
- cervical; min. 1.5cm diameter; mostly unilateral
4. Strawberry Tongue
/red crack lips, +/- red oral & pharynx mucosa
5. Hands (Palms + Soles)
- red & edema; periungal desquamation in subacute
56
Incomplete KD Def'n
Fever 5 d + 2 or 3 criteria OR infant with fever min. 7d without explanation
57
2 B/W if Incomplete KD
CRP (min. 3 suggestive)
| ESR (min. 40 suggestive)
58
KD BW findings.. list any.
1. high CRP, ESR
2. WBC > 15
3. Anemia
4. Plt > if after 7th day of fever
5. Hypoalbumin
6. ++ ALT
7. Urine sterile pyuria
59
Describe Pompe Disease.
- glycogen storage dx
- AR
- CC: in first 5 mon
- big tongue
- CHF
- hepatomegaly
- hypotonia
- ECG: huge QRS + short PR
- die before 2nd y.o. unless enzyme replacement (Myozyme)
60
4 week old with CHF. Huge voltage on ECG, short PR. Hypotonic, weak, HSM and large tongue.
Pompe Disease.
61
List meds w/ long QT.
1. Abx- clarithro/ erythro/ azithro, TMP/Sulfa, fluroquinolone
2. Antidepressant- TCA (imipramine), amitriptyline (Elavil)
3. Antipsychotic (haldol, risperidone)
4. Ondansetron
5. Antifungal
6. Diuretics (Lasix= low K)
62
Pulseless Electrical Activity. Which drug?
0. 1 mL/kg
| 1: 10 000 IV/IO Epi
63
CPR qualities
1. hard + fast= push min. 1/3 anterior-posterior diameter; min. 100 bpm
2. rotate every 2 min.
3. If no advanced airway 15:2; advanced airway then continuous with breath 8-10 per minute
4. avoid interruption
64
VF/VT arrest.
```
= Shockable Rhythm
CPR immediately
1. Shock= 2J/kg
2. IV access
3. R/A
4. Same Shockable Rhythm
5. Shock= 4 J/kg
6. Epi= 1:10K 0.1mL/kg
Consider advanced airway
```
65
Cardiac Arrest: Asystole/PEA
```
= Unshockable Rhythm
CPR immediately
1. IV access
2. Epi 1:10K 0.1mL/kg
Consider advanced airway
```
66
How do you know if asynchronous or not?
No palpable pulse= Asynchronous.
Pulse= Synchronous.
67
Signs of SVT and Tx
1. Hx (nonspecific; abrupt change)
2. Invariable HR (infant usually 220+; kids 180+)
3. P wave absent/abN
Tx: Adenosine 0.1mg/kg rapid bolus (max 6mg)
68
Neonatal Goitre. What anti-arrhythmic is mom on?
Amiodarone.
69
Bradycardia PALS Drug options
1. Epinephrine
| 2. Adenosine
70
V TACH w/ a pulse. PALS drug options.
Monomorphic= Amiodarone.
If ever w/out pulse = Epi -> Amiodarone or Lidocaine
71
Two things for SVT in stable child.
1. Vagal maneuver (ice, valsalva, breath holding, bear down)
| 2. Adenosine (keep code blue cart nearby as can initiate afib)
72
SVT + unstable. What do you do?
Synchronized DC conversion (1J/kg first; then 2J/kg)
73
Hyperkalemia ECG Findings.
1. Tall peaked T waves.
2. Prolonged PR
3. Disappearing P waves
4. Wide QRS
74
Treatment of Hyperkalemia
1. Calcium gluconate
2. Sodium bicarb (if acidosis)
3. Insulin + Glucose
4. Inhaled salbutamol
5. Ion exchange resin (Kayexelate)
6. Furosemide
75
Neonate with complete heart block. List causes.
1. Maternal SLE
2. Maternal Sjogren Syn
3. Structural: ASD, Post VSD closure, Myocardial Tumour
4. Myocarditis
5. Genetic Association (i.e. Long QT Syn).
76
Single S2 Association. Name Two.
1. TGA
2. Pulmonary Atresia
3. Aortic Atresia.
Single S2= aorta more anterior.
77
Congenital Cyanotic Dx
Pan systolic Murmur
ECG: RAD
TOF
78
HF in Teenager
Acquired likely.
1. Myocarditis
2. Cardiomyopathy.
3. Infective Endocarditis (acquired valvular dx)
3. Other Non-Structural
- HTN, KD, Anemia, Hypothyroidism, Muscular Dystrophy
4. Structural
- R side pressure: severe PS
- L side pressure: severe AS, coarc
- Vol L-R: VSD
- Vol from valve: AR, PR
79
DOL 2. Hydrocephalus + CHF.
Vein of Galen Aneurysm.
Neo w/ AV malformation ppt with HF + progressive hydrocephalus or sz. Dx: Murmur over cranium + Head imaging.
80
What is the Vein of Galen Aneurysm?
NICU + CHF + Hydrocephalus.
| Murmur over cranium.
81
Which virus associated with increased risk of nec fasciitis?
Varicella
82
When to discontinue PALS resus?
1. Usually within 30 min. should see spontaneous circulation efforts as unlikely to survive after 2 doses of epi.
UNLESS recurrent VT, VF, toxic exposure, hypothermia.
83
Hypothermia and when to d/c resus.
When core temp < 30= CPR continues.
1. Rewarm until 32-34C
2. If no effective rhythm then may D/C. Don't have to complete rewarm to stop.
84
RF for Atherosclerosis. List 4.
1. HTN
2. Obesity (abdo fat pad esp)
3. DM
4. FHX premature coronary artery dx (hyperlipidemia familial dx)
5. Smoking
6. Other: Physical inactivity, homocysteine dx, lipoprotein dx.
Risk Factors for Coronary Artery Dx:
1. Male
2. Low BW
3. LGA
4. Hyperlipidemia
5. HTN
6. DM (1 or 2)
7. Smoking
8. Obesity
9. FHX (CAD, premature MI/stroke, PVD)
85
% of population with congenital heart disease
1-2%
86
List CHD with maternal DM:
HOCM
PDA
VSD
87
List CHD with maternal lupus:
heart block
cardiomyopathy
myocarditis
88
List CHD with FASD:
VSD
ASD
PDA
89
List CHD with T21:
AVSD (most classic)
VSD (most common)
ASD
TOF
90
List CHD with Turner Syndrome:
Coarctation
| Bicuspid Ao. Valve
91
Noonan CHD:
Pul Stenosis
| Hypertrophic cardiomyopathy
92
What are pathologic murmurs?
1. Diastolic
2. Grade 3-6
3. Click, thrill, gallop
4. No change with position
(usually benign if louder w/ inspiration or supine)
93
What causes diastolic murmurs?
1. Aortic or pul insufficiency (descrendo)
| 2. Mitral/tricuspid stenosis (mid-diastolic rumble)
94
When is a Holter useful?
1. correlate symptoms w/ ECG changes
2. follow response to med
3. follow pacemaker f'n
95
When is exercise testing helpful?
Heart functional assessment
96
T or F: cardiothoracic ratio > 0.5 is normal
False.
NORMAL= Cardio/Entire thoracic diameter < 0.5 (0.6 if newborn)
97
How do you interpret an ECG?
1. Rate: 300-150-100-75-60-50
2. Rhythm
- p for every QRS
- QRS for every P
- P wave axis normal (upright I, II, AvF)
3. Axis
- I and AVF point twd= R
- I and AVF opposite= Left
4. P wave
- Tall (>3)= RA big
- Wdie (>3)= LA big
5. PR
- PR> 3= 1st
- 2nd - type 1= progression w/ dropped beat and sinus beat return w/ shorter PR
- 2nd- type 2= drop
- 3rd= no relation btwn P + QRS
6. Delta wave= WPW
7. QRS
< 3 box
RBBB= RAD, (V1) MoRRoW (V6)
LBBB= LAD, (V1) WiLLiaM(V6)
8. QTc= QT/square root (RR)
9. ST
- normal up to 1mm
- diffuse up= pericarditis, myocarditis, pericardial effusion
- local ST= coronary ischemia
10. T wave
- 0-7 DOL= T up V1
- 7d-7 y.o.= T inverted V1
- teen= T upright in V1
11. U wave
98
Describe WPW ECG findings:
1. Delta wave
2. Short PR followed by wide QRS
WPW= Wolf-Parkinson-White
- cut through conduction pathway (bundle of Kent)
99
What type of axis does AVSD have?
Left or northwest
100
ASD commonly has what ECG finding?
RBBB pattern in V1
101
Hypokalemia ECG findng
Flat T wave (or U wave)
102
First questions if QRS wide on ECG?
QRS: Narrow or Wide
- Wide= V-Tach
* also consider WPW
- Narrow= Look at P/QRS ratio
1:1= SVT or AVNRT
p>QRS Reg= Flutter
p>QRS chaotic= Fib
p>QRS variable= Ectopic tachy
103
Which supra ventricular tachycardia has slow to start and slow to cool down tachycardia?
Atrial ectopic tachy
vs. sudden= AVNRT, AVRT
104
In which patients do you see a-flutter or a-fib?
Post-op CHD
105
First line long-term treatment for supra ventricular tachycardia?
Beta blocker.
If resistant can try others or radio ablation.
106
Why do we worry about WPW?
You have 1:1 with atrial fibrillation= high rate= syncope and risk of sudden death
107
If you see atrial fibrillation what associated condition do you always look for on ECG?
WPW
= Delta Waves!
108
List causes of ventricular tachycardia?
"CHILL KLM"
- CHD
- Idiopathic VT
- Long QT
- Lytes= ++ K, low Mg
- Myocarditis
- Arrhythmogenic RV dysplasia
109
How do you manage ventricular tachycardia?
ABC- PALS
Etiology
Acute: *amiodarone, lidocaine
Chronic: amiodarone, defibrillator, ablation
110
List two reasons for PAC and PVC:
PAC: stimulant, caffeine, hypoxia, hyperthyroid
PVC: *hypoxia, cardiomyopathy, lytes, cardiac tumours
111
When do I care about PVC's?
- underlying CHD
- polymorphic
- > 100 in 24 hour
- pmhx or fhx of sudden death or syncope
112
What causes CHF:
L-R shunt: VSD, AVSD, ASD, PDA
Cardiomyopathy (dilated, hypertrophic, restrictive)
Obstructive:
- coarc
- interrupted Ao. arch
- hypoplastic L heart
- Ao. stenosis
113
CHF Management
- Rest as needed
- Diet: more calories (120% nutritional intake)
- Low Na not recommended routinely
- Tx any specific cause (i.e. SVT, anemia, low thyroid)
- Med Tx: Lasix q6h
- If structural- grow until big enough for Sx
114
CHF: 2's of what
```
2 tachy + megaly
= tachy HR
= tachy RR
= cardiomegaly
= hepatomegaly
```
115
Name causes of CHF per pop'n:
- Fetus
- Neonate
- Infant/Toddler
- Child
- Teen
Fetus:
- severe anemia (hemolysis, fetal-materal transfusion)
- SVT
Prem: PDA, fluid ++
1st week: HLH (d3-5), severe AS, Coarc (d7-10), SVT > 24h
week 2-6:
- L-R: VSD, AVSD
- L obstructive: Coarc, AS
- KD
Kid: PUMP
- Viral myocarditis (RF, Endocarditis, Arrhythmia)
- Cardiomyopathy (acute HTN, cor pulmonate)
116
When does the PDA functionally versus anatomically close?
```
Functional= 24-48h
Anatomy= 4-6 wk
```
117
Most common type of ASD?
Secundum (50-70%) (around PFO)
> Primum (inferior part)
> Sinus Venous (superior)
118
ECG of ASD?
Right ++
= RAD, RA enlargement, RVH, incomplete RBBB
119
Close ASD if:
1. symptomatic
2. CHF
3. +++ pul pressure
4. volume load RV
5. big (>8mm)
6. sinus venosus ASD (superior location)
120
List 3 complications of ASD:
1. pul HTN (in 30s-40s)
2. arrhythmia (Afib, flutter- in 40-50s)
3. stroke (rare)
4. CHF (rare)
121
Most common CHD?
VSD
122
When does CHF with VSD present
3-4 weeks of age
- CHF
- FTT
- high RR
- 3/6 pan systolic murmur at LLSB
123
Child with large VSD get better at 6-9 mon. and quieter. Why is there no murmur anymore?
- PUL HTN
| - Not because it closed, large do not close on own (vs. 80% small muscular do)
124
What is an unrestricted VSD?
When RV pressure= LV pressure b/c VSD very large
125
Optimal time for VSD Sx
4-6 mo. old
| Sx patch
126
Contraindication for VSD Sx?
Pulmonary HTN
127
Baby presents with shock at 2 wks of age. List three categories to think of:
1. Sepsis
2. Cardiac- critical coarc, AS, hypo plastic LH
3. Metabolic-
128
All F babies with coarctation must be screened for:
Turner's syndrome.
129
Most common congenital cardiac anomaly associated with Coarc:
```
Hypoplastic arch
OR
Bicuspid Aortic Valve
OR
VSD
```
130
Older child with HTN. Which Cardiac lesion must you R/O and how?
Coarc.
- HTN
- Arm/leg BP gradient (worry if > 20)
- femoral pulses
- ECG: LVH
131
List two CXR findings of coarc in newborn and older kids.
Newborns= CHF:
- cardiomegaly
- pul edema
Older=
1. Rib notching
2. 3 sign
132
List complications of coarc Sx:
1. Rebound HTN
2. Aortic Aneurysm
3. Re-coarc
4. Aortic dissection
133
Hypo plastic Left Heart usually presents how?
Cardiogenic shock
@4-7d due to PDA closure.
Acyanotic
134
HLH Sx?
Norwood-Fontan
135
Most common cyanotic lesion of childhood
TOF
136
Which syndrome do you think of w/ TOF
DiGeorge
```
CATCH-22
C: cardiac (aortic arch, TOF)
A: abN facies (small jaw, funky ears)
T: thymic aplasia (T cell related)
C: cleft palate
H: hypoCa (no PTH= low Ca, high phosphate, low PTH)
```
137
Tell me the difference btwn Pink vs. Blue TET
RVOT obstruction
little RVOT= PINK
- balanced shunt across VSD, more signs of CHF
++ RVOT= BLUE
- pul Q depend on PDA but as close you have severe cyanosis and R-L shunt
138
What is a tet spell?
```
R-L shunt +++
- crying, agitated
= more RVOTO
= more R-L shunt across vSD
= less Pul Q
= systemic hypoxemia + acidosis
= further aggravate RVOTO
= if profound cyanosis =sycnope
```
139
How do you treat a txt spell?
1. ABC
- O2 (lower PVR)
- +/- Bolus
2. Knee to chest to squat (increase BP to reduce R-L shunt)
3. Reduce HR/ obstruction
- morphine (Sedate)
- cool
- beta blocker
- phenylepinephrine
140
TOF ECG findings
RAD
| RVH
141
Untreated TOF at risk for:
1. cerebral thrombosis (if < 2 and why avoiding dehydration and Hct ++ key)
2. bacterial endocarditis
3. brain abscess (if > 2)
142
Primary repair for TOF
4-6 month
Early Sx w/ PGE if severe
143
Most common TOF complications post-op
1. Residual RVOTO/ VSD
| 2. Pul Valve Regurg
144
Most common cyanotic lesion in newborns?
TGA
- RF: gDM, M sex
145
Single S2 + no murmur + cyanosis at birth
TGA
146
Why do you want to do TGA Sx repair within 2 week of life?
- LV mass reduce over 1st week of life as pulmonary pressure decrease
- if try Sx later LV mass and pressure reduced = LV can't generate enough pressure to pump blood through high pressure systemic circulation
- so if present > 4 week do PA band to re-condition LV and then arterial switch
147
What is acute Rhematic fever? (lay terms)
systemic immune dx that develop after infection w/ streptococcus bacteria (usually GAS)
148
What types of infections does Group A streptococcus infection produce?
Suppurative
- Pharyngitis
- Tonsillitis
- Impetigo
- Cellulitis
- Pneumonia etc.
Non-Suppurative
- ARF
- Acute PSGN
- Meningitis
- TSS
- Nec Fas
149
What is usually the first symptom of ARF?
- arthritis (large joint, migratory)
150
List symptoms of ARF:
- large joint migratory arthritis
- pericardial rub or murmur
- jerky movements (chorea)
- small nodule or bump under skin (subcut nodules)
- rash (erythema marginatum)
- fever
151
What is the name of ARF Criteria:
Jones Criteria.
2 major or 1 major + 2 minor
152
How do you meet criteria for ARF:
Jones Criteria
Evidence of GAS infection+
2 major
OR 1 major + 2 minor
153
What are the Jones Criteria?
Recent strep (Cx, rapid, ASOT)
```
Major:
J= Joints= polyarthritis
O= other= pancarditis (affect valves first)
N= Nodules subcut
E= Erythema Marginatum
S= Sydenham chorea
```
```
Minor: ABC FPR
Arthralgia
B= BW (WBC, ESR, CRP)
F= Fever
Previous ARF
PR prolonged
```
154
How do you treat ARF?
1. Arthritis: pred or ibuprofen
2. CHF
- diuretics, nutrition
- +/ Sx if severe
- carditis= pred until BW normal
3. Nodules + Rash self resolve
4. Chorea
- haldol
- Na valproate
4. Infection
= Pen G
5. Prophylaxis
to avoid recurrent cardiac dx
- pen V daily
- generally ~x 5 year or until 21 y.o. (which ever longer)
155
Which pt do you check BP on in appointments?
1. min. 3 y.o.
2. < 3 IF
- prem
- CHD
- renal dx
- solid organ transplant
- CA
- tx w/ drug that raises BP
- other assoc. illness (NF, TS)
- ICP signs
156
How do you check BP
- auscultation
- sit x 5 min
- cuff cover 2/3 of arm
- cuff cover 80-100% of circumference
157
How many measurements do you need to dx BP?
3
158
Defined HTN stages:
** old definition**
preHTN: 90-94% tile for ht, wt, gender
Stage 1: 95th to 99%+5
Stage2: > 99% +5 (usually assoc. w/ secondary causes)
159
What is a HTN crisis/emergency?
symptomatic elevated BP + evidence of end-organ damage (brain/encephalitis, eye, kidney/AKI, HF)
vs. urgency= acute severe but no target organ damage
160
Common cause of secondary HTN in prem
- umbilical a. catherization
| - renal a. thrombosis
161
Common causes of secondary HTN in pre-teen
- renal dx (GN, congenital anomaly, reflux)
- coarc
- pheo, cushing
162
List conditions associated w/ chronic HTN in kids:
- Renal: chronic pyelo, GN, congenital dysplastic kidney, multi cystic kidney etc.
- Vascular: coarc, renal artery lesion (stenosis, fibromuscular dysplasia, thrombosis), umbilical a. cath, NF
- Endo: pheochromocytoma, hyperaldosteronism (Conn= low K), Cushing (+++ steroid), hyperthyroid, hyperparathyroid, CAH
- CNS: mass, hemorrhage, following brain injury, OSA
- Drugs:
OCP, nasal decongestant, immunosuppressant, steroid use
163
T or F: primary HTN more common than secondary in adolescence
True
164
When do you start drugs in HTN?
- symptomatic (H/a, vomiting, vision, encephalopathy)
- end-organ damage
- stage 2
- secondary HTN cause
- stage 1 w/ DM (T1, T2)
- stage 1 + failed 4-6 wks lifestyle change
165
General HTN drug to consider
ACEI (enalapril, captopril)
- good for DM, cautious for RF (watch K, Cr)
*Contraindicated in renal artery stenosis.
166
List 2 Primary and secondary causes of hyperlipidemia:
Primary= inherited
- Familial Hypercholesterolemia
- Familial Combined Hypercholesterolemia
Secondary
- up cholesterol= *hypothyroid, *nephrotic, cholestasis, *cyclosporine
- up TG= obesity, *T2DM, *cushing, hepatitis, steroids
- reduce HDL= smoking, *obesity, T2 DM
167
What's the most common gene mutation associated with CAD in adults?
Heterozygous Familial Hypercholesterolemia
- very high cholesterol in kids should prompt screen
168
Who gets screened for hyperlipidemia?
Fasting lipid panel between 2-10 y.o. if meet 1 of:
- FHX (premature dx)
- missing fhx but RF (obesity, HTN, smoking, DM)
- DM>5 or 12 y.o.
- high cholesterol
169
First line treatment for dyslipidemia?
6 month of lifestyle modification.
- Diet: fruit, veg, whole grain, low fat dairy
- Activity: 60 min. mod-big play daily
If fail= drug= statin 1st line. Contraindicated if pregnant.
3. Bile acid sequestration (cholestyramine)
4. Niacin
170
Two AE to look Statin (why we do BW)
1. Myositis (CK)
| 2. Hepatitis (AST, ALT)
171
How is Marfan syndrome inherited?
AD (fibrillin mutation)
172
List some features of Marfans
- ectopia lentis (superior subluxation)
- pneumothorax
- aortic root dilation
- mitral valve prolapse
- pectus excavatum
- scoliosis
- arm/ht ratio > 1
- long finger
- joint laxity (thumb sign, wrist sign)
- pes plenus
- lax skin
173
Two cardiac conditions associated with Marfan Syndrome.
1. Mitral valve prolapse.
| 2. Aortic root dilatation
174
low pitch SEM + fixed S2
ASD
175
SEM radiate to neck
AS
176
SEM radiate to back
PS, PDA, coarc
177
high pitch short systolic murmur at LLSB
small VSD
| MR
178
When are you at risk of Torsades de Pointes?
1. Long QT syn
2. Hypomagnesia
Torsade de Pointes= Polymorphic VT
179
What is the difference between Jervell and Lange Nielsen Syndrome and Romano-Ward Syn for Long-QT?
J and L-N:
- AR
- sensorineural hearing loss
Romano-Ward
- AD
- more common
- cardiac only
180
List Lytes that cause Issues
Long-QT= LOW
- low K
- low Ca
- low Mg
181
Classic ppt of long-QT syndrome?
Syncope w/ exercise, fright, startle
182
Normal QTC
Boy: < 0.45
Girl: < 0.47
183
First line med for long-QT syndrome?
Beta blocker
*always make sure not acquired (meds, lytes)
184
T or F: length of QTC predict sudden cardiac death.
TRUE
185
WPW at risk of:
1. SVT
2. Syncope
3. Sudden death
186
ECG: LAD.
Association:
1. AVSD
2. Small RV (tricuspid atresia)
3. Noonan
187
When do you given Plaivizumab ( monoclonal IgG antibody against RSV) to kids with CHD?
< 1 y.o.
w/ cyanotic CHD
or hemodynamically significant CHD (requiring med)
- 5 doses throughout season; can give any time after OR too
- don't forget about flu (if > 6 mo.) + regular immunization
188
List two complications to be aware of if prompt says Fontan procedure:
1. Protein losing enteropathy.
2. Plastic Bronchitis (productive cough)
Note: Fontan part of single functional ventricle as 2nd Sx (2-4 yr).
189
Broad System based DDX for cyanotic newborn
1. Heart
- cyanotic CHD
- severe CHF
2. Lung (parenchymal like RDS, pul hem; non parenchymal like pleural effusion, CDH)
3. Neuro (hypovent)
4. Blood (polycythemia, methemglobinemia)
190
Initial Management of Cyanotic BB
!!! ABC + IV!!!
- Transillumination, CXR
- CBC, Ca, Mg, glucose, gas, BCX
- Correct issue, Temp
!!! - ABX if sepsis
!!!!- If no change w/ O2 think PGE (prostaglandin 0.05 mcg/k/gmin.)
- Cardio call
191
Most common cause of myocarditis
Viral.
- Other: Bacterial, Fungal, Protozoal
- Non-infectious: AI KD, SLE, ARF, IBD, Drugs (chemo, cocaine)
192
Common VS change on myocarditis presentation?
+++ tachy HR out of proportion to degree of fever
193
```
Prodromal Illness
+ Fever
+ Disproportionate Tachy
+ HF symptom
=
```
Myocarditis
194
Common categorical of pericarditis aetiologies?
Infectious: viral, bacterial, protozoal, fungal
AI: SLE, ARF, Sarcoidosis
Metabolic: uremia, thyroid
Other: CA, trauma, FMF
195
Stabbing pleuritic CP that is worse laying flat=
Pericarditis
196
Friction Rub
+ Muffled Heart Sounds
+ HF/JVP up
Pericarditis
197
ECG stages of Pericarditis (1-4)
```
1= ST elevation
2= T wave flat
3= Inverted T
4= Normal
```
198
First line treatment for stable pericarditis
Ibuprofen or prednisone.
Unstable = ABC + Pericardiocentesis.
199
Do ASD's typically cause CHF
NO!
- unless something blocking mitral valve!
200
Janeway lesion versus Osler Node
Janeway= palms + soles; flat; hemm
* NON-TENDER
Osler= tips of fingers + toes; immunologic
*VERY PAINFUL; "O it hurts!!"
201
Aschoff bodies on pathology=
Rheumatic Fever
