Cardiology Flashcards
Pulsus Paradoxus
decrease BP > 8-10mmHg in inspiration
DDX: tamponade, asthma, constrictive pericarditis, pericardial effusion
Pulsus Bigeminus
= two heartbeats close together followed by pause
DDX: HOCM, dig toxicity, low thyroid
Atrial Fibrillation DDX
PIRATES PE Ischemia MR Anemia Thyrotoxicosis Toxins Electrolytes Sepsis, Stimulants
Name 3 Cyanotic CHD + Low pul blood flow
"To-Tri" TOF Tricuspid Atresia TR Ebstein Anomaly TAVPR w/ obstruction
IDM Hypertrophic Cardiomyopathy Tx
Spontaneous resolution.
If symptomatic (Resp, CO, HF) then support (i.e. propranolol).
Fetal pO2
25-30 mmHg
% Asymptomatic PFO in Adults
15-25
LVH Findings on ECG
LAD V1= S Deep Big + wide V6= (R'R= R big) V5-V7= Deep Q waves V5-V7= ST depression, T wave inversion
RVH Findings on ECG
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.
T21 with previous CHD repair. 2 considerations for diff Sx:
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.
Familial Hypercholesterolemia Mngmt
- HMG-CoA reductase inhibitors (Statins)
- Ezetimibe (block cholesterol absorption from gut)
- LDL aphaeresis from blood
- Liver transplant
Indomethacin/Indocid AE
- Low plt function (GI bleed, IVH)
- NEC
- Transient renal insufficiency
- Spontaneous GI perforation
First line med for HF
Diuretics; Furosemide most commonly used.
Cyanotic Heart Disease: Murmur or not?
NOT. Most have murmur and no distress.
Name 3 Cyanotic with increased pulmonary volume
“The Great-Trunk”
TGA
Truncus Arteriosus
Single Ventricle
TAPVR w/o obstruction
Name cyanotic heart lesions
- 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
CXR: Egg on String
TGA
to-and-fro murmur (systole + diastole)
Truncus Arteriosus
CXR: Boot Shaped
TOF
CXR: small heart with pulmonary venous congestion (snowman)
TAPVR
4 Parts of TOF
PROV
- Pulmonary atresia/RV outflow tract obstruction
- RVH
- Overriding Aorta
- Large VSD
What is a truncus arteriosus
dilated aorta overriding a large VSD
CXR for TAPVR
Snowman
How does Hypoplastic Left Heart Syn (HLHS) present?
Cardiogenic shock (i.e. 3 d old when PDA closed)
Cardiac Assoc. W/ Williams Syn
Supravalvular AS
Williams: elfin, friendly, DD, high Ca2+
Cardiac Assoc. W/ Marfan
Mitral Valve Proplapse
Aortic Root Dilation
Tricuspid atresia has normal CXR.
Sorta true +/- decreased pulmonary vasculature (dependent on if associated PS)
Prolonged RV Ejection in ASD Causes…
Fixed split S2.
TGA vs. Trun Arter. P/E difference.
“The Great Trunk”
Both single S2
TGA: no murmur
Trunc Art: (+) murmur
4 Complications PGE1
- Fever
- Apnea
- Hypotension
- Tachycardia
- Flushing
Vibratory Murmur =
Still’s Murmur
- 2-6 yr commonly
- vibratory
- LLSB to apex; NO back
- loud supine, quiet standing
Peripheral Pul Stenosis Murmur =
high pitched grade 1-2, base of heart and radiate to axillae and back
Supraclavicular Bruit=
low pitch brief SEM at clavicle and radiate to neck. Gone with hyperextending shoulders. No click (which is why not AS)
Venous Hum
3-8 y.o.
Roaring Continuous murmur
By clavicles
Loud when sitting
Pt with ASD have fixed split S2 due to:
prolonged RV ejection
For Fun: Split S2 DDX
ASD
Severe PS
TAPVR
RBBB
Still vs. Venous Hum
Still: LLSB, vibratory
Venous: Clavicular, Continuous, gone supine
4 Flags for Cardiac Syncope
- No prodrome
- Mid-exertion
- prolonged LOC (>5 min)
- Fright/startle induced
- Associated CP, palpitation
- (+) Hx heart dx
- New med with potential cardiotoxicity
- Fhx sudden death, long QT
- AbN cardiac P/E
Viral, Disproportionate Tachy, HF symptoms +/- Rash =
Viral myocarditis
Friction Rub=
Pericardial Effusion (i.e. Think Pericarditis)
Gallop=
Myocarditis
Cardiac Tamponade Beck Triad
- JVP distension
- Muffled Heart Sounds
- HYPOtn for age
Diffuse ST elevation
Pericarditis
Myocarditis ECG
non specific
- sinus tachy
- ventricular hypertrophy
- low QRS voltage
- inverted T waves
Abx Prophylaxis for Infective Endocarditis (IE)
- Previous IE
- Unprepared cyanotic congenital heart dx (including palliative shunt and conduit)
- Prosthetic valve
- Within 6 mo. of completely repaired congenital heart defect w/ prosthetic material or device
- Repaired congenital heart dx w/ residual defect at or adjacent to site of prosthetic patch
- Cardiac transplant w/ valvulopathy
- Rhematic heart dx (if prosthetic material used in repair)
What Abx Prophylaxis for IE to Give
Amox single dose 1h before (to 2h after) procedure
Dental prophylaxis needed for what dental procedures
- Gingival tissue manipulation
2. Oral mucosa perforation
True or False: You do not need GI/GU IE ABX prophylaxis
TRUE
Common Bacterial IE (list w/e you know)
- Strep viridians
- Staph aureus
- Enterococcus (Strep bovis or faecalis)
- HACEK= Haemophilus influenzae, Acetinobacillus, Cardiobacterium hominis, Eikenella corrodens, Kingella species
- IVDU= pseudomonas aeurginosa, Serratia marcescens
- Immunosuppressed, Neo= fungal
Infect. Endo. Pathological Dx
Microorganism (Cx or Histology)
OR pathologic lesion via histology showing active IE
Name of Clinical Diagnosis Criteria for Infect. Endo
Duke Criteria.
2 major
OR 1 major + 3 minor
OR 5 minor
Name the Duke Criteria. What Does it Dx.
Dx: Infective Endocarditis
Major:
- (+) BCX for typical bug in 2 sep. Cx.
- (+) 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)
List four clinical signs of Endocarditis
- Fever
- New or change in murmur
- Conjunctival hemorrhage
- Janeway Lesion (painless on finger + soles)
- Roth spot (hemm w/ pale centre)
- Osler nodes (painful + pad on finger or soles)
- Splinter hemorrhages
- Petechiae
- Signs of HF (rales, edema)
- Hematuria
Most common IE complication
Congestive Heart Failure
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
Incomplete KD Def’n
Fever 5 d + 2 or 3 criteria OR infant with fever min. 7d without explanation
2 B/W if Incomplete KD
CRP (min. 3 suggestive)
ESR (min. 40 suggestive)
KD BW findings.. list any.
- high CRP, ESR
- WBC > 15
- Anemia
- Plt > if after 7th day of fever
- Hypoalbumin
- ++ ALT
- Urine sterile pyuria
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)
4 week old with CHF. Huge voltage on ECG, short PR. Hypotonic, weak, HSM and large tongue.
Pompe Disease.
List meds w/ long QT.
- Abx- clarithro/ erythro/ azithro, TMP/Sulfa, fluroquinolone
- Antidepressant- TCA (imipramine), amitriptyline (Elavil)
- Antipsychotic (haldol, risperidone)
- Ondansetron
- Antifungal
- Diuretics (Lasix= low K)
Pulseless Electrical Activity. Which drug?
- 1 mL/kg
1: 10 000 IV/IO Epi
CPR qualities
- hard + fast= push min. 1/3 anterior-posterior diameter; min. 100 bpm
- rotate every 2 min.
- If no advanced airway 15:2; advanced airway then continuous with breath 8-10 per minute
- avoid interruption
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
Cardiac Arrest: Asystole/PEA
= Unshockable Rhythm CPR immediately 1. IV access 2. Epi 1:10K 0.1mL/kg Consider advanced airway
How do you know if asynchronous or not?
No palpable pulse= Asynchronous.
Pulse= Synchronous.
Signs of SVT and Tx
- Hx (nonspecific; abrupt change)
- Invariable HR (infant usually 220+; kids 180+)
- P wave absent/abN
Tx: Adenosine 0.1mg/kg rapid bolus (max 6mg)
Neonatal Goitre. What anti-arrhythmic is mom on?
Amiodarone.
Bradycardia PALS Drug options
- Epinephrine
2. Adenosine
V TACH w/ a pulse. PALS drug options.
Monomorphic= Amiodarone.
If ever w/out pulse = Epi -> Amiodarone or Lidocaine
Two things for SVT in stable child.
- Vagal maneuver (ice, valsalva, breath holding, bear down)
2. Adenosine (keep code blue cart nearby as can initiate afib)
SVT + unstable. What do you do?
Synchronized DC conversion (1J/kg first; then 2J/kg)
Hyperkalemia ECG Findings.
- Tall peaked T waves.
- Prolonged PR
- Disappearing P waves
- Wide QRS
Treatment of Hyperkalemia
- Calcium gluconate
- Sodium bicarb (if acidosis)
- Insulin + Glucose
- Inhaled salbutamol
- Ion exchange resin (Kayexelate)
- Furosemide
Neonate with complete heart block. List causes.
- Maternal SLE
- Maternal Sjogren Syn
- Structural: ASD, Post VSD closure, Myocardial Tumour
- Myocarditis
- Genetic Association (i.e. Long QT Syn).
Single S2 Association. Name Two.
- TGA
- Pulmonary Atresia
- Aortic Atresia.
Single S2= aorta more anterior.
Congenital Cyanotic Dx
Pan systolic Murmur
ECG: RAD
TOF
HF in Teenager
Acquired likely.
- Myocarditis
- Cardiomyopathy.
- Infective Endocarditis (acquired valvular dx)
- Other Non-Structural
- HTN, KD, Anemia, Hypothyroidism, Muscular Dystrophy - Structural
- R side pressure: severe PS
- L side pressure: severe AS, coarc
- Vol L-R: VSD
- Vol from valve: AR, PR
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.
What is the Vein of Galen Aneurysm?
NICU + CHF + Hydrocephalus.
Murmur over cranium.
Which virus associated with increased risk of nec fasciitis?
Varicella
When to discontinue PALS resus?
- 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.
Hypothermia and when to d/c resus.
When core temp < 30= CPR continues.
- Rewarm until 32-34C
- If no effective rhythm then may D/C. Don’t have to complete rewarm to stop.
RF for Atherosclerosis. List 4.
- HTN
- Obesity (abdo fat pad esp)
- DM
- FHX premature coronary artery dx (hyperlipidemia familial dx)
- Smoking
- Other: Physical inactivity, homocysteine dx, lipoprotein dx.
Risk Factors for Coronary Artery Dx:
- Male
- Low BW
- LGA
- Hyperlipidemia
- HTN
- DM (1 or 2)
- Smoking
- Obesity
- FHX (CAD, premature MI/stroke, PVD)
% of population with congenital heart disease
1-2%
List CHD with maternal DM:
HOCM
PDA
VSD
List CHD with maternal lupus:
heart block
cardiomyopathy
myocarditis
List CHD with FASD:
VSD
ASD
PDA
List CHD with T21:
AVSD (most classic)
VSD (most common)
ASD
TOF
List CHD with Turner Syndrome:
Coarctation
Bicuspid Ao. Valve
Noonan CHD:
Pul Stenosis
Hypertrophic cardiomyopathy
What are pathologic murmurs?
- Diastolic
- Grade 3-6
- Click, thrill, gallop
- No change with position
(usually benign if louder w/ inspiration or supine)
What causes diastolic murmurs?
- Aortic or pul insufficiency (descrendo)
2. Mitral/tricuspid stenosis (mid-diastolic rumble)
When is a Holter useful?
- correlate symptoms w/ ECG changes
- follow response to med
- follow pacemaker f’n
When is exercise testing helpful?
Heart functional assessment
T or F: cardiothoracic ratio > 0.5 is normal
False.
NORMAL= Cardio/Entire thoracic diameter < 0.5 (0.6 if newborn)
How do you interpret an ECG?
- Rate: 300-150-100-75-60-50
- Rhythm
- p for every QRS
- QRS for every P
- P wave axis normal (upright I, II, AvF) - Axis
- I and AVF point twd= R
- I and AVF opposite= Left - P wave
- Tall (>3)= RA big
- Wdie (>3)= LA big - 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 - Delta wave= WPW
- QRS
< 3 box
RBBB= RAD, (V1) MoRRoW (V6)
LBBB= LAD, (V1) WiLLiaM(V6) - QTc= QT/square root (RR)
- ST
- normal up to 1mm
- diffuse up= pericarditis, myocarditis, pericardial effusion
- local ST= coronary ischemia - T wave
- 0-7 DOL= T up V1
- 7d-7 y.o.= T inverted V1
- teen= T upright in V1 - U wave
Describe WPW ECG findings:
- Delta wave
- Short PR followed by wide QRS
WPW= Wolf-Parkinson-White
- cut through conduction pathway (bundle of Kent)
What type of axis does AVSD have?
Left or northwest
ASD commonly has what ECG finding?
RBBB pattern in V1
Hypokalemia ECG findng
Flat T wave (or U wave)
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
Which supra ventricular tachycardia has slow to start and slow to cool down tachycardia?
Atrial ectopic tachy
vs. sudden= AVNRT, AVRT
In which patients do you see a-flutter or a-fib?
Post-op CHD
First line long-term treatment for supra ventricular tachycardia?
Beta blocker.
If resistant can try others or radio ablation.
Why do we worry about WPW?
You have 1:1 with atrial fibrillation= high rate= syncope and risk of sudden death
If you see atrial fibrillation what associated condition do you always look for on ECG?
WPW
= Delta Waves!
List causes of ventricular tachycardia?
“CHILL KLM”
- CHD
- Idiopathic VT
- Long QT
- Lytes= ++ K, low Mg
- Myocarditis
- Arrhythmogenic RV dysplasia
How do you manage ventricular tachycardia?
ABC- PALS
Etiology
Acute: *amiodarone, lidocaine
Chronic: amiodarone, defibrillator, ablation
List two reasons for PAC and PVC:
PAC: stimulant, caffeine, hypoxia, hyperthyroid
PVC: *hypoxia, cardiomyopathy, lytes, cardiac tumours
When do I care about PVC’s?
- underlying CHD
- polymorphic
- > 100 in 24 hour
- pmhx or fhx of sudden death or syncope
What causes CHF:
L-R shunt: VSD, AVSD, ASD, PDA
Cardiomyopathy (dilated, hypertrophic, restrictive)
Obstructive:
- coarc
- interrupted Ao. arch
- hypoplastic L heart
- Ao. stenosis
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
CHF: 2’s of what
2 tachy + megaly = tachy HR = tachy RR = cardiomegaly = hepatomegaly
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)
When does the PDA functionally versus anatomically close?
Functional= 24-48h Anatomy= 4-6 wk
Most common type of ASD?
Secundum (50-70%) (around PFO)
> Primum (inferior part)
> Sinus Venous (superior)
ECG of ASD?
Right ++
= RAD, RA enlargement, RVH, incomplete RBBB
Close ASD if:
- symptomatic
- CHF
- +++ pul pressure
- volume load RV
- big (>8mm)
- sinus venosus ASD (superior location)
List 3 complications of ASD:
- pul HTN (in 30s-40s)
- arrhythmia (Afib, flutter- in 40-50s)
- stroke (rare)
- CHF (rare)
Most common CHD?
VSD
When does CHF with VSD present
3-4 weeks of age
- CHF
- FTT
- high RR
- 3/6 pan systolic murmur at LLSB
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)
What is an unrestricted VSD?
When RV pressure= LV pressure b/c VSD very large
Optimal time for VSD Sx
4-6 mo. old
Sx patch
Contraindication for VSD Sx?
Pulmonary HTN
Baby presents with shock at 2 wks of age. List three categories to think of:
- Sepsis
- Cardiac- critical coarc, AS, hypo plastic LH
- Metabolic-
All F babies with coarctation must be screened for:
Turner’s syndrome.
Most common congenital cardiac anomaly associated with Coarc:
Hypoplastic arch OR Bicuspid Aortic Valve OR VSD
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
List two CXR findings of coarc in newborn and older kids.
Newborns= CHF:
- cardiomegaly
- pul edema
Older=
- Rib notching
- 3 sign
List complications of coarc Sx:
- Rebound HTN
- Aortic Aneurysm
- Re-coarc
- Aortic dissection
Hypo plastic Left Heart usually presents how?
Cardiogenic shock
@4-7d due to PDA closure.
Acyanotic
HLH Sx?
Norwood-Fontan
Most common cyanotic lesion of childhood
TOF
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)
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
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
How do you treat a txt spell?
- ABC
- O2 (lower PVR)
- +/- Bolus - Knee to chest to squat (increase BP to reduce R-L shunt)
- Reduce HR/ obstruction
- morphine (Sedate)
- cool
- beta blocker
- phenylepinephrine
TOF ECG findings
RAD
RVH
Untreated TOF at risk for:
- cerebral thrombosis (if < 2 and why avoiding dehydration and Hct ++ key)
- bacterial endocarditis
- brain abscess (if > 2)
Primary repair for TOF
4-6 month
Early Sx w/ PGE if severe
Most common TOF complications post-op
- Residual RVOTO/ VSD
2. Pul Valve Regurg
Most common cyanotic lesion in newborns?
TGA
- RF: gDM, M sex
Single S2 + no murmur + cyanosis at birth
TGA
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
What is acute Rhematic fever? (lay terms)
systemic immune dx that develop after infection w/ streptococcus bacteria (usually GAS)
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
What is usually the first symptom of ARF?
- arthritis (large joint, migratory)
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
What is the name of ARF Criteria:
Jones Criteria.
2 major or 1 major + 2 minor
How do you meet criteria for ARF:
Jones Criteria
Evidence of GAS infection+
2 major
OR 1 major + 2 minor
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
How do you treat ARF?
- Arthritis: pred or ibuprofen
- CHF
- diuretics, nutrition
- +/ Sx if severe
- carditis= pred until BW normal - Nodules + Rash self resolve
- Chorea
- haldol
- Na valproate - Infection
= Pen G - Prophylaxis
to avoid recurrent cardiac dx
- pen V daily
- generally ~x 5 year or until 21 y.o. (which ever longer)
Which pt do you check BP on in appointments?
- min. 3 y.o.
- < 3 IF
- prem
- CHD
- renal dx
- solid organ transplant
- CA
- tx w/ drug that raises BP
- other assoc. illness (NF, TS)
- ICP signs
How do you check BP
- auscultation
- sit x 5 min
- cuff cover 2/3 of arm
- cuff cover 80-100% of circumference
How many measurements do you need to dx BP?
3
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)
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
Common cause of secondary HTN in prem
- umbilical a. catherization
- renal a. thrombosis
Common causes of secondary HTN in pre-teen
- renal dx (GN, congenital anomaly, reflux)
- coarc
- pheo, cushing
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
T or F: primary HTN more common than secondary in adolescence
True
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
General HTN drug to consider
ACEI (enalapril, captopril)
- good for DM, cautious for RF (watch K, Cr)
*Contraindicated in renal artery stenosis.
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
What’s the most common gene mutation associated with CAD in adults?
Heterozygous Familial Hypercholesterolemia
- very high cholesterol in kids should prompt screen
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
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.
- Bile acid sequestration (cholestyramine)
- Niacin
Two AE to look Statin (why we do BW)
- Myositis (CK)
2. Hepatitis (AST, ALT)
How is Marfan syndrome inherited?
AD (fibrillin mutation)
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
Two cardiac conditions associated with Marfan Syndrome.
- Mitral valve prolapse.
2. Aortic root dilatation
low pitch SEM + fixed S2
ASD
SEM radiate to neck
AS
SEM radiate to back
PS, PDA, coarc
high pitch short systolic murmur at LLSB
small VSD
MR
When are you at risk of Torsades de Pointes?
- Long QT syn
- Hypomagnesia
Torsade de Pointes= Polymorphic VT
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
List Lytes that cause Issues
Long-QT= LOW
- low K
- low Ca
- low Mg
Classic ppt of long-QT syndrome?
Syncope w/ exercise, fright, startle
Normal QTC
Boy: < 0.45
Girl: < 0.47
First line med for long-QT syndrome?
Beta blocker
*always make sure not acquired (meds, lytes)
T or F: length of QTC predict sudden cardiac death.
TRUE
WPW at risk of:
- SVT
- Syncope
- Sudden death
ECG: LAD.
Association:
- AVSD
- Small RV (tricuspid atresia)
- Noonan
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
List two complications to be aware of if prompt says Fontan procedure:
- Protein losing enteropathy.
- Plastic Bronchitis (productive cough)
Note: Fontan part of single functional ventricle as 2nd Sx (2-4 yr).
Broad System based DDX for cyanotic newborn
- Heart
- cyanotic CHD
- severe CHF - Lung (parenchymal like RDS, pul hem; non parenchymal like pleural effusion, CDH)
- Neuro (hypovent)
- Blood (polycythemia, methemglobinemia)
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
Most common cause of myocarditis
Viral.
- Other: Bacterial, Fungal, Protozoal
- Non-infectious: AI KD, SLE, ARF, IBD, Drugs (chemo, cocaine)
Common VS change on myocarditis presentation?
+++ tachy HR out of proportion to degree of fever
Prodromal Illness \+ Fever \+ Disproportionate Tachy \+ HF symptom =
Myocarditis
Common categorical of pericarditis aetiologies?
Infectious: viral, bacterial, protozoal, fungal
AI: SLE, ARF, Sarcoidosis
Metabolic: uremia, thyroid
Other: CA, trauma, FMF
Stabbing pleuritic CP that is worse laying flat=
Pericarditis
Friction Rub
+ Muffled Heart Sounds
+ HF/JVP up
Pericarditis
ECG stages of Pericarditis (1-4)
1= ST elevation 2= T wave flat 3= Inverted T 4= Normal
First line treatment for stable pericarditis
Ibuprofen or prednisone.
Unstable = ABC + Pericardiocentesis.
Do ASD’s typically cause CHF
NO!
- unless something blocking mitral valve!
Janeway lesion versus Osler Node
Janeway= palms + soles; flat; hemm
* NON-TENDER
Osler= tips of fingers + toes; immunologic
*VERY PAINFUL; “O it hurts!!”
Aschoff bodies on pathology=
Rheumatic Fever
