Cardiology Flashcards
What features differentiate a benign vs pathological murmur in children?
Pathological
History: Exercise intolerance, pre-syncope, failure to thrive
Onset: Persistant onset and does not change with position or maneuvers
Timing: Diastolic, pan-systolic or continuous
Intensity: >= grade 4 or palpable thrill
Quality: Harsh
Splitting: Consistent splitting
Extra Heart Sounds: click, snap, S3, or S4
Radiates
Abnormal Echocardiogram
List some of the common pathological murmurs in children and their associated clinical findings
Atrial septal defect: systolic murmur at upper left sternal border, splitting of S2
Ventral septal defect: pan-systolic harsh murmur at left sternal border
Pulmonic stenosis: harsh systolic ejection murmur at left upper sternal border, radiates to infraclavicular, axilla and back
Patent ductus arteriosus: continuous machine-like harsh murmur
Tetralogy of Fallot: systolic ejection murmur at left upper sternal border with thrill
Co-arctation of aorta: systolic ejection murmur at inter-scapular region with delayed femoral pulse
Mitral regurgitation: blowing, high pitched systolic murmur at apex
Aortic stenosis: systolic ejection murmur at right upper sternal border that radiates to carotids
What test is most useful for examination of a child with a murmur?
Echocardiogram
List the differential for murmurs in children
Acyanotic Murmurs:
- Left to right shunt: atrial septal defect, ventral septal defect, patent ductus arteriosus, septal defect
Obstructive: coarctation of aorta, aortic stenosis, pulmonic stenosis
Cyanotic Murmurs:
5 Ts: transposition of great vessels, turncus arteriosus, Tetrology of Fallot, tricuspid atresia, total anomalous pulmonary venous drainage
Other: hypoplastic left heart syndrome, Ebsteins abnormality
What history/physical exam findings are useful for a benign murmur in a child?
Auscultation reveals non-concerning murmur
Negative review of systems for heart disorder
Negative family history
Normal physical exam, except for murmur
Discuss the target goals for resuscitation in shock
BP >5th percentile for age (>60 for 1-2 months, 70+2xage for 1-10, >90)
Pulses strong throughout
Good skin perfusion with normal capillary refill
Normal mental status
Urine output >1mL/kg/hr
Provide bolus of 20mL/kg (5-10 in cardiogenic) over 5-10 minutes with possible epinephrine as well
List the common benign pediatric murmurs and their characteristics
Vibratory/Still’s murmur: early systolic ejection murmur (crescendo-decrescendo) that is musical. Heard at the left sternal border and increases with dehydration
Pulmonary Flow murmur: Occur in later childhood and is murmur at the left upper sternal border.
Physiological peripheral pulmonary stenosis: Occur in newborns to age 1 is a soft murmur heard at the left sternal border that radiates to the axilla and back
Carotid bruit: heard supraclavicular and decreases with shoulder movement foreward
Venous hum: continuous murmur located infraclavicular that decreases with supine positioning or occlusion of the IJV.
List the type of murmurs and they pathology they are often associated with
Systolic ejection murmur: crescendo-decrescendo
- semilunar valve stenosis
- high flow across the pulmonary or aortic valve (ASD or PSD)
- innocent Still’s murmur
Pansystolic murmur:
- Regurgitant: Mitral Regurgitation, TR, VSD
Continuous murmur:
- PDA
- Venous hum
Early diastolic murmur:
- Semilunar valve regurgitation: Aortic insufficiency, PI
Diastolic flow murmur:
- Mitral stenosis
Describe the heart sounds:
S1: Closure of the atrioventricular valves
S2: Closure of the semilunar valves
- splitting occurs during inspiration due to lower intrathoracic pressure resulting in increased venous return to right heart and delayed closure of the valve
S3: follows S2, and is due to increased ventricular volume
- normal in children and in pregnancy
- could represent LV failure
S4: occurs before S1, is due to increased ventricular pressure
- LVH: aortic stenosis, hypertrophic cardiomyopathy
- decreased ventricular compliance: acute MI or MR
Ejection Click: follows S1
- stenosis semilunar valve
- dilated artery
List the causes for a wide, consistently split S2
Delayed RV activiation due to RBBB
Prolonged RV ejection due to pulmonary hypertension
Increased volume due to ASD
List the defects present in the cyanotic heart diseases
0: Hypoplastic left heart syndrome
- Small left ventricle
1: Truncus arteriosus
- Common outflow tract with RV and LV contributing to aorta and pulmonary veins arteries
2: D-Transposition
- Switched connection of the pulmonary artery to LV and aorta to RV
3: Total Anomolous Pulmonary Venous Return
- Pulmonary veins connect to systemic veins instead of to the LA
- Tricuspid atresia
- ASD
4: Tetrology of Fallot
- Pulmonary stenosis
- Overriding aorta
- RVD
- VSD
5: Tricuspid Atresia
- Tricuspid atresia
- Severely hypolastic RV
- VSD
- ASD
- Pulmonary Hypertension
Discuss which heart defects require PGE
Prostaglandin E1 opens and maintains the ductus arteriosus
- Suspect when saturation low despite 100% O2
D- transposition Tetralogy of Fallot Critical Pulmonary Stenosis Tricuspid atresia Critical left sided obstruction Coartation of the aorta Left sided obstruction (AS) Hypoplastic left heart syndrome
Discuss the differences in pediatric ECG
LV/RV - early have larger RV than LV - As get older ration normalizes to LV being larger - Means that axis becomes more leftward with age P Wave - Amplitude <2.5mm T Wave - Upright at birth - Inverts between days 3-7 of life - Upright again in adolescence HR - 0-1mon: 120 - 10yrs: 100 - 16: 70
