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Pediatric Emergency Medicine > Cardiology > Flashcards

Cardiology Flashcards

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1
Q

What are typical presentations of ductal dependant congenital heart disease?
What is the initial treatment?
What treatment complication should you be prepared for?

A
  • 2 typical presentations: 1) infant who is hypoxic and unresponsive to oxygen and 2) Patient presenting in shock unresponsive to fluids
  • Tx with prostaglandin E1 and perform a sepsis eval
  • You should consider intubating the patient as prostaglandin can induce apnea
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2
Q

How does a new diagnosis of congestive heart failure typically present and how should it be managed in the ED?

A
  • Presents as a 2-6mo w/sxs of wheezing, retractions, tachypnea, hepatomegally, diaphoresis with feeds, failure to thrive, edema
  • Tx it symptomatically, consider lasix for fluid overload, cards consult
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3
Q

Give a ddx for acquired heart disease

A

myocarditis, kawasaki disease, pericarditis, endocarditis, cardiomyopathy

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4
Q

What sxs should alert you to the possibility of myocarditis?

What history is typically present with myocarditis?

A
  • Consider myocarditis w/persistent tachypnea CHF like sxs such as dyspnea on exertion, hepatomegally, SOB, fatigue
  • Myocarditis it often preceded by URI
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5
Q

When vagal maneuvers are ineffective with SVT, what is your first line medication to give and how is it dosed?

A
  • Adenosine!
  • Dosed 0.1 mg/kg, maximum of 6mg
  • remember to never give adenosine if qrs widening is present
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6
Q

Following vagal maneuvers and adenosine what are 2nd line treatment options to consider for SVT?

A
  • Consider performing synchronized cardioversion
  • secondary meds to consider include amiodarone, procainamide
  • Cards can perform rapid atrial pacing
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7
Q

What are examples of vagal maneuvers?

A

-ice bag to the face for 15 seconds, blowing through a syringe, hang patient upside down

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8
Q

In which leads are T waves normal until adolescence?

A

V1-V3

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9
Q

What are indications to obtain an EKG?

A
  • Syncope
  • Drug ingestion
  • Tachy/brady arrhythmia (ex. SVT or heart block)
  • Exertional symptoms, ex. chest pain with running
  • Electrolyte disturbance, ex. renal disease worry about potassium
  • Diagnosis of congenital heart disease
  • Heart failure
  • Kawasaki
  • Myocarditis
  • Seizure
  • Pericarditis
  • Rheumatic fever
  • Cyanotic episode
  • S/p cardiac surgery
  • Myocardial contusion (comotio cordis)
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10
Q

How should we check for sinus rhythm?

A

Ensure the following:

  • every P followed by QRS
  • every QRS followed by P wave
  • P-wave axis between 0-90 degrees
  • P wave morphology constant
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11
Q

What is a normal p wave axis and which should we look at to determine this?

A
  • 0-90 degrees

- P waves are positive in I, II and aVF, and negative in aVR

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12
Q

Which leads should always have upright T waves?

A

T waves should always be upright in the following leads:

  • Inferior leads: II, III, aVF
  • lateral leads: V5, V6
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13
Q

Give heart rate estimates based on number of big boxes between qrs intervals

A

Sequentially: 300, 150, 100, 75, 60, 50

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14
Q

Give a ddx for prolonged qrs interval

A

-bundle branch blocks, toxin, acidosis, electrolyte abnormality, aberrant conduction from atrial foci (WPW), ventricular hypertrophy, cardiac surgery

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15
Q

When should you consider prolonged QT?

A

Anytime the QT interval is >/= 1/2 the R-R interval

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16
Q

What are potential causes of prolonged QT?

A

hypokalemia, hypocalcemia, hyopmagnesemia, neurological injury, medications

17
Q

What are etiologies of R ventricular hypertrophy and what would you see on EKG?

A
  • AV canal defect, VSD, ASD, TAPVR, ToF, pulmonary stenosis, pulmonary HTN
  • R wave amplitude >98% for age in v1 or S wave >98% for age in v6, increased R/S ratio for age in v1 or decreased ratio in v6
18
Q

What are etiologies of L ventricular hypertrophy and what would you see on EKG?

A
  • VSD, PDA, aortic stenosis, systemic hypertension, cardiomyopathy
  • R wave > 98% in v6, or S wave is > 98% in v1, increased R/S ratio in v6 or decreased in v1
19
Q

The T wave of which lead is expected to invert on day of life 3-4 in a neonate?

A

V1-remember that the right heart is initially working harder to compensate for higher pulmonary pressures.

20
Q
  • What is the most sensitive sign of ischemia in a pediatric ekg?
  • What are other signs of myocardial ischemia on EKG?
A
  • Q wave prolongation
  • Along with the obvious ST elevation, prolongation of the QT interval may indicate ischemia in the pediatric population, peaked T waves can be seen in early myocardial ischemia
21
Q

-What is the most common EKG finding with tricuspid atresia?

A

The EKG is TA often shows right atrial enlargement, which is indicated by a peaked P-wave higher than 3mm in any lead

22
Q

What are findings consistent with familial hypertrophic cardiomyopathy on EKG?

A

90% of patients with familial hypertrophic cardiomyopathy will demonstrate some abnormality, including left ventricular hypertrophy (R in V6 or S in V1 above 98% for age), atrial enlargement (p-wave >0.1 seconds), or ST-T wave changes.

23
Q

What is the formula for correcting the QT interval?

A

Measured QT (seconds)/ the square root or the preceding RR interval (seconds)

24
Q
  • Which are the best leads to pick up a delta wave on EKG?

- What does a delta wave signify?

A
  • It is best seen in leads 1, V5, and V6
  • The delta wave, a slow upslurring of the QRS complex causing slight widening on a sinus rhythm EKG, represents the depolarization of the ventricle through both the AV node and the accessory pathway.
25
Q
  • What is a benign cause of ST elevation you may see on pediatric EKGs?
  • Which leads do you see this on?
A

Early repolarization can cause ST elevation in the anterior (V1 to V4), and occasionally inferior (II, III, and aVF), leads of the EKGs of healthy adolescents.

26
Q

Describe the anatomical relationships of EKG leads, i.e., what are:

  • inferior leads
  • lateral leads
  • anterior leads
  • R atrium and L ventricle
A
  • inferior-II, III, AvF
  • lateral-aVL, I, V5, V6
  • Anterior leads-V1-V4
  • R atrium and L ventricle leads-V1, aVR
27
Q

What common cyanotic congenital heart lesion is associated with a normal EKG in the early neonatal period?

A

transposition of the great arteries!

28
Q
  • What types of surgeries generally lead to prolonged PR intervals on EKG?
  • What is the most common congenital heart defect repair that leads to prolonged PR intervals?
A
  • Any surgery which requires cutting around the AV node is going to predispose a patient to PR prolongation.
  • The most common of these is ventricular septal defect repair.
29
Q

What is a common EKG finding of patients who have undergone either a VSD or tetrology of fallot repair?

A

R bundle branch blocks

30
Q

What is the most common organism causing infective bacterial endocarditis in children?

A

Staphylococcus Aureus is the most common bacteria associated with infective endocarditis (57%), followed by Viridans Streptococi (20%), coagulase-negative Staphylococci (14%), and Group A Streptococcus (3%).

31
Q
  • How should complete heart block be managed and what diagnosis would this appear similar to at first?
  • What medication can be used for this indication to stabilize heart rate?
  • Is this a shockable rhythm?
A
  • Management of acutely symptomatic bradycardia always starts with airway and breathing; heart rate and circulation should be supported with CPR with epinephrine or atropine in accordance with PALS.
  • In the subacute and/or stable phase of CCHB, heart rate can be supported with medications such as isoproterenol. The definitive treatment, however, is pacing in the neonatal period if heart rate is less than 55.
  • Complete heart block is not a shockable rhythm via cardioversion. However, cardioversion may eventually become applicable if bradycardia progresses to pulseless electrical activity (PEA).
32
Q
  • What is a failure of a pacemaker?
  • What are causes of pacemaker failure?
  • What is pacemaker capture?
A
  • When pacers fail to produce an adequate electrical stimulus to depolarize the heart it is called non-capture or loss of capture.
  • This pacemaker dysfunction can be caused by a number of problems; including, lead failure or break, decreased electrode conductance caused by fibrosis around the lead, low pacemaker output or battery depletion, or if the capture threshold is set too high.
  • Pacemaker capture is set on the pacer and is the lowest threshold at which the depolarizing output current causes myocardial contraction.
33
Q
  • How do you define hypertensive urgency?

- How do you treat hypertensive urgency?

A
  • A severe elevation in BP without symptoms or evidence of acute target-organ damage (brain, kidneys, eyes, or heart) describes a hypertensive urgency
  • treat the underlying cause, if able to take oral meds start with clonidine or isradipine, if not give an IV labetolol dose. Consider fluid overload and the need for diuretics as well.
34
Q
  • How do you define hypertensive emergency?

- How do you treat hypertensive emergency?

A
  • Hypertensive emergency is defined as elevated blood pressure with evidence of end-organ damage (brain, kidneys, eyes, or heart).
  • If seizure, AMS, papilledema consider increased ICP and obtain head imaging and give mannitol vs hypertonic saline and consult NSGY. If no neuro signs start with IV labetalol and follow algorithm on uptodate requiring q30 minute assessments of BP status. Treat the underlying cause.
35
Q
  • What are presenting symptoms of short QT syndrome?
  • What would you see on EKG that should make you consider short QT syndrome?
  • How should short QT syndrome be managed?
A
  • Cardiac Arrest (28%), Syncope (24%), Dizziness, Palpitations / Arrhythmias (MC arrhythmias are Afib, SVT, Polymorphic Vtac, Vfib), Asymptomatic
  • QTc = 360 ms) with at least one additional risk factor is also considered worrisome: known pathogenic mutation, family history of short QT syndrome, family history of sudden death before 40 years of age, survival of V-Tach/V-fib episode in absence of known heart disease
  • Stabilize any arrhythmia, cards consult as definitive treatment is implantable cardiac defibrillator and patient can be managed with hydroquinidine until surgery
36
Q

Give a ddx for the the cyanotic neonate

A
  • Cyanotic disease heart lesion mnemonic of the five “Ts”-transposition of the great arteries, tetralogy of Fallot, tricuspid atresia, total anomalous pulmonary venous connection, and truncus arteriosus
  • Other lesions to consider in a cyanotic neonate include pulmonary atresia and Ebstein anomaly.
37
Q
  • Give an appropriate antibiotic regimen for a child with a prosthetic heart valve who presents with fevers, night sweats, and fatigue
  • What are the most common organisms that cause infective endocarditis?
A
  • first line=amp-sulbactum+gentamicin; If the heart surgery occurred within 1 year, choose vanc+gent
  • beta hemolytic strep (GAS), strep viridians, staph aureus, coag negative staph, enterococcus
38
Q

What are common findings on an EKG in a patient who has myocarditis?

A

-diffuse ST segment elevations, diminished QRS complexes, and conduction delays

Pediatric Emergency Medicine (18 decks)

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