Cardiology Flashcards
What is the only artery in our body that carries deoxygenated blood?
Pulmonary artery (arteries carry blood away from body)
Where does fetal circulation occur?
The placenta. Not the Lungs.
What is the foramen ovale
Opening between two atria; closes hours after birth
In order to switch from fetal to pulmonic circulation. What has to occur?
Clamping of umbilical cord (increases SVR)
The foramen ovale closes when:
Right sided heart pressure decreases in resistance
The ductus arteriosis connects:
pulmonary artery and aorta. Smooth muscle senses increase 02 in blood and decrease in prostaglandin (signals that placenta is gone) and it will contract close.
If a child is squatting frequently, why are they doing it?
Increase blood flow to the lungs. Usually this is caused by hypoxia and is common in TOF.
Fatigue from decreased cardiac output occurs:
In the evening
Cyanosis is more common in:
Poor perfusion d/t decreased CO. Examples: patent ductus arteriosis or foramen ovale
Point of maximal impulse is found in the
4th intercostal space in babies and kids
If PMI is raised, widened or far to left
if raised on lower left sternal border
suspect left ventricular hypertrophy.
suspect right ventricular hypertrophy
Murmmurs stemming from pulmonary valve are best heard
Left; second intercostal space
Ventricular septal defects are best heard in
the left lower sternal border/erb’s point
Av. infant HR
Toddler
120-180 bpm
80-105bpm
Blood pressure ___ with age, HR ___with age
increases; decreases
Extracardiac signs include
Cyanosis, enlarged liver (normal to have 1-2cm in newborns), respirations (labored or tachypnea), failure to thrive, displaced PMI, sinus arrhythmia, or murmurs
Pulse oximetry must be done within____ after birth
24hr. They need a pre-ductal right hand and post ductal foot)
Passing pulse oximetry must be
> 95%, only <3% points or less difference in r hand and foot
Failing pulse ox.
<90%
Repeat pulse ox if:
if >90 but less than 95% or >3% difference, repeat in 1 hour.. If the same after 3rd screen, they failed.
S1 is the closure of the_____
Mitral and tricuspid valve best heard over the heart’s apex and coincides with the start of ventricular systole and precede a palpable carotid pulse.
S2 is the closure of
closure of aortic and pulmonic valves. Please her over Erb’s point or pulmonic area
Splitting of S2 can be normal? True or false.
True. Can occur in children upon inspiration.
S3 is caused by
vibrations heard during rapid/passive ventricular filling, low pitch, and best heard with bell of stethoscope. Best heard in <20 or athletes
S4 occurs at the end of____
diastole when atrial contraction further stretches and fills the ventricles. Abnormal and best heard with bell in lateral left recumbent position
Heart murmurs are classified by
Location and Intensity
Grade 1
Faint, possibly intermittent, heart with stethoscope
Grade 2 murmur
Faint, heard as soon as you place stethoscope
What grade is an easily heard murmur, moderately loud?
Grade 3
what grade is a loud murmur, possible with palpable thrill that may radiate to flow of blood
Grade 4
Mummurs that are loud enough to be heard only with the edge of stethoscope on chest wall and are ALWAYS accompanied by thrill and radiation
Grade 5
Loud enough to be heard without stethoscope touching chest wall; always accompanied with thrill and radiation
Grade 6
Mitral regurgitation causes
high pitch, blowing holosystolic murmur; heard best at apex; radiates to axilla. Incompetent mitral valve causing back flow (often seen in rheumatic heart disease)
Systolic heart murmurs (Mr. Pass wins Most Valuable Player)
Mitral Regurgitation, Physioloic (innocent, functional), Aortic Stenosis, Systolic, Mitral valve prolapse
Aortic Stenosis
crescendo decrescendo (softer) that radiates to carotids with sometimes palpable thrill.
Mitral Valve prolapse
Mid systolic click murmur due to valve balloning in atria.
Diastolic heart murmurs (Ms. ARDS)
Mitral Stenosis, Aortic Regurgitation (early diastolic murmur heard best in aortic/pulmonic area or mitral area, soft and blowing), Diastolic.
Mitral Stenosis is a___
Mid late diastolic murmur
Cyanotic heart defect is:
Cardiac anomaly where oxygenated blood entering the aorta and systemic circulation is mixed with deoxygenated blood/ can result from any condition that increases pulmonary vascular resistance (right to left shunt) or structural defat that allows aorta to receive blood from right side of heart
Assess for ____ in cyanotic heart defects
Cyanosis, especially while crying. CBC shows polycythemia as hypoxia stimulates body to increase RBC production, clubbing of digits
Tetralogy of Fallot (TET) has 4 defects…what are they
4 defects: Pulmonary valve stenosis Right ventricular hypertrophy Ventricular Septal Defect Overriding Aorta (oxygenation and deoxygenated blood)
TET is a:
Severity is based on degree of dyspnea and right heart hypertrophy in history
cyanotic heart defect: mixing of oxygenated blood and deoxygenated blood into systemic circulation. stems from increased pressure in R ventricle. blood shunts right to left across VSD, forcing deoxygenated blood into L side
Acute blue spells may cause a child to squat to increase _____ and force blood into pulmonary artery and therefore lungs
SVR
Infindibular spasm (muscle below pulmonary valve) in TET
creates obstruction to blood flow in lungs
Assessment of TET
Grade 3-5 harsh systolic ejection murmur ;eft mid upper sternal border with thrill, sternal lift secondary to RV hypertrophy, cyanosis of mucous membranes, dyspnea
Transposition of Great Vessels
Aorta is attached to R side, PA to left ; parallel circulation. May give prostaglandins to keep PAD open but will need surgery
Hypoplastic Left Heart Syndrome
Consists of aortic valve atresia, mitral atresia, or stenosis, small or absent left ventricle, or severe hypoplasia of ascending aorta or arch. Prostaglandins given to keep ductus open. Need 3 stage surgical repair
The difference of cyanotic and acyanotic heart defects is that
blood entering the aorta is fully oxygenated
Acyanotic heart defects include
VSD (left to right side shunt or increased blood volume on right side will cause right sided hypertrophy and increased blood flow to lungs)
CHF is frequently seen in Acyanotic Heart defects d/t
left to right shunting
Early symptoms of acyanotic heart defects
Tachycardia, diaphoresis, tachypnea, fatigue, and mild cyanosis
Other signs: congested cough, hepatomegaly, poor growth and development
VSD
hole between R and L ventricle. Most common congenital heart defect.
Watch for CHF, patch placed when child is older, correction can lead to heart block, can spontaneously close by age 3.
VSD interventions
Digoxin, monitor fluis, Lasix, high calorie formula, surgery consult
Artrial Septal Defect
Management: per cardiology
May fatigue early, Exertional dyspnea, thin, frequent URIs, may or may not have a murmur (1-3, in pulmonic area), possible l sternal border left, FIXED S 2 split
Obstructive defects
Valves/Ventricles are narrowed to the point that it completely blocks flow of blood.
Pulmonary Stenosis
Narrowing of valve increased right side pressure. Asym or exertion dyspnea or Right side heart failure, chest pain with exercise, murmur 2-4 harsh, mid late, systolic ejection, hear at l sternal border over pulmonic radiates to neck, back, and lungs)
Aortic Stenosis
Severity ranges from mild to extremely severe. Activity intolerance, fatigue, chest pain in addition to Left side heart failure, pulmonary congestion, syncope.
Murmur:3-4 loud, harsh, crescendo/decresendo heard best over upper right sternal border radiating to neck and left lower sternal border and apex. Thrill at sternal notch.
Coarctation of Aorta
Repair :angioplasty
Decreases blood flow from trunk and extremities and increases flow to head and arms which will predispose the child to a stroke
Assess for: full bounding pulses in arms and weak or absent pulse in legs
Assess for increased BP in arms/decreased in legs
Palpate warm upper body and cold lower.
Chest Pain
Non cardiac
Costochondritis
Palpate the chest
unilateral sharp stabbing pain exacerbated by deep breathing, no sings of inflammation or tenderness on palpation
Tietze Syndrome
Hx. recent URI with lots of coughing. nonsupprative inflammation of costochondral, costosternal, or sternoclavicular joint
Usually in older kids for NSAIDs okay
Idiopathic Chest Pain
Sharp pain that lasts a few seconds and localizes to middle of stream, exacerbated by deep breathing or manual pressure on rib cage
Noncardiac Chest Pain Treatment
Rest, Reassurance, Analgesia- warm compress, non steroidal or anti inflammatory drugs NSAIDS x 1 week
If pulmonary or Airway related
We think of bronchitis, plural effusion, asthma, pneumonia. Ask what they were doing when the pain started.
Cardiac Chest Pain causes
Aortic dissections (Marfan syndrome which affects smooth muscle and have larger arm span than height, can cause extremely severe painful tearing in mid sternum)
Palpitations
Congential heart disease
pulmonary hypertension (heaves)
toxic exposure
If laying down or distant heart sounds (pericarditis)
Analysis of fasting lipid profile identifies which 2 major dislipidemic patterns in childhood?
familial hypercholesterolemia and combined dsylipidemia.
Non-HDL-C (TC-HDL-C) is
new accurate screen for dyslipidemia in childhood. Accurate in non fasting state.
In adults, better predictor of cardiac events than LDL-C.
2-8y are not usually screened for lipids. However they will be tested twice with results averaged if:
Parent, grandparent, aunt/uncle, or sibling with MI, angina, stroke, CABG at <55 M or <65 F.
Parents with TC >240 mg/dL or known dyslipidemia
Child has DM, HTN, or BMI >95th % or smokes
Child has moderate to high risk medical condition
Universal screening for lipids starts at
9-11
Non fasting HDL-C.
If Non-HDL C is >145 or HDL <40 when screening, what is the next test?
Two fasting lipid profiles
OR
FLP rewear FLP in 2w but within 3 months
17-21 second lipid screening with
Non-FLP calculating HDL-C or FLP
If greater than 21 you can do a FLP and if abnormal repeat in 2 w but within 3 months and average score.
When to start pharmacotherapy in a child with HTN
Persistent HTN despite lifestyle change for 6 months Presence of target end organ damange DM 1 or 2 Kidney disease secondary HTN Stage II HTN symptomatic primary HTM multiple risk factors
Meds used for HTN treatment:
ACE (1m-16yo)
ACE inhibitors (preventing angiotensin 1 to 2, increase plasma renin and reduce aldosterone)
Lisinopril and Captopril
Monitor BP q 1-3 hours, BUN, Cr, WBC, serous K and glucose
Adverse: hypotension, tachycardia, syncope, dyspnea, fatigue, dizziness, HA, per K, muscle cramps, diminished renal function.
ARBs
>6
Selective and competitive angiotensin II receptor antagonists. reduces vasoconstriction and aldosterone)
Losartan 0.7mg
Monitoring is the sane.
Adv effects: chest pain, cough, URIs, nasal congestion, anemia, thrombocytopenia, fatigue, dizziness, hypoglycemia
Beta blockers
Metroprolol and Atenonolol 1mg
Monitor HR/BP
SE: nightmares, insomnia, confusion, depression, bradycardia, AV block, hypotension, chest pain, edema, CHF, Raynaud’s, bronchospasm, nausea, pruritus
Calcium Channel blockers (Amlodipine)
6-17yo
prevents calcium ions from entering vascular smooth muscle and myocardial cells via specific slow calcium channel during depolarization
2.5-5mg
monitor: BP, electrolytes, BUN/Cr, CBC, and UA
Adv effects: flushing, palpitations, peripheral edema, pulmonary edema, nose bleeds, fatigue, dizziness, HA, diarrhea, anorexia, constipation, dyspepsia, dysphasia, pancreatitis, diploma, hyperglycemia, thrombocytopenia, eye pain
What disease results in vasculitis of small and medium blood vessels (coronary arteries at most risk for aneurysm) and is the leading cause of acquired heart disease in children?
Kawasaki disease
T or F: Kawasaki Disease is self limiting (6-8w), happens in kids less than 5, and has an unknown etiology
T
Symptoms of Kawasaki
Pink eye, oral mucosa change, enlarged lymph nose, patchy rash, peeling skin
Acute phase heart effects
Hyperdymanic precordium, tacky, Gallop rhythm, innocent flow murmur fever, depressed myocardial contractility d/t myocarditis, mitral regurgitation pan systolic murmur, prolonged PR with unspecific T wave changes,
Acute phase (day 0-14) assessment
Persistent high fever (102) that is unresponsive to antipyretics (lasts longer than 5 days)* must have
Swelling of conjunctiva without draining
Rash (polymorphous exam them)
Swollen red hands ad feet
Cervical lymphadenopathy
Inflammation of mouth, lips, and tongue (strawberry tongue)
Subacute phase (2-4w)
Begins with resolution of fever and ends when all outward symptoms are gone.
Arthritis or arthralgia on large weight bearing joints
Hands and feet peel
Irritability persists
Convalescent Phase:
Begins when all clinical signs of KD have resolved and ends when blood values normal (ESR, CRP)
ESR and CPR remain elevated, thrombocytosis still present, arthritis still present
Lab findings of Kawaskai
Leukocytosis : WBC >15,000 Anemia can develop ESR and C-reactive protein elevated Thrombocytosis- Platelet count 500,000 to >1 million (highest 2-3rd week and gradual return 2-8w) Echo: screen for coronary enlargement
Treatment of Kawasaki
Aspirin (anti-inflam/anti-platelet)
Dose 80-100 mg/kg a day (duration varies from 48h-72h after child is afebrile to 14 days) then begin low dose 3-5 mg/kg per day until no evidence of coronary changes by 6-8w after illness onset
IVIG
Anti-inflammatory effect, modulation of cytokine production, suppress antibody synthesis, and neutralize bacterial super antigens
Dose: 2g per kg (give within first 10 days)
Kawasaki Follow Up
Pharm Therapy: ASA, antiplatelet therapy or warfarin
Physical activity: should avoid contact or high impact d/t risk of bleeding
Testing: Cards follow up (echo, ECG, risk, stress test, maybe angiogram
What is an acquired autoimmune immune-complex disorder occurring 2-5w after.a group A beta-hemolytic streptococcal infection?
Rheumatic fever
T or F, streptococcal infection is found in the heart?
F.
RF is caused by production of antibodies against the toxin and these antibodies attack the heart valves because of similarities in antigenic markers
Five major manifestations of RF
Migratory arthritis (involving large joints)
Carditis and valvulitis (pancarditis)
CNS involemtn (chorrea = sudden involuntary movements)
Erythema marginatum (temporary, disk=-like red macule that are non pruitiic and faded in center)
Subcutaneous nodules
4 minor RF manifestations
arthralgia, fever, elevated acute phase reactants (ESR/CRP), prolonged PR
AHA Jones criteria
2 major criteria or 1 major and 2 minor criteria for RF
RF tx.
Aspirin (80-100mg/kg daily or 4-8 in adults) for anti-inflame and relief os symptoms
Severe carditis (cardiomegaly, CHF, 3rd degree block) need conventional HF meds
Antibiotics for group A beta hemolytic strep
Refer to cards when:
Chest pain (with exertion, palpitations, sudden syncope with exercise)
Abnormal EKG or echo
Hx. of cards surgery.intervention
Family hc. or sudden cardiac death
Kawasaki
First degree relative with hypercholesterimia
