Cardiopulmonary Flashcards
1
Q
Kawasaki disease
A
Asian children < 4 yo
Acute (1-2 wks):
- Fever
Subacute (2-4 wks):
- desquamation
- thrombocytosis
- coronary aneurysms
- highest risk of death
Convalescent (6-8 wks)
- clinical signs gone
- ESR nl
Other sx:
- Cervical lymphadenitis (usually unilateral)
- Conjunctival injection
- Strawberry tongue
- Hand-foot erythema
- Desquamating rash
Complications:
Coronary aneurysms –> MI (2nd-3rd wk)
Tx:
- IV Ig
- ASA
2
Q
Churg Strauss syndrome
A
Vasculitis
Asthma
Sinusitis
Palpable purpura
Peripheral neuropathy
+ pANCA
increased IgE
3
Q
Henoch-Schonlein purpura
A
Most common childhood systemic vasculitis
Often follows URI
Peak age 4-8yo
Vasculitis 2/2 IgA complex deposition in small vessels
Classic triad:
- Skin –> palpable purpura (butt + legs)
- Arthralgias
- GI –> pain, melena
- *GI pain can be 2/2 GI bleed or Intussusception
Most lab tests normal
Coag studies normal
Tx:
- supportive (self limited)
- steroids for GI and CNS complications
4
Q
Cystic hygroma
A
Cavernous lymphangioma of neck
Assoc w/ Turner syndrome
5
Q
Sturge Weber disease
A
Congenital vascular d/o affecting capillary sized blood vessels
- Port wine stain on face
- ipsilateral leptomeningeal angiomatosis (intracerebral AVM)
- seizures
- early onset glaucoma
6
Q
Choanal atresia
A
Septum between nose and pharynx
High association with CHARGE syndrome
- Coloboma
- Heart dz
- Atresia choanae
- Retarded growth
- GEnital anomalies (hypogonadism)
- Ear anomalies (deafness)
Presentation
- cyanosis w/ crying
- newborns are basically nose breathehrs
7
Q
Epistaxis
A
1 cause = picking nose
Nosebleed, usually from anterior septum
Also consider juvenile nasopharyngeal angiofibroma in pubertal boys
8
Q
Most common sites for foreign body
A
< 1 yo = larynx
> 1 yo = trachea and bronchi (esp R main stem bronchus)
9
Q
Asthma
A
Reversible obstructive airway disease affecting small and large airways
3 components to attack:
- bronchospasm
- mucous production
- airway edema
Dx:
- eosinophilia in blood and sputum
- allergy skin testing to ID environmental allergens
- PFTs
- increased lung markings on CXR; also hyperinflation and atelectasis
You start as respiratory alkalosis first and then turn into respiratory acidosis
10
Q
Tx asthma
A
Short acting beta agonist (not regularly though)
Long acting beta agonist (daily controller)
11
Q
Mild intermittent asthma
A
Sx =< 2x / wk
Night sx =< 2x / month
Daily meds not needed
Tx flares with inhaled or systemic steroids if necessary
12
Q
Mild persistent asthma
A
Sx > 2x / wk
Night sx > 2x / month
Need daily:
- low dose steroid vs cromolyn
- Short acting beta agonist prn
13
Q
Moderate persistent asthma
A
Daily sx
Asthma exacerbation >= 2s / wk
Need daily:
- Low dose inhaled steroids (vs lekotriene receptor antagonist) + LABA
OR
- medium dose inhaled steroids
14
Q
Severe persistent asthma
A
Continual sx
Frequent exacerbation
Need daily:
- high dose ICS + LABA
15
Q
Tx exercise induced asthma
A
Prevent by B2-agonist immediately before exercise
16
Q
Ddx wheezing
A
Asthma CF Postinfectious Infectious CHD Ciliary dyskinesia Chronic aspiration FOreign body Immunodeficiency Congenital airway anomaly Extrinsic airway compression
17
Q
Tx apnea
A
Adenotonsillectomy
18
Q
3 types of apnea
A
Central - lack of respiratory effort
Obstructive - total airway obstruct
Mixed
19
Q
Types of mixed apnea
A
Apnea of prematurity
- preemies < 30 wks old
- bradycardia
- Tx: theophylline or caffeine or intubation
Cyanotic breath holding
- < 3 yo
- hold breath because of anger
- tx = reassurance
Pallid breath holding
- happens after painful stimulus
- turn pale and have asystole and seizure
- Tx = atropine
Obesity hypoventilation
- 2/2 airway obstruction
- obesity
- somnolence
- polycythemia
- cor pulmonale
- Tx: weight loss
20
Q
Sudden infant death syndrome
A
#1 cause of death in infants 1-12 mo of age Peak at 2-3 mo age
Prevention:
- sleep on back
- electronic monitoring of HR, respiratory pattern, oxygenation
21
Q
An innocent murmur is never…
A
Diastolic
> 2/6
22
Q
Acyanotic heart disease
A
L —> R shunting
VSD ASD PDA Endocardial cushion defects Coartctation of aorta
23
Q
Harsh holosystolic murmur at left lower sternal border
A
VSD
24
Q
EKG changes seen in large VSD
A
BIventricular hypertrophy
NOtched peaked P waves
25
Tx VSD
Usually small defects close
Abx to ppx endocarditis
Surgery for large defects w/ pulm HTN that has not yet become severe
26
ASD - most common type
Ostium secundum most common
27
Systolic ejection murmur in left mid and upper sternal border
Wide fixed split S2
ASD
28
Complications of ASD
Sx usually appear in 30s
Endocarditis rare - ppx not recommended
29
Wide pulse pressure
Bounding arterial pulses
Machinery continuous murmur
PDA
wide PP and bounding arterial pulses happen in large PDA
30
Associations of PDA
Maternal rubella
Prematurity
31
CXR PDA
Prominent pulm A
INcreased pulm vascular markings
32
Tx PDA
Indomethacin
Spontaneous closure
- but rare to close after infancy so need surgery
Risk of endocarditis and CHF if don't close
33
What is an endocardial cushion defect?
ASD and VSD occur and are continuous
AV valves also abnormal
Higher risk with trisomy 21
34
Complications of large AV defects
Heart failure early in infancy
Eisenmenger
LAD
Death 2/2 heart failure
Heart block 2/2 surgery
ALWAYS DO SURGERY ON THESE!
35
Most coarctations of aora occur
Just below origin of L subclavian A
More common in boys
Increased incidence in Turner
36
CXR of coarctation of aorta
Cardiac enlargement
pulm vascular markins
Rib notching in older kids
37
Should coarctation be corrected?
Yes, as soon as pt is stable
Keep PDA open w/ prostaglandin E1
38
Cyanotic Heart disease
```
Tetralogy of Fallot
Transposition
Pulmonary atresia
Tricuspid atresia
Total anomalous pulmonary venous return
Truncus arteriosus
Hypoplastic left heart
```
39
Tetralogy of fallot features
Pulmonary stenosis
VSD
Overriding aorta
RVH
Most common cyanotic heart dz
40
Murmur of ToF
Loud
Harsh
Systolic ejection murmur @ LUSB
S2 is single or soft b/c of pulm stenosis
41
CXR ToF
Boot shaped heart
| Lung fields clear
42
Sx of ToF depend on....
Size of VSD
Degree of RV outflow tract obstruction
Increase in pulm vascular resistance causes shunting of deoxygenated blood from RV --> aorta --> CYANOSIS!
- therefore want to increase systemic vascular resistance to reduce degree of R to L shunting
43
Transposition of great arteries association
More common in infants of diabetic mothers and in boys
#1 congenital hear disease to present with cyanosis in first 24 h of life
44
CXR Transposition
Egg on a string appearance - caused by change in relationship of great vessels as exit heart
45
Tx transposition and Tof
Med management
- PGE1 to maintain DA
Surgery
46
Pulmonary atresia
Right ventricular blood backs up to RA and shunted across foramen ovale
Cyanosis happens 2-3 days when ductus closes
can hear 1 2nd heart sound
EKG - spiked P waves of RA enlargment + LVH
47
Cyanosis at birth
Pansystolic murmur along LSB
Underdevelopment of pulm valve and/or artery ---> decreased pulmonary markings on CXR
EKG - LAD + LVH
Tricuspid atresia
Causes RV outflow tract obstruction - blood shunts across FO
48
Total anomalous pulmonary venous return
Pulm V drain back into systemic venous circulation!
Mixed blood reaches LA through ASD or foramen ovale
49
CXR of TAPVR
"snowman" pattern (aortic knob and hear look like snowmen blobs)
50
Truncus arteriosus
VSD always present
No cyanosis initially b/c of high pulm vascular resistance at birth causing normal pulm blood flow
Systolic ejection murmur with thrill at LSB
51
Hypoplastic L heart
Cyanosis
Dyspnea
Hepatomegaly
RVH
Surgery!
52
Myocarditis causes
Viral most common
- adenovirus
- coxsackie
Other:
- diptheria
- rickettsia
- toxins
- CT and granulomatous dz
53
Most common presentation of myocarditis
Heart failure
- dyspnea
- syncope
- tachy
- hepatomegaly
54
CXR myocarditis
Large heart
| Pulm edema
55
How do you confirm dx of myocarditis?
Endomyocardial biopsy = inflammatory infiltrate of myocardium w/ myocyte necrosis
56
Tx myocarditis
Manage heart failure and arrhythmias
steroids maybe?
Heart transplant
Mortality mostly in newborns that are infected
57
Endocardial fibroelastosis
Thickened, white, fibroelastic endocardium
Primary EFE
- no predisposing valvular lesion or congenital anomaly
- dilated LV
Secondary EFF
- severe left-sided obstructive heart disease
- contracted ventricular cavity
Presentation:
- CHF
Tx:
- transplant if fail med management of CHF
58
What should all children with seconday HTN have?
Renal eval
59
Heart defects presenting with murmur and signs of CHF in infancy
VSD
Severe aortic stenosis
Coarctation of aorta
large PDA
60
What has been shown to improve sx in infants with CHF 2/2 VSD?
DIgoxin
Diuretics (Furosemide)
61
Contraindicated tx in Kawasaki disease
Glucocorticoids - due to higher rate of coronary aneurysms
62
Pulmonary sequestration - intralobar sequestration
a medical condition wherein a piece of tissue that ultimately develops into lung tissue is not attached to the pulmonary arterial blood supply
Venous drainage is usually to the left atrium via pulmonary veins establishing a left to right shunt.
63
Pulmonary sequestration - extralobar sequestration
a medical condition wherein a piece of tissue that ultimately develops into lung tissue is not attached to the pulmonary arterial blood supply
the arterial supply of ELS comes from an aberrant vessel arising from the thoracic aorta.
- It usually drains via the systemic venous system to the right atrium, vena cava, or azygous systems
64
#1 cause of bacterial PNA in CF person
- kid
- adult
Kid ( give vanco
Adult (> 20) - Pseudomonas
65
Pathologic cardiac murmurs in children - associated signs adn sx
Infants
- diaphoresis or tiring w/ feeds
- poor wt gain
Kids
- CP
- dizziness
- syncope
- SOB
- fatigue
66
Pathologic cardiac murmurs in children - PE findings
Harsh or holosystolic
Diastolic
Grade 3/4 intensity or higher
Increases w/ standing or valsalva
Assoc w/
- abnormal S2 (loud, fixed split, or single)
- decreased or absence femoral pulses
67
Pathologic cardiac murmurs in children - workup
CXR for cardiomegaly
EKG for hypertrophy
Echo for structure
Cards referral
68
What is unique of intussusception in kids in HSP?
Most intussusception is ileo-colic
HSP insussusception is small bowel or ileo-ileal.
- there can't be seen on contrast enema
- dx via target sign on US
- tx w/ area or contrast enema but those that don't reduce spontaneously often need surgery
69
Beck's triad
Distant heart sounds
Distended jugular veins
Hypotension
In tamponade!
PUlsus paradoxus can be present
70
Sx CHF in infant
Poor feeding
Tachycardia
Pulm edema / SOB
71
#1 cause of polycythemia in term infants
Delayed clamping of umbilical cord --> excess transfer of placental blood
If get sx from polycythemia...:
- lethargy
- irritability
- respiratory distress
- poor feeding
- hypoglycemia
- hypocalcemia
- neuro manifestations
Tx:
- hydration
- partial exchange transfusion
72
RSV infection in child may cause increased risk for
Asthma
73
Laryngomalacia
Increased laxity of supraglottic structures
Sx:
- inspiratory stridor worse when supine, crying or feeding. better in prone position
- peaks at age 4-8 mo, resolves by 12-18 mo
Dx:
- flex laryngoscopy --> collapse of supraglottic structure w/ inspiration
Management:
- reassurance
- supraglottoplasty for severe sx
74
Congenital heart associations
- ASD + endocardial cushion defects
- Supravalvular aortic stenosis
- congenital heart block
- PDA
- pulmonary valvular stenosis
ASD - Trisomy 21
Supravalvular aortic stenosis - williams
Congenital heart block - neonatal lupus
PDA - congenital rubella
Pulmonary valvular stenosis - Noonan's syndrome
75
Order of events for tx croup
ALWAYS give trial of epi
then intubation if epi doesn't work
76
Stridor in infants and children - ddx
Croup
Laryngomalacia
Foreign body aspiration
Vascular ring
77
Croup vs laryngo malacia vs foreign body aspiration vs vascular ring - how do you tell the difference?
> 6 mo --> usually croup
< 6 mo stridor --> vascular ring
Croup
- barky cough + fever + rhinorrhea + congestion
Laryngomalacia
- worsen in supine position, better in prone
Foreign body aspiration
- acute onset
- mod-severe resp distress
Vascular ring
- improves with neck extension
- assoc w/ cardiac abnormalities
78
Most common cardiac finding in Downs syndrome
Complete atrioventricular septal defect
- endocardial cushions of common AV canal merge and form AV septum and mitral and tricuspid
- result in Downs is ASD + VSD + abnl mitral and tricuspid valves
Can result in heart failure ~ 6 weeks old
Auscultation:
- Loud S2 2/2 pulm HTN
- systolic ejection murmur from increased flow across pulm valve from L--> R across ASD
- holosystolic murmur of VSD
79
Ddx of T wave inversion
MI
Myocarditis
Old pericarditis
Myocardial contusion
Dig toxicity
80
Infant p/w cyanosis aggravated by feeding and relieved by crying...what do you suspect?
Choanal atresia
Confirm dx w/ CT scan w/ contrast
81
Tet spell vs choanal atresia
Cyanosis in choanal atresia NOT triggered by stress but by anything that will keep infant's mouth closed long enough (eg feeds)
ToF will have systolic ejection murmur of pulm stenosis + continuous VSD mumur
82
Increase risk of RDS in infants with
```
prematurity
male sex
csection without labor
perinatal asphyxia
maternal diabetes
```
83
Decrease risk of RDS in infants with
prolonged rupture of membranes
IUGR
Maternal HTN
Antenatal corticosteroids
84
When start eval of kids with 1st or 2nd degree relative with early onset CHD for coronary heart dz
> 2 yo
85
Conditions other than CF that may manifest an elevated sweat chloride
```
Adrenal insufficiency
Ecotdermal dysplasia
nephrogenic diabetes insipidus
hypothyroidism
malnutrition
```
86
How long does it take after exposure before hypersensitivity to tuberculin develops on TB test?
3-8 weeks
TB tests usually negative in infants, even if active TB
87
Are small children with TB contagious to others?
No
They are not capable of coughing up and producing sputum
- sputum when produced is promply swallowed
88
Idiopathic pulmonary hemosiderosis
Recurrent PNA + rapid clearing of radiologic findings
Hemoptysis
Digital clubbing
Microcytic and hypochromic anemia
Low serum Fe levels
occult blood in stool from swallowed pulm secretions
BAL will reveal hemosiderin laden macrophages
89
Pneumatization order of sinuses
Infancy
- maxillary
- ethmoid
3-5 yo
- Sphenoid
6-10 yo
- frontal
90
Pus in middle meatus of nose suggests
Maxillary
frontal
or anterior ehmoid sinusitis
91
Pus in superior meatus indicates
sphenoid
| or posterior ethmoid sinuses
