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Paediatrics > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

In ~30% children you may hear an innoSent murmur, what are the 4 hallmarks of innoSent murmurs? and other features?
:)

A

-aSymptomatic
-Soft blowing murmur
-Systolic murmur only
-left Sternal edge
There should be normal heart sounds w/ no added sounds, no parasternal thrill and no radiation :)

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2
Q

Why are innocent/flow murmurs sometimes heard in children during a febrile illness/anaemia?

A

Increased CO (so examine child after such illnesses are corrected)

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3
Q

What can help you differentiating innocent from pathological murmurs in children?

A
  • referral to paediatric cardiologist for exho
  • CXR
  • ECG
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4
Q

Why may newborns with potential shunts e.g. PDA, VSD have no murmur/symptoms at birth? When may they become apparent?

A
  • as at birth pulmonary vascular resistance is still high

- several weeks of age when pul. vasc. resistance falls

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5
Q

Where could a “VSD” be present? Anywhere in the ..

A
  • ventricular septum
  • perimembranous region (next to tricuspid valve)
  • muscular area
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6
Q

How are VSDs categorised? What mm?

A

-By size: “small” is smaller than the aortic valve in diameter (up to ~3mm)
“large” are the same size or bigger than the aortic valve

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7
Q

Describe signs of a small VSD:

A
  • asymptomatic

- signs: loud pansystolic murmur at lower left sternal edge, quiet pulmonary second sound (p2)

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8
Q

What investigations would you do/see for a small VSD:

A
  • CXR will be normal
  • ECG will be normal
  • Echo: allows visualisation of defect, doppler to assess haemodynamics
  • No pulmonary HT
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9
Q

Small VSDs management:

A
  • close spontaneously, confirm by ECG/normal echo at follow up
  • while present, prevent bact. endocarditis by maintaining good dental hygeine
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10
Q

Name some symptoms of large VSDs:

A
  • heart failure, breathlessness & faltering growth after 1 week old
  • recurrent chest infections
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11
Q

Name some signs of large VSDs:

A
  • tachypnoea, tachycardia, hepatomegaly from HF
  • active precordium
  • soft pansystolic murmur/no murmur
  • apical and mid-diastolic murmur (from increased flow across mitral valve after the blood has circulated through lungs)
  • loud p2 from raised pulmonary arterial pressure
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12
Q

Large VSD CXR findings:

A
  • cardiomegaly
  • enlarged pulmonary arteries
  • increased pulmonary vascular markings
  • pulmonary oedema
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13
Q

What ECG and Echo findings may be present in a large VSD?

A
  • ECG: biventricular hypertrophy by 2months olg

- Echo: can visualise defect size and doppler for flow which is high flow so pulmonary HT also present

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14
Q

What is the management of large VSDs?

A
  • Diuretics + captopril for the HF
  • additional calorie input
  • surgery ~3-6months to manage HF and faltering growth and to prevent permanent lung damage from pulmonary HT and high blood flow
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15
Q

What is the most common congenital cause of cyanotic heart disease? What direction is the shunt?

A

Tetralogy of Fallot

Right to Left

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16
Q

What are the 4 clinical features of the tetralogy of Fallot?

A
  • large VSD
  • overriding of aorta w respect to the ventricular septum
  • subpulmonary stenosis causing RV outflow obstruction
  • RV hypertrophy as a result
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17
Q

How is Tetralogy of Fallot often recognised?

A
  • antenatally

- following murmur identification in first months of life +/- cyanosis

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18
Q

Although rare in developed countries, classic T of F: severe cyanosis, squatting on exercise and especially hypercyanotic spells are important to recognise as these spells can lead to__ if untreated

A
  • MI
  • CVA
  • death
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19
Q

What characterises a hypercyanotic spell in Tetralogy of Fallot? Often associated with_?
NB: a very short murmur can be auscultated during a spell.

A

-rapid increase in cyanosis often associated with irritability/inconsolable crying because of severe hypoxia, breathlessness & pallor because of tissue acidosis.

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20
Q

**A clinical sign of Tetralogy of Fallot: is finger and toe __ in older children. Describe the murmur present and how it changes?

A
  • clubbing
  • loud harsh ejection systolic at left sternal edge from birth
  • with increasing RV outflow tract obstruction (from muscle) below the pulmonary valve, the murmur will shorten and cyanosis will increase
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21
Q

What will a CXR show in a child with Tetralogy of Fallot?

A

-small heart +/- uptilted apex (due to RV hypertrophy)
-pulmonary artery ‘bay’-a concavity on the L heart boarder where the convex PA and RV outflow tract would normally be.
+/- right sided aortic arch

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22
Q

What may an ECG/Echo show for Tetralogy of Fallot?

A

ECG: normal at birth, more RV hypertrophy with age
Echo: cardinal features but need cardiac catheter to detail coronary artery anatomy

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23
Q

Tetralogy of Fallot management is initially medical w surgery ~6months of age, what does the surgery aim to do and how?

A
  • close the VSD

- relieve the RV outflow obstruction (can be with an artificial patch that extends across the pulmonary valve)

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24
Q

In very cyanosed neonates with tetralogy of fallot, what can be done to increase pulmonary blood flow and how? (between which arteries or using a __)

A

-shunt via surgical placement of tube between subclavian and pulmonary artery or via balloon dilatation of the RV outflow tract.

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25
Q

Hypercyanotic spells in TofF are often self-limited followed by sleep, if prolonged >15mins, what prompt treatments should be given and why: (name 3+)

A
  • sedation and pain relief e.g. morphine
  • IV propranolol or a-agonist, for peripheral v.constriction and to relieve subpulmonary muscular obstruction that is causing reduced pulmonary flow
  • IV fluid
  • bicarbonate to correct acidosis
  • muscle paralysis and artificial ventilation to reduce metabolic o2 demand
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26
Q

Give 3 causes of cyanosis in a new-born with resp distress (>60breaths/min)

A
  • cyanotic congenital heart disease
  • persistent pulmonary HT of new-born
  • infection e.g. GBAHS
  • inborn errors of metabolism
  • respiratory disorders such as:..
    • resp distress syndrome
  • -meconium aspiration
  • -pulmonary hypoplasia
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27
Q

Give 3 examples of left to right shunts in newborns? Presents w breathlessness or can be asymptomatic..

A
  • ASD
  • VSD
  • PDA
28
Q

Give 2 examples of right to left shunts in newborns? Presents w blue baby

A

TETRALOGY OF FALLOT

TRANSPOSITION OF THE GREAT ARTERIES

29
Q

Name 1 condition that will cause outflow obstruction in a child but is asymptomatic/well and 1 outflow obstruction cause that will –> sick neonate:

A
  • well: aortic or pulmonary stenosis

- sick: coarctation, HLHS (hypoplastic left heart syndrome)

30
Q

What is the anatomical difference between these ASDs (both L->R)

  • secundum ASD (80%)
  • primum ASD aka partial AV SD
A
  • secundum: defect in centre of atrial septum involving foramen ovale
  • primum/partial = AV septum defect either interatrial communication between atrial septum and AV valves or the valves are abnormal and regurgitant
31
Q

ASDs mostly are asymptomatic or -> recurrent chest infections, what signs may you notice on auscultating the chest?

A
  • ejection systolic murmur loudest on upper L sternal edge (due to shunt -> more flow across pulmonary valve)
  • fixed, widely split 2nd heart sound (as RV SV is equal in both inspiration and expiration)
  • if AV valve regurg in partial AVSD -> apical pansystolic murmur
32
Q

What ECG change may you see in an ASD (secundum ASD)

A
  • partial RBBB common

- right axis deviation (as RV enlarges)

33
Q

Children with ASDs -> RV enlargement require rx. What is the rx for:

  • secundum ASDs
  • partial AVSDs
A
  • secundum: cardiac catheterisation + insert an occlusion device
  • partial AVSD: surgical correction
34
Q

suggest 2 locations of a VSD

A
  • anywhere in ventricular septum
  • perimembranous area
  • muscular area
35
Q

Small VSDs are asymptomatic (<3mm) what signs may you notice on chest auscultation?
NB: CXR, ECG, no pulmonary HT will be normal

A
  • loud pansystolic murmur at L sternal edge (louder murmur = smaller defect)
  • quiet pulmonary 2nd sound (P2)
36
Q

Small VSDs management?

A
  • none
  • close spontaneously
  • murmur will disappear as closes
37
Q

Large VSDs = > size of aortic valve

  • symptoms
  • signs
  • murmur
  • loud P2 why
A
  • sx: HF, breathlessness, faltering growth from week1 and recurrent chest infections
  • signs: tachyC, tachyP, hepatomegaly, active precordim
  • murmur: soft pansystolic murmur or none (massive defect), apical mid-diastolic murmur (increased flow across mitral valve
  • loud P2 from raised pulmonary arterial pressure
38
Q

What will you see on CXR and ECG with a large VSD

A

CXR: cardiomegaly, enlarged pulmonary arteries, increased pulmonary vascular markings, pulmonary oedema
-ECG: biventricular hypertrophy

39
Q

How are large VSDs managed?

A
  • drug therapy for HF w diuretics +/-catopril
  • additional calorie input
  • surgery by 6months to manage HF and growth and prevent permanent lung damage from p HT
40
Q
  • surgery on large VSDs is done by 6months to prevent permanent lung damage
  • why does this damage happen
  • what is it called in adults
A
  • persistent pulmonary hypertension irreversibly damages the pulmonary capillary vascular bed
  • Eisenmenger Syndrome
41
Q

Persistent ductus arteriosus..flow of blood from aorta to pulmonary artery (L->R), what are clinical fts?

A
  • continuous murmur beneath left clavicle
  • increased pulse pressure -> collapsing/bounding pulse
  • heart failure and pulmonary hypertension due to increased pulmonary blood flow
42
Q

How is PDA managed

A
  • closure to reduce lifelong risk of bacterial endocarditis and pulmonary vasc disease
  • close with coil/occlusion device, introduce by cardiac catheter at ~1yr
  • or surgical ligation
43
Q

R -> L shunts like ToF and TGA present w cyanosis in first week, what is the hyperoxia nitrogen washout test used for?

A
  • to identify if theres heart disease in a cyanosed neonate

- put infant in 100% O2 for 10mins, if radial PaO2 on ABG is still low can diagnose cyanotic congenital heart disease

44
Q

State 2 principles in the management of the cyanosed neonate:

A
  • ABC
  • Prostaglandin infusion (maintains ductal patency-child may be duct dependent)
  • watch for SEs of the infusion e.g. apnoea, seizures, vasodilation and hhpotension
45
Q

Tof the great arteries: RV connects to aorta -> body, LV connects to pulmonary artery -> lungs, not compatible with life but along with VSDs/ASDs/PDA can achieve mixing.. name some clinical features:

A
  • cyanosis (profound, life threatening)
  • presents ~day 2 (as ductal closure-> marked decrease in mixing)
  • loud, single second heart sound
46
Q

What are the classic findings on chest XR of baby with transposition of the great arteries?

A
  • narrow upper mediastinum
  • ‘egg on side’ appearance of cardiac shadow
  • increased pulmonary vascular markings
47
Q

State 3 principles of the management of T of great Arteries:

A
  • improve mixing in cyanosed neonate
  • maintain patent DA with prostaglandin infusion
  • balloon atrial septostomy can be life-saving (allows systemic and pulmonary venous blood to mix in atrium)
  • all require surgery (arterial switch procedure + CAs are switched to new aorta)
48
Q

Eisenmenger Syndrome is…

A
  • high pulmonary blood flow (due to large L->R shunt) -> thick walled pulmonary arteries
  • more resistance to flow
  • in early teens, shunt REVERSES & teenager becomes blue
  • progressive, adult will die in R HF in 40s/50s
49
Q

Common mixing in a child will present

  • blue and
  • breathless
  • Suggest a cause of this?
A
  • complete atrio-ventricular septal defect (AVSD)

- complex congenital heart disease e.g. tricuspid atresia

50
Q

complete AVSD

  • commonly seen in children w …
  • what is it?
  • due to the large defect what develops
A
  • w Down’s syndrome
  • defect in middle of heart with a single 5-leaflet vale between atria and ventricles
  • often leaks
  • due to large -> pulmonary hypertension
51
Q

Give 2 features of a complete AVSD:

e.g. how presents antenatally, at birth, at ~3weeks, how is lesion detected?

A

-present on antenatal US screening
-cyanosis at birth/ HF by 3 weeks of life
-no murmur heard, lesion detected on routine ECHO (for Down’s babies)
-always superior axis on ECG
-

52
Q

Management for complete AVSD?

as for large VSDs

A
  • manage HF medically

- surgical repair by 6months

53
Q

What is tricuspid atresia (a form of complex congenital heart disease)
-how does it present?

A
  • only LV is effective (RV is small and non-functional)
  • ‘common mixing’ in LA
  • presents with cyanosis and breathlessness in neonatal period
54
Q

AS, PS and coarctation of aorta -> outflow obstruction in a child,
will they be well or not?

A

Well child

55
Q

Name 2 clinical fts/signs on exam of aortic stenosis in a chlid?
e.g. describe the murmur, pulse, carotids, heart sounds..?

A
  • asymptomatic murmur +/- reduced exercise tolerance, syncope
  • ejection systolic murmur, maximal at upper R sternal edge, radiates to neck
  • apical ejection click
  • small volume, slow rising pulse
  • carotid thrill
  • delayed and soft aortic second sound
56
Q

How is outflow obstruction caused by aortic stenosis in a child managed?

A
  • regular assessment and ECHOs
  • balloon valvotomy for those w sx on exertion/high resting P across valve
  • balloon dilatation in older children is safe
  • eventually will probs need aortic valve replacement
57
Q 
Pulmonary Stenosis (PS) = valve leaflets partly fused together  (restricted exit from RV)
-give 3 features/signs
A
  • most asymptomatic (if duct-dependent will -> cyanosis in first days =critical)
  • ejection systolic murmur, loudest at upper L sternal edge
  • +/- thrill
  • ejection click at upper L sternal edge
  • when severe -> prominent RV heave
58
Q

Treatment of choice for sx children/ high pressure in pulmonary stenosis is:

A

-transcatheter balloon dilatation

59
Q

Adult-type coarctation of aorta =uncommon, gradually becomes more severe over yrs.

  • give 3 clinical fts:
    e. g. murmurs? BP? radio-fem delay-why?
A
  • asymptomatic
  • systemic HT in the RIGHT arm
  • Ejection Systolic Murmur at upper L sternal edge
  • Continuous murmur at the back
  • Radio-Femoral Delay (as blood bypasses the obstruction via collateral vessels in the chest wall hence pulse in legs is delayed)
60
Q

Adult-type coarctation of aorta, CXR and ECG findings, name 2

A
  • CXR: rib notching due to large collateral intercostal arteries running under ribs posteriorly to bypass
  • 3 sign on CXR (visible notch in descending aorta at site of coarctation)
61
Q

Adult-type coarctation of aorta is assessed with ____, when severe what management may be needed?

A
  • ECHO
  • stent inserted in cardiac cath lab
  • or surgical repair
62
Q

Coarctation of aorta, interruption of aortic arch and hypoplastic left heart syndrome are outflow obstruction causes in a well or unwell child? Present how?

A
  • UNWELL

- present sick with HF and shock in neonatal period

63
Q

Coarctation of aorta, interruption of aortic arch and hypoplastic left heart syndrome all -> outflow obstruction in SICK child, principle of management =

A
  • resuscitate (ABC)
  • prostaglandin infusion ASAP
  • refer to cardiac centre for early surgical intervention
64
Q

Interruption of aortic arch

  • what is it?
  • association with which chromosome abnormality?
  • what is also often present that will be repaired during surgery?
A
  • no connection between proximal aorta and distal so CO depends on R-> L shunt via DA
  • associated w: DiGeorge Syndrome= chromosome 22q11.2 microdeletion.. no thymus, hypoCa2+, palate defects..)
  • VSD often present too
65
Q

The Norwood procedure neonatal operation is done for the sickest duct-dependent outflow obstruction cause? What am i describing? How do neonates present as ductal closure occurs?

A
  • Hypoplastic Left Heart Syndrome
  • underdeveloped L heart (small Mitral valve, tiny LV, v small ascending aorta often + coarctation)
  • present w profound acidosis, rapid CV collapse, no peripheral pulses

Paediatrics (12 decks)

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