Cardiovascular disorders Flashcards
Name signs and symptoms suggestive of cardiac disease in children
Central cyanosis unresponsive to oxygen Pallor Sweatiness Failure to feed SOB when feeding Sweating when feeding Tachypnoea Tachycardia Palpable spleen Recurrent LRTI FTT Puffy eyes Sudden weight gain Sudden oedema Hepatomegaly Heart murmurs Abnormal pulse rate/rhythm Apnoea Syncope
Which children is idioipathic congestive cardiomyopathy more common in?
Black children
Why is cor pulmonale common in children?
Enlarged adenoids and tonsils -> upper airway obstruction
Although less likely than in adults, what is the arrythmia in children almost certainly?
Supraventricular tachyarrythmia
Why does a VSD take time to become audible in neonates and how long can it take?
High pulmonary pressure at birth -> fall in pulmonary pressure and vascular resistance
6-8 weeks
Give a differential diagnosis for cyanosis
Cyanotic congenital heart defect Pulmonary conditions CNS issue Metabolic issue - hypoglycemia - hypocalcemia
Why should you stop giving oxygen if a cyanosis is of cardiac origin?
Oxygen -> closure of ductus arteriosus -> aggravate situation
Discuss your short term management of a child with a cyanosis of cardiac origin?
- Maintain infant’s temperature
- Give 5% IV glucose
- Give IV sodium bicarbonate for acidosis if confirmed
- Give oral prostraglanding E2
- - 30-60mcg/kg hourly
- dissolve 500mcg tablet in 10ml sterile water
- 1ml = 50mcg
- alternative is IV - Give IV prostaglandin E1 as continuous infusion
- 0.05-0.1mcg/kg
What is stunted growth in a cardiac child a sign of?
Increased pulmonary blood flow
Cardiac failure
How can cyanosis affect the anterior fontanelle?
Delayed closure
What haematocrit do you expect in a severe cyanosis case?
Raised haematocrit
Why must we correct an iron deficiency in cardiac patients, especially in children below the age of 2?
May lead to cerebral thrombosis
Why is it a priority to treat septic lesions and dental caries in children with cyanotic heart defects?
Risk of paradoxical embolisation -> cerebral abscesses
Give signs of a brain abscess in children
Intractable headache
Unexplained fever
Neurological signs
Name the potential cardiac anomalies that are known as congenital cyanotic conditions
- Transposition
- Pulmonary atresia w/ intact ventricular septum
- ricuspid atresia
- Tetralogy of Fallot
- Ebstein’s anomaly
- Eisenmenger syndrome
- Crticical pulmonary stenosis
- Truncus arteriosus
- Total anomalous pulmonary venous connection
- Atrioventricular communis canal
- Hypoplastic left-heart syndrome
Concerning transposition of the great vessels
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis within 1st week of life Normal pulse Auscultation: usually without murmur but may be a precordial systolic murmur Plethora on CXR ECG - right axis, RVH - upright wave in V4R, V1
Concerning pulmonary atresia with intact ventricular septum
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis from birth Poor/normal pulse Auscultation: pansystolic xiphisternum (T1) and single HS2 Oligaemia on CXR ECG - normal to left access - poor RV forces
Concerning tricuspid atresia
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis from birth Poor/normal pulse Auscultation: no murmur/soft systolic over precordium and single HS2 Oligaemia on CXR ECG - left axis, poor RV forces - P pulmonale
Concerning tetralogy of fallot
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis is variable Normal pulse Auscultation: ejection systolic murmur at LSB and single HS2 Ologaemia on CXR ECG - right axis, RVH
Concerning ebstein’s anomaly
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis from birth that tends to improve
Normal pulse
Auscultation: pansystolic murmur and diastolic scratch at xiphisternum
Oligaemia on CXR
ECG
- large RA, poor RV forces, RBBB
Concerning eisenmenger syndrome
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Initially not cyanosed -> progressive Normal pulse Auscultation: ejection systolic click at LSB + soft ejection systolic murmur + very loud pulmonary HS2 Oligaemia on CXR ECG - right axis, RVH
Concerning critical pulmonary stenosis
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis is mild to moderate Normal pulse Auscultation: ejection systemic murmur at 2nd LICS and soft pulmonary HS2 Oligaemia on CXR ECG - right axis - RVH - P pulmonale
Concerning truncus arteriosus
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis is moderate Collapsing pulse Auscultation: systolic ejection click and long systolic murmur at LSB w/wo early diastolic murmur Plethora on CXR ECG - normal to right axis - biventricular hypertrophy
Concerning total anomaly pulmonary venous connection
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis is mild to moderate Small pulse Auscultation: ejection systolic murmur 2nd LICS + wide split of HS2 + middiastolic murmur at xiphisternum Plethora on CXR ECG - right axis - RVH
Concerning atrioventricular communis canal
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis is variable Normal pulse Auscultation: precordial systolic murmur Plethora on CXR ECG - left axis - biventricular hypertrophy - prolonged PR
Concerning hypoplastic left-heart syndrome
- when does cyanosis appear
- what is the pulse
- what would you hear on auscultation
- what would you see on chest x ray
- what would you see on ECG?
Cyanosis is mild to moderate Very poor pulse Auscultation: precordial systolic murmur + ejection systolic click + gallop Plethora on CXR ECG - right axis - RVH - poor LV forces
Name causes of heart failure in infancy
Acyanotic CHD w/ increased PBF or severe ventricular outflow obstruction Cyanotic CHD w/ increased PBF Myocarditis Cardiomyopathy Tachyarrythmias Bradyarrythmias
Name signs of cardiac failure in children
Tachypnoea Inspiratory crepitations at lung base Elevated JVP Hepatomegaly Dependent oedema
Discuss your treatment of heart failure in a child
- Nurse baby at 60 degrees
- Give oxygen
- Restrict fluid intake
- Give inotropes
- digoxin - Diuretics
- furosemide
- spirinolactone - Vasodilators
- ACE-I
What formulations of digoxin are there?
Elixir 0.05mg/ml
Tablets 0.125mg/0.25mg
Injection 0.25mg/ml
What is the dose of digoxin used to treat heart failure in a child?
5-10mcg/kg/day in 2 divided doses
What precaution must you take when administering IV digoxin?
3/4 of oral/intramuscular dose under ECG control
What infusion can you add to the digoxin in severe cardiac failure?
Dobutamine 5-20mcg/kg/min
OR
Dopamine 3-20mcg/kg/min
What is the dose and administration of furosemide in acute heart failure?
IV initially then oral maintenance
1-6mg/kg/day in 2-4 divided doses
What is the dose of captopril in acute heart failure?
0.5-6mg/kg/day in 3-4 doses
What must you give if you are administering a diuretic that causes potassium loss?
Potassium supplement 1-2mmol/kg/day
OR
Spirinolactone 2-3mg/kd/day in 2-3 doses orally
What systolic murmurs in children should be considered significant?
Persists
Loud
Assoc w/ signs of cardiac disorder
Which murmurs in children are always significant?
Diastolic murmurs
Name common features of a functional systolic murmurs
Usually
What does a pectum carinatum with Harrison sulci in children suggest?
Intrathoracic ariway obstruction
What is pectum carinatum usually due to in the cardiac context?
Pulmonary arterial hypertension
How common is CHD?
7-10/1000 live births (1%)
What is the cause of CHD in the majority of instances?
Unknown 85-90% of the time
What is the top congenital cardiac anomaly?
VSD
List the top congenital cardiac anomalies from most common to least
- VSD
- PDA
- Coarctation
- TOF
- AS
- ASD
- PS
What is the pressure and oxygen saturation in the aorta
Pressure 105/75-85
Oxygen 98%
What is the pressure and oxygen saturation in the LA
Pressure 6-8
Oxygen 100%
What is the pressure and oxygen saturation in the LV
Pressure 105/0-5
Oxygen 98%
What is the pressure and oxygen saturation in the RA
Pressure 0-4
Oxygen 72%
What is the pressure and oxygen saturation in the RV
Pressure 20/0-4
Oxygen 72%
What is the pressure and oxygen saturation in the pulmonary trunk
Pressure 20/10-14
Oxygen 72%
Name signs of cyanotic CHD with increased PBF
CYANOSIS SOB FTT CCF Sweating Chest deformities Tachycardia Tachypnoea Cardiomegaly Plethora
Name causes of cyanotic CHD with increased PBF
TGA Truncus arteriosus TAPV HLHS Single ventricle complex with no PS
Name signs of cyanotic CHD with decreased PBF
CYANOSIS No cardiomegaly No CCF Oligaemia Stunting
Name causes of cyanotic CHD with decreased PBF
TOF PA TA Critical PS Ebstein anomaly Eisenmenger syndrome Single ventricle complex with PS
Name signs of acyanotic CHD with increased PBF
Acyanotic SOB FTT Sweating CCF Recurrent LRTIs Chest deformities Tachycardia Tachypnoea Cardiomegaly Plethora
Name causes of acyanotic CHD with increased PBF
VSD
PDA
ASD
AVSD
Name signs of acyanotic CHD with normal PBF
Asx unless severe
Ventricular hypertrophy
Low CO
Name causes of acyanotic CHD with normal PBF
AS PS Coarctation Tricuspid regurgitation Mitral regurgitation
Name the potential cardiac anomalies that are known as congenital acyanotic conditions
Coarctation Aortic stenosis VSD Endocardial cushion defect (ASD+MI) ASD PDA PS
Concerning coarctation of the aorta
- comment on the pulse
- comment on systolic murmur
- comment on diastolic murmur
- comment on 2nd heart sound
- what do you see in CXR
- what do you see in ECG
Brachial bounding and delayed/absent femorals Ejection systolic at back Mid diastolic at apex Normal 2nd heart sound CXR - large proximal aorta - 3 sign descending aorta (older children) ECG - normal - LVH
Concerning aortic stenosis
- comment on the pulse
- comment on systolic murmur
- comment on diastolic murmur
- comment on 2nd heart sound
- what do you see in CXR
- what do you see in ECG
Small volume pulse Ejection systolic at 2RS radiates to neck and click if valvar (with thrill = severe) Early diastolic Normal 2nd heart sound CXR - large proximal aorta ECG - normal axis - LVH if severe
Concerning VSD
- comment on the pulse
- comment on systolic murmur
- comment on diastolic murmur
- comment on 2nd heart sound
- what do you see in CXR
- what do you see in ECG
Normal pulse Pansystolic at 4LS grade 3-5 + can have thrill Mid diastolic at apex Loud P2 CXR - cardiomegaly - pulmonary plethora ECG - biventricular enlargement
Concerning endocardial cushion defect
- comment on the pulse
- comment on systolic murmur
- comment on diastolic murmur
- comment on 2nd heart sound
- what do you see in CXR
- what do you see in ECG
Normal pulse Ejection systolic at 2LS Mid diastolic at 4LS Fixed split and loud P2 CXR - cardiomegaly - pulmonary plethora ECG - QRS axis -60 - RsR in V1
Concerning ADS
- comment on the pulse
- comment on systolic murmur
- comment on diastolic murmur
- comment on 2nd heart sound
- what do you see in CXR
- what do you see in ECG
Normal pulse Ejection systolic at 2LS in infants Continuous machinery sound Mid diastolic at 4LS Fixed split CXR - RA enlarged - RV enlarged - pulmonary plethora ECG - Rt axis RsR in V1
Concerning PDA
- comment on the pulse
- comment on systolic murmur
- comment on diastolic murmur
- comment on 2nd heart sound
- what do you see in CXR
- what do you see in ECG
Collapsing pulse Ejection at 2LS with click (thrill = severe) Mid diastolic at apex Loud P2 CXR - cardiomegaly - asx pulmonary plethora ECG - normal - biventricular enlargement
Concerning pulmonary stenosis
- comment on the pulse
- comment on systolic murmur
- comment on diastolic murmur
- comment on 2nd heart sound
- what do you see in CXR
- what do you see in ECG
Normal pulse No diastolic Soft P2 and wide split CXR - large MPA - RV enlargement - normal lung vascularity ECG - Right axis - RVH
Name the cardiovascular adaptations of the foetus
Umbilical vein Ductus venosus Foramen ovale Ductus arteriosus Umbilical artery
What is the physiological mechanism of clamping the umbilical vessels?
Wharton’s jelly exposed to air -> temperature falls -> contraction
Which chemical is the ductus arteriosus sensitive to?
Prostaglandin E2
What are the mechanisms by which the ductus arteriosus closes?
- Oxygen from aortic blood flowing into pulmonary artery causes smooth muscle to constrict
- Decrease in prostaglandins due to lack of placenta
- Lungs release bradykinin
What are the mechanisms by which the umbilical arteries close?
- Oxygen from iliac veins causes smooth muscle to constrict
2. High pressure from lack of placenta
What % of PDAs are isolated?
90% isolated
10% associated eg congenital rubella syndrome
What is the continuous murmur of PDA also known as?
Gibson’s murmur
How can a PDA become an Eisenmenger syndrome?
R to L shunt -> increased pulmonary volume -> pulmonary hypertension -> L to R shunt becomes R to L shunt
Where is the continuous murmur of PDA found?
ULSB
Why is the PDA murmur continuous?
Pressure in systole AO >PA
Pressure in diastole AO>PA
Why is PDA Eisenmenger syndrome only cyanotic in the lower extremities?
Blood before the PDA is oxygenated and goes to the upper extremities and head
Which infants does the ductus arteriosus often remain patent?
Preterm infants esp with respiratory distress
How is a PDA treated?
Preterm infant -- NDAIDs eg indomethacin, ibuprofen Term infant - before 6 to 12 months of age EVEN if asx - device closure in cath lab - surgical ligation
What defect are the majority of VSDs caused by?
Defect in membranous septum
Which conditions are VSDs associated with?
FAS
Down syndrome
Give another term for a pansystolic murmur
Holosystolic murmur
What is the most common CHD?
VSD
What heart sounds are heard in a VSD?
Pansystolic murmur LLSB
Smaller VSD= louder murmur
Mid-diastolic murmur at apex if VSD large enough
Loud P2 if pulmonary hypertension
Name the changes with time in VSD
Left heart dilates -> PA pressure rises -> CCF better -> right heart hypertrophies -> PA pressure rises higher -> CCF better -> RH hypertrophies more -> CCF -> pressures balance -> shunt reverses
How does VSD present clinically?
Left heart dilates - CCF - tachypnoea - dyspnoea - failure to feed PA pressure rises - cyanosis RVH - parasternal heave - epigastric heave
What is a left parasternal heave a sign of?
RVH
How does the pansystolic murmur in VSD change?
As PA pressure rises, less pressure difference between LV and RV -> softer murmur
Discuss management of VSD
Manage CCF
Prophylactic amoxicillin for IE 1hr before teeth extraction
Small defects -> spontaneous Moderate defect -> smaller Large defect -> CCF -> requires closure - surgery - device closure in cath lab
If a child with a VSD fails to respond to anti-failure treatment, what should you expect?
A coexistent defect
What is the most common CHD in ADULTS?
Ostium secundum ASD
Why is ASD often missed until adulthood?
Low pressure shunt
What is heart sounds are heard in ASD?
Ejection systolic at ULSB
Split S2
Can hear tricuspid diastolic at LLSB
Discuss the changes with time in ASD
Right heart dilates -> RV dilates -> pulmonary hypertension -> CCF
How can you differentiate a VSD using ECG?
Ostium primum = right axis deviation
Ostium secundum = left axis deviation
Discuss management of ASD
Manage CCF
Monitor for arrythmias
Refer for closure: Secundum - before school going age Primum - large
What is a complete AVSD?
Ostium primum ASD + inlet VSD with common AV valve
What is a partial AVSD?
Ostium primum ASD
What would you see on an ECG of AVSD?
Left anterior hemiblock with left QRS axis between 0 and -90 degrees and Rsr’ pattern in V1
Name the signs of aortic stenosis
Displaced apex (LVH)
Suprasternal thrill
Carotid thrill
What heart sounds are heard in aortic stenosis?
Ejection systolic 2nd RICS and into neck
25% early diastolic murmur
Which gender predominates in congenital aortic stenosis?
Males 4:1
What kind of aortic valve is often found in congenital AS?
Biscupid
What sign of AS is seen on CXR?
Enlarged proximal aorta
Cardiomegaly if severe
What does absence of a click in AS suggest?
Subvalvar stenosis
Supravalvar stenosis
If the lower limb pulse are reduced or absent what do you suspect?
Coarctation of the aorta
What heart sounds are heard in coarctation of the aorta?
Systolic betw L scapula and spine
1/3 apical mid-diastolic
Suprasternal thrill
Why must the right arm always be used for BP recordings in suspect coarctation of the aorta?
L subclavian aa is occasionally involved
What is the figure ‘3’ sign?
Indentation to in descending aorta to the L of vertebral column - coarctation of the aorta
Why can notching of the inferior edges of the 3rd to 8th ribs in older children be seen in coarctation of the aorta
Formation of collaterals -> enlarged collateral intercostal arteries
What age should elective surgical repair of an asymptomatic aortic coarctation take place?
Two years
What should you suspect in a child >1year with signs of coarctation and CCF?
Aortic arteritis
What is aortic arteritis also known as?
Takayasu’s arteritis
Name the causes of mitral incompetence
Congenitally abnormal mitral valve
OR
2nd to L heart dilation
What heart sound is heard in mitral incompetence?
Pansystolic murmur at the apex
What is a sign of pulmonary stenosis?
Left parasternal heave
What heart sound is heard in pulmonary stenosis?
Ejection systolic 2nd LICS and into lungs
What is a sign of severe tricuspid incompetence?
Palpable liver
What heart sound is heard in tricuspid incompetence?
Pansystolic murmur at LLSB
Which test do you use to differentiate respiratory and cardiac cyanosis?
Hyperoxia test
Name the causes of cyanosis in children
ABCs Airway obstruction - choanal atresia - laryngomalacia - vocal cord paralysis - tracheal stenosis - vascular ring - external mass
Breathing
- pneumonia
- bronchiolitis
- congenital lung abnormality
- congenital DH
- hypoventilation
Circulation
- methaemoglobinaemia
- congenital cardiac lesions
- persistent pulmonary hypertension
Name the features of tricuspid atresia
Hypoplastic right ventricle
Pansystolic murmur LLSB -> VSD
Single heart sound
Left axis deviation on ecg
What is wall-to-wall heart on CXR diagnostic of?
Ebstein’s anomaly
Pulmonary atresia
Critical pulmonary stenosis
What syndrome is Ebstein’s anomaly associated with?
Wolff-Parkinson-White (WPW)
What is a common cause of Ebstein’s anomaly?
Mother’s with bipolar -> lithium
What word is associated with the right ventricle in Ebstein’s anomaly?
Atrialisation of the right ventricle
How does a child fare with Ebstein’s as it gets older after birth?
Gets better after birth (less cyanotic)
What heart sound can be heard in Ebstein’s anomaly?
Pansystolic LLSB (tricuspid regurgitation)
What are the 4 abnormalities of TOF?
Right ventricular outflow tract obstruction
RVH
VSD
Overriding aorta
What is the most common cyanotic CHD?
TOF
What is TOF associated with?
Chromosome 22 deletion
DiGeorge Syndrome
What are signs of TOF in a child?
Cyanosis
Clubbing
Polycythaemia
What is a hypercyanotic spell in TOF also known as?
“Tet” spell
Why do TOF children squat?
Squatting -> kinks femoral arteries -> incr SVR -> pressure L > right -> shunt reverses
Discuss management of a hypercyanotic spell
Place child in knee-chest/squatting position
Administer morphine 0.1-0.2mg/kg
Administer fluid bolus 10-29ml/kg crystalloid/colloid
Administer esmolol 0.5mg/kg stat then 0.1mg/kg/min
Phenylephrine
Administer sodium bicarbonate 1mmol/kg IV
Check hct and treat
What is a bootshaped heart on CXR diagnostic of?
TOF (RVH)
What heart sound is heard in TOF?
Ejection systolic LUSB
How will a pulmonary atresia with VSD appear on CXR?
Boot shaped heart
How will a pulmonary atresia without VSD appear on CXR?
Wall-to-wall heart
What are the trouble 3Ts?
Cyanotic heart lesions with increased PBF
- Transposition
- Truncus arteriosus
- TAPVD
- HLHS
At what age do cyanotic heart lesions with increased PBF present?
Young age <6months
What is complete TGA also known as?
Right TGA (aorta on right)
What is supportive management of PDA-dependent lesions?
Prostaglandin E1 IVI
Oral prostaglandin E2 orally
What TGA is acyanotic?
Levo-TGA
‘Congenitally corrected’
What is egg-on-side/string cardiac silhoutte on CXR diagnostic of?
TGA
What syndrome is truncus arteriosus associated with
DiGeorge Syndrome
What is 22q11.2 deletion syndrome also known as?
DiGeorge Syndrome
What are characteristics of a truncus arteriosus?
To-and-fro murmur - pansystolic LLSB - mid-diastolic Bounding/collapsing peripheral pulses Wide PP Loud ejection click Single S2 Cardiomegaly w/ plethora
What is TAPVD also known as?
TAPVC
Drainage vs connection
Where are the 3 potential locations of TAPVD?
Supracardiac (SVC)
Infracardiac (IVC)
Infradiaphragmatic (hepatic vv)
Cardiac (RA/coronary sinus)
What is a snowman CXR diagnostic of?
TAPVD
What heart sounds can be heard in TAPVD?
Pulmonary stenosis = ejection systolic LUS
Tricuspid stenosis = mdm LLSB
What is snowman CXR also called?
Figure of 8
Name complications of right to left shunting
Chronic hypoxia Myocardial and somatic tissue dysfunction Paradoxical emboli Neurological sequelae Hemiplegia/paresis Cerebral abscess Polycythaemia Hyperuricacidaemia Thrombocytopenia Iron deficiency Exercise intolerance
What does HLHS usually comprise of?
Aortic valve atresia
Mitral atresia
Hypoplastic ascending aorta
Diminutive LV
What does HLHS require for survivability?
ASD
PDA
