Cardiovascular Issues & Disorders

Question 1

Peds CV - S1

Answer 1

-“Lubb”
-Mitral/tricuspid (AV) valve closure
-Aortic/pulmonic valves open

Question 2

Peds CV - S2

Answer 2

-“Dubb”
-Aortic/pulmonic (semilunar) valve closure
-Mitral/tricuspid valves open

Question 3

Peds CV - Systole

Answer 3

-Period between S1 and S2 - ventricles contract

Question 4

Peds CV - Diastole

Answer 4

-Period between S2 and S1 - ventricles relax and fill

Question 5

Peds CV - Auscultation Areas

Answer 5

-Aortic: RUSB
-Pulmonic: LUSB
-Mitral: Apex (bottom)
-Tricuspid: LLSB

Question 6

Peds CV - Blood Flow

Answer 6

-Fetal: increased pulmonary vascular resistance and decreased systemic vascular resistance - no lung flow
-Neonatal: decreased pulmonary vascular resistance and increased systemic vascular resistance - lung flow

Question 7

Peds CV - Characteristics to Note

Answer 7

-VSD: most common heart defect - has a thrill

-Obstructive defects:
*Ejection clicks due to turbulence
*Referred or radiated sound noted

Question 8

Peds CV - Murmur Characteristics

Answer 8

-Grade I: soft, barely audible
-Grade II: clearly audible, but faint
-Grade III: moderately loud
-Grade IV: loud, with thrill *****
-Grade V: loud, heard with PART of the stethoscope on chest wall, thrill palpable
-Grade VI: very loud, heard WITHOUT stethoscope, thrill palpable and visible

Question 9

Peds CV - Congenital Heart Diseases/Anomalies

Answer 9

-Etiology: chromosomal abnormalities, adverse environmental conditions
-Occurs in about 1% of births per year
-VSD, most common

-Acyanotic: left-to-right shunt (oxygenated blood goes from left to right side)
*Atrial septal defect (ASD)
*Ventricular septal defect (VSD)
*Patent ductus arteriosus (PDA)

-Cyanotic: right-to-left shunt (deoxygenated blood goes from right to left side)
*Transposition of the great arteries
*Tetralogy of Fallot

-Obstructive lesions
*Aortic stenosis
*Pulmonic stenosis
*Coarctation of the aorta

Question 10

Peds CV - ASD

Answer 10

-Opening between RA and LA
-Acyanotic (left-to-right shunt) - oxygenated blood goes from left to right side
-Grade II-III/VI systolic ejection murmur
-EKG: RVH
-XR: Cardiomegaly
-Management: small ASDs close on their own - refer to cardio

Question 11

Peds CV - VSD

Answer 11

-Opening between RV and LV
-Most common cardiac defect (30%), especially in Trisomy 21
-Acyanotic (left-to-right shunt) - oxygenated blood goes from left to right side
-Associated with a thrill (thrill has 2 LL and so does LLSB, which is where it is felt)
-Grade II-V/VI systolic ejection murmur - holosystolic thrill - LLSB
-EKG: LVH
-XR: Cardiomegaly
-Management: small VSDs close on their own - refer to cardio

Question 12

Peds CV - PDA

Answer 12

-Opening between pulmonary artery and aorta
-Acyanotic (left-to-right shunt) - oxygenated blood goes from left to right side
-Very common in premature infants
-Murmur: LUSB, “machinery” sound, grade II-IV/VI holosystolic
-EKG: LVH
-XR: Cardiomegaly
-Management: refer to cardio - for preterm infants, give prostaglandin inhibitors (ibuprofen, indomethacin) may be used

Question 13

Peds CV - Transposition of the Great Arteries

Answer 13

-Aorta and pulmonary artery are switched - blood goes from RV to aorta (deoxygenated)
-Cyanotic (right-to-left shunt) - deoxygenated blood goes from right to left side
-EKG: RVH
-XR: Egg on a string ***
-Management: refer to cardio for surgical repair - long-term supportive care and screening for developmental delays due to hypoxemia

Question 14

Peds CV - Tetralogy of Fallot

Answer 14

-Four defects:
*Large VSD
*RVH
*Overriding aorta
*Pulmonary stenosis

-Cyanotic (right-to-left shunt) - deoxygenated blood goes from right to left side
-Murmur: Loud systolic ejection CLICK at the middle and LUSB
-XR: Boot-shaped heart ***
-Management: refer to cardio

Question 15

Peds CV - Aortic Stenosis

Answer 15

-Obstructive lesion
-Murmur: systolic thrill at RUSB, systolic ejection click but DOES NOT vary with respirations
-EKG: LVH
-XR: CHF, if severe
-Management: refer to cardio, balloon aortic valvuloplasty, need clearance for sports

Question 16

Peds CV - Pulmonic Stenosis

Answer 16

-Obstructive lesion
-Murmur: systolic, loudest at LUSB, thrill at LUSB radiating to the back and sides, grade II-V/VI ejection click decreases with inspiration and increases with expiration
-EKG: RVH
-Management: refer to cardio, follow-up every 6 months to 2-5 years, needs clearance for sports

Question 17

Peds CV - Coarctation of the Aorta

Answer 17

-Obstructive lesion
-Narrowing of aorta
-Common in trisomy 21
-Murmur: II-III/VI systolic ejection murmur with radiation to the left inter scapular area
-Cardinal finding: BP and pulse in lower extremities will be lower than in upper extremities ***
-XR: Cardiomegaly, rib notching due to collateral circulation
-Management: refer to cardio

Question 18

Peds CV - Genetic Syndromes and Associated Cardiac Defects

Answer 18

-DiGeorge: aortic arch anomalies
-Trisomy (18 and 21): atrioventricular septal defects, VSD
-Marfans: aortic root disease, mitral valve prolapse - risk for aneurysm, BB therapy
-Turners: coarctation of the aorta, bicuspid aortic valve

Question 19

Peds CV - S/S in Cardiac Defects

Answer 19

-Most common is feeding problems and FTT (tachypnea and diaphoresis during feeding)

Question 20

Peds CV - Innocent Murmurs

Answer 20

-Functional, benign
-Have no associated symptoms
-More than 50% of children have innocent murmurs
-Most common in ages 3-7 years
-Low-intensity, grades I-III/VI
-May vary with position change - good sign
-No radiation

-Types:
*Still’s Murmur
*Venous Hum

Question 21

Peds CV - Still’s Murmur

Answer 21

-Most common innocent murmur
-Musical systolic, vibratory murmur
-Heard in periods of anxiety/stress
-Between LLSB and apex
-Louder when SUPINE ***

Question 22

Peds CV - Venous Hum

Answer 22

-Continuous humming murmur
-RUSB, infraclavicular area
-Heard best in the SITTING position ***, disappears when supine or when turning the head

Question 23

Peds CV - Heart Failure

Answer 23

-Example: obese teenager that continuously comes in for a cough - consider CHF and check a BNP

-S/S Infant/very young child:
*Poor feeding or prolonged feedings (vomiting after feeds is not associated with CHF)
*Irritability
*Chronic cough
*Tachypnea: nasal flaring, retractions
*FTT: poor weight gain

-S/S Older child/adolescent
*Exercise intolerance
*Abdominal pain
*Chest pain
*Syncope

Question 24

Peds CV - HTN

Answer 24

-Acquired heart disease, usually secondary HTN - underlying cause
-To dx, must have a persistent high BP >95th percentile in at least 3 separate occasions

-Labs:
*Aldosterone: rule out aldosteronism
*Morning and evening cortisol: rule out Cushing’s
*UA, CBC, BMP, cholesterol, and triglycerides
*EKG to check for dysrhythmias

-Management:
*Refer to cardio
*DASH diet
*Treat underlying cause

Question 25

Peds CV - Rheumatic Fever/Heart Disease - Overview

Answer 25

-Post-inflammatory disease
-Affects heart, joints, and CNS
-Follow a group A beta hemolytic strep (GABHS) infection
-Common in children 5-15 years old
-Mitral valve is most commonly affected ***
-Rheumatic heart disease can develop years after one or more episodes of rheumatic fever

Question 26

Peds CV - Rheumatic Fever/Heart Disease - Diagnostic Criteria

Answer 26

-Diagnosis: need to have rheumatic fever plus 2 major or one major and two minor Jones’ criteria - required criteria regardless of major or minor is an antecedent Strep infection

*Major manifestations:
**Carditis
**Polyarthritis
**Chorea (movement disorder that causes sudden, unintended, and uncontrollable jerky movements of the arms, legs, and facial muscles)
**Erythema marginatum - ring-shaped rash
**Subcutaneous nodules

*Minor manifestations:
**Arthralgia without objective inflammation
** Fever >102.2F
**Elevated ESR and CRP
**Prolonged PR interval on EKG with evidence of GABHS infection

Question 27

Peds CV - Rheumatic Fever/Heart Disease - Labs/Diagnostics

Answer 27

-Positive throat culture or rapid strep assay
-Increased or rising ASO titer
-EKG
-Echo

Question 28

Peds CV - Rheumatic Fever/Heart Disease - Management

Answer 28

-Refer to cardio
-Aggressive management of strep
-Check UA after antibiotic therapy to evaluate for presence or RBCs, which can indicate secondary glomerulonephritis
-Bed rest if acute
-Prophylactic antibiotics for invasive procedures

Question 29

Peds CV - Kawasaki Disease - Overview

Answer 29

-Acute febrile syndrome causing vasculitis
-Leading cause of CAD in children
-Usually dx in children under 2 years old

Question 30

Peds CV - Kawasaki Disease - Diagnostic Criteria

Answer 30

-Must have a fever for at least 5 days (fever has 5 words and lasts for 5 days)
-Bilateral conjunctival injection without exudate
-Polymorphous rash (urticarial or pruritic)
-Inflammatory changes of the lips and oral cavity (peeling lips) - difficulty eating or drinking, causing decreased appetite
-Changes in extremities (erythema of soles/palms, edema, peeling skin)
-Cervical lymphadenopathy

*Can have strawberry tongue

Question 31

Peds CV - Kawasaki Disease - Stages

Answer 31

-Acute:
*Fever lasting 7-14 days

-Subacute: Starts once fever decreases and lasts until about week 4 - risk of sudden death is highest at this stage
*Desquamation of digits
*Thrombocytosis
*Development of coronary aneurysms

-Convalescent: resolution of s/s - happens within 3 months of presentation

Question 32

Peds CV - Kawasaki Disease - Labs/Diagnostics

Answer 32

-CBC
-ESR
-Positive CRP
-EKG changes: prolonged PR or QT interval

Question 33

Peds CV - Kawasaki Disease - Management

Answer 33

-Immediate hospitalization
-IVIG single infusion, over 10-12 hours
-High dose aspirin therapy (because there is a concern for clots) - once fever free for about 48 hours, change to low-dose aspirin