CBL:cardiology Flashcards
Characteristic of the murmur: Ventricular Septal Defect
- Pansystolic murmur
- lower left sternal border
Characteristic of the murmur: Coarctation of the Aorta
- Crescendo-decrescendo murmur
- upper left sternal border
Characteristics of the murmur: Patent ductus arteriosus
- continous
- upper left sternal border
Characteristics of the murmur: Pulmonary stenosis
- ejection systolic
- upper left sternal border
Where do we check for the pulse in BLS of:
A. child under 1 year old
- child 1 year old and over
A. child under 1-year-old -> brachial and femoral
B. In a child 1 and over -> femoral and carotid
Antibiotics (2) given for a child <3 years old when meningitis is suspected
Meningitis in children < 3 months: give IV amoxicillin in addition to cefotaxime to cover for Listeria
What’s Trident hand deformity?
What is it suggestive of?
short, stubby fingers with separation between the middle and ring fingers -> achondroplasia (dwarfism)

History of palpitations. What questions to ask?
Questions to ask in history of palpitations:
- onset (on rest , exercise)
- any fainting/ collapse?
- how long for do they last?
- can you show me the rhythm (regular or not)
- any changes in frequency recently
- any pain/when (before the palpitation, with or after onset of palpitations)
- any SOB with it
- recent stressors (as possible trigger)
- FHx (cardiac, syncope, unexpected death)
- medication/ drugs
- lifestyle
- how does it affect you -> severity
- does anything makes it worse/better (SOCRTES); previous treatments eg. Valsava manouver
How to do Valsalva Manoeuvre?
How to do Valsava:
- take breath in, close your nose/mouth hold it and blow ou
- OR Hold end of straw, pinch it and blow through a closed space as hard as you can – blow against an obstruction
- blow into 10 ml syringe to move the plunger
Mechanism: increased intrathoracic pressure and improves venous return as it increases Vagus stimulus ->slows the HR down
*Vagus is linked with parasympathetic nervous system = induces bradycardia
Investigations to be considered in ‘on-off symptoms’ of an arrhythmia e.g. palpitations
- ECG as baseline
- Electrolytes level: Ca++ , Magnesium and K+ -> as may cause irregular HR (imbalance by e.g. vomiting, diarrhea, anorexia/ bulimia)
- 24 hour ECG-> depends on history and ordered tests (e.g. if once every few months-> cannot really rule out anything as we may not ‘cupture’ the moment) -> useful if symptoms happen everyday
- CarioMemo -> if symptomatic only occasionally, pt puts it on the chest and ECG is recorded *but some people may not be able to record e.g. due to collapse, then CardioMemo is not useful unless the carers would put it on; then we can implant
- RevelDevice, that sends the information through WiFi; useful in e.g. unexplained fainting -> but can have interference from electrical devices (e.g. hairdryer)
Picture (on ECG) of hyperkalaemia
Possibly picture of hyperkalaemia
As K + rises (> 6.0 mmol/L):
- Tall peaked T waves, best seen in precordial leads
- Prolongation of QRS duration
- Prolongation of PR interval
- Disappearance of P waves
- Wide bizarre biphasic QRS complexes (sine waves)
- Eventual asystole

Common causes of hyperkalaemia in children
Common causes of hyperkalaemia in children:
- kidney problems (acute or chronic)
- adrenal insufficiency (eg. Addison’s) -> as Na+ will not be retained -> more K+ retained
- dehydration
- destruction of RBCs -> due to burns, injuries
- type 1 diabetes
Supraventricular tachycardia in children - what are the considerations for management?
- reassurance
- safety netting (symptoms that may change/ come to A&E)
- if we find that something is not right -> decide if to treat or not to treat
How do we decide if to treat or not -> depends on history (associated symptoms, duration, frequency, how does it affect their life)
If it happens e.g. every second moth -> then discuss with the patient how much it affects them, if they want to take anti-arrhythmic every day for something that is occasional BUT if bothering then go ahead with medication
- if anything changes (symptoms/ frequency) then consider re-assessment and treatment (e.g. ablation, medication)
*ablation is useful but risky (it may do an ablation on the pathways we did not intend to and mess up with the conduction further)
What is a possible connection between a baby being SOB and not gaining weight?
In a case: Child is breathless, have a murmur, not gaining weight = failure to thrive
*child is has SOB -> difficult to feed if breathing so fast as there will be L->R shunt so more overload of the R side -> pulmonary oedema/congestion (ask how long does it take for a child to finish the feed – takes longer due to being breathless etc)
Case: Child is breathless, have a murmur, not gaining weight (failure to thrive)
What further investigations would you do?
- ECHO
- ECG
Case: Child is breathless, have a murmur, not gaining weight (failure to thrive)
Management
Management:
- diuretics -> less congestion -> better feeding
- NG feed -> feed goes directly into the tummy (but danger of overfeeding)
- PEG
- IV fluids (but electrolytes and all nutrition would not be enough to satisfy nutritional needs)
*surgery not always the best option, think how severe the hole is -> any other symptoms, can we wait a bit rather than putting a child through an invasive procedure *do cardiology review if in any doubts to make sure we can only ‘watch and wait
S1 is a result of what?
S2 is a result of what?
- S1 – result on M/T valve closing
- S2 – aortic and pulmonary close
S1 - S2 is what?
S2 - S1 is what?
In terms of cardiac cycle…
S1 and S2 = systolic
S2 – S1 = diastolic
Why do we hear a murmur? Is it a result of what?
Why do we hear the murmurs -> pathopysiology:
- Increase flow across normal structure / flow murmurs -> e.g. increased output (exercise, pregnancy, fever, hyperthyroidism, anaemia, fistula)
- Normal flow across abnormal structure -> valvular problem (structure)
- Pressure gradient -> e.g. if stenosis gets worse -> more pressure needs to be generated -> lauder murmur (so the severity of the murmur may be dictated by a pressure gradient)
Is a loud murmur always bad?
Murmur soft vs loud - is it good or bad?
- Example of VSD:
Loud murmur in VSD is good = hole is smaller (as more resistance more pressure is required)
Softer murmur in VSD = hole is bigger (so worse/more severe)
- Example of aortic stenosis:
Aortic stenosis: the louder them murmur = the bigger the gradient = the worse the stenosis is
Possible causes of: Pansystolic murmur, L sternal age
Pansystolic murmur, L sternal age – possible causes:
- Mitral regurgitation
- Tricuspid regurgitation
- VSD
Characteristics of mitral regurgitation murmur and tricuspid murmur (compare)
*mitral regurgitation usually radiates to the axilla + does not increase with inspiration
*tricuspid murmur same as above (radiation to the axilla + pansystolic) but increase with resp
How to approach an adult ECG (up to HR)
How to approach ECG (adult):
(In order)
- Patient details
- When it was done
- Rhythm (irregular/regular)
- HR: count big squares and /300 (you may do range)
How to approach adult ECG: consider P wave
*what does bifid P wave imply?
- P wave - is it normal, how big is it? (the bigger -> the bigger the R atrium is)
- bifid P wave -> mitral stenosis
- duration of PR (3-5 little squares) *in children we want shorter; it is rate dependant: if fast HR and long PR -> 1st degree heart block (longer for depolarization to spread between atria nad ventricly)
Approach to ECG: QRS
- size
- dominance
QRS complexes:
- Broad/narrow -> location
- Dominance -> L vent hypertrophy V5 V6, tall; on the R -> deep/inverted
Approach to ECG: axis
What are the deviations in adults and children?
- Axis -> look at I and aVF
Calculate the voltage
*in children R axis deviation normal
* in adult L axis deviation possible

ECG: T wave
- how it should look like
- hyperkalaemia appearance
- hypokalaemia appearance
- MI appearance
- T wave - should be upright
- Hyperkalaemia: T waves get taller and toller
- Hypokalaemia: flat
- MI: inverted T wave, pathological Q waves, ST elevated/depressed
ECG: QT - how shall we calculate it
- what does long Q-T may mean
*QTc -> Q-T corrected interval; e.g. long Q-T due to ion channel problems (usually Na+) -> to label someone as ‘long QT’, do genetic testing as well and other tests
* short QT also possible
Corrected Q-T used in Bazzett’s formula
Delta wave
U wave
what do they imply?
- Delta wave -> Wolf-Parkinson White (slurred upstroke due to faster conduction that went through vent)
- U wave -> hypothermia/ hypocalcaemia