CV Flashcards
Infantile CHD S/S?
No mumurs initially
- Sweating w/ feeds OR FTT - 1st S/S
Older children w/ CHD may present w/?
Chest pain
Standard cardiac tests of PEDs?
CXR - AP/LAT (r/o pulm dz) O2 test EKG Echo Cardiac Cath
Oxygen test is used to?
Differs lung vs Cardiac etiology in cyanotic infant
Oxygen test is performed how?
- Baseline SO2 or PaO2
- 100% O2 for 30m
- Recheck O2 sat/abg
Results - no Change = cardiac process
MC symptomatic arrhythmia is?
SVT - responds to vagal maneuvers or adenosine
Definitive Dx cardiac test?
Echo > confirmed w/ Cardiac cath (dx/txt)
EKG may help differ what?
Hypertrophy from dilation
Fx murmur is AKA?
Benign or innocent
Types of Fx(benign) murmurs?
Fx murmur of peripheral arterial PS
Venous hum
Stills murmur (LV outflow)
Pulmonary flow murmur (RV outflow)
Types of pathologic murmurs?
AS/PS - AR/PR MS/TS - MR/TR ASD/VSD PDA MVP
Still murmur attributes?
Systolic EJ
LLSB or between LLSB and apex
Musical vibratory
Upright will decrease intensity
V-Hum murmur attributes?
Continuous murmur Infraclavicular region (R>L) Upright = louder Changes = turn head, jugular vein compression
Carotid Bruit attributes?
Systolic EJ - neck, over carotid artery
Types of atrial dysrhythmias?
WAP - wandering atrial PM
PAC - Premature atrial contractions
A-Flut - Regular/Rapid - s/p surgery, myocarditis
A-Fib - Irregular/Rapid - s/p surgery, myocarditis
SVT
MC atrial dysrhythmias? attributes?
SVT - rapid, regular, narrow QRS
HR - 280-300 in infants
TXT of SVT?
Vagal maneuvers
IV adenosine
CV compromise = cardiovert
SVT may be caused by what other dysrhythmias?
WPW
Ventricular dysrhythmias?
PVCs - premature ventricular contraction
V-Tach
V-Fib
PVC attributes?
Benign - Premature beat - NO p-wave
- Wide/bizarre QRS
When should PVC be eval?
Syncope or Fam Hx
V-tach attributes?
> 3 Consecutive PVCs = serious dz
TXT of V-tach?
PVT - V-fib
Symptomatic pt = Cardiovert
Asymptomatic/alert = Lidocaine or Amiodarone
Types of Heart blks?
1st D* - Prolonged PRI - asymp
2nd D* - Mobitz I vs II
3rd D* - Complete HB
Difference between Mobitz I vs II?
Mobitz I
- Progressive PRI prolonged until QRS drops - sleep
- no txt
Mobitz II
- PRI unchanged BUT QRS dropped intermittently
- +- Pacemaker to PVT 3rd D*
Compete HB - 3rd D* attributes?
Atria and Ventricles have NO relationship
Must TXT
Fetal circulation shunts?
FO - R > L shunt between atria - bypass lungs
DA - R > L shunt between Pulm artery and Aorta - lungs
DV - Opening between Umbilical vein/IVC -O2 blood from placenta bypasses liver.
What is used to keep PDA open? and Why/When used?
Rx - Prostagladin E - to keep PDA open
IF
Cyanotic lesion is present
Types of acyanotic lesions?
ASD/VSD
PDA
Coarc
PS/AS
What type of shunt is an acyanotic lesion?
L > R shunt
MC congenital heart defect is?
VSD
VSD size correlation?
<3mm - Asymp
3-5mm - Mod S/S
> 5mm - CHF or FTT
VSD sounds like?
HARSH pansystolic murmur at LLSB
II-V
VSD W/u?
CXR - Biventricular enlargement, CHF, Cardiomegaly
EKG - LVH
VSD TXT?
1/3 - spon closure
> 3mm - Diuretics +- digoxin (reduce afterload)
Surgical if, FTT or Pulm HTN
When is surgery indicated for VSD?
FTT or Pulmonary HTN despite Rx TXT
ASD sounds like?
Early systolic at LUSB - I-III
- Fixed split of S2
+- rumbling diastolic murmur = flow across TV
ASD w/u?
CXR - RAE, Cardiomegaly, Pulm artery prominent
EKG - RAD, RVH (deviation to hypertrophy)
TXT of ASD?
Rare - mostly asymptomatic
BUT
Sig ASD shunt present >3yo - closure via cath/surgery
2nd MC congenital heart defect?
PDA
PDA s/s - size correlation?
Small - asymp
Mod-LRG - CHF
PDA sounds like?
Continuous machine like murmur
- LUSB infraclavicular > Left back
PDA pulses will be?
Bounding, w/ Widened pulse pressure
PDA eval?
CXR - full pulmonary silhouette/vascularity
EKG - RVH and +- LVH if pulm HTN present
PDA TXT?
Indomethacin- will close, CI if PDA is keeping PED alive
Cardiac cath
SE of Indomethacin for PDA?
Transient renal insufficiency
AS/PS s/s?
DOE and fatigue
AS sounds like?
II-III rough Systolic w/ EJ click of LUSB radiating to BACK
PS sounds like?
II-III rough Systolic w/ EJ click of RUSB radiating to NECK
AS/PS w/u?
CXR/EKG
PS - EKG = RAD/RVH and CXR = Pulm artery dilation
AS - EKG = LVH and CXR = LVH/Aortic dilation
TXT of AS/PS?
1L - Balloon valvuloplasty (PS > AS outcomes)
2L - Surgery - Fails or Subvalvular PS
Types of AS/PS?
Supra-valvular
Valvular
Sub-valvular
COA is AKA?
Coarctation of the Aorta
MC site of COA?
Thoracic next to DA
COA is ass/w what other lesions?
PDA
VSD
Aortic valve lesions
COA is ass/w what genetic anomaly?
Turners syndrome
COA sounds like?
I-II systolic murmur at LUSB w/ radiation to Left upper back next to scapula
+- continuous if collaterals develop
BP/Pulses of COA?
Femoral pulse - delayed/weaker than R radial pulse
BP Legs > Arms (HTN in arms)
COA is essential what?
Narrowed aorta
COA W/U? Infants vs Children?
CXR
Infants - RVH w/ cardiomegaly and PULM edema
Children - LVH, RIB NOTCHING and aortic bulge
EKG
Infants - RVH
Children - LVH
TXT of COA?
PG E1 - Alprostadil (PGE) - keeps DA open until
Surgery TOC
- Balloon angioplasty
Purpose of Prostaglandin E1 (PGE)?
Keeps DA open
Cyanotic lesions are essentially what type of shunt?
R > L - pushes deoxy blood into circulation
Types of Cyanotic lesions?
TOF TGA Tri-atresia Trunc-arteriosus TAVR - total anomalous venous return Hypoplastic Left heart syndrome Ebstein's Anomaly
Mnemonic for Cyanotic lesions?
HE has 5Ts
MC cyanotic heard defect?
TOF
TOF attributes?
Requires all 4
- Overriding Aorta into RV
- PS
- VSD
- RVH
What is the indicator of S/S severity w/ TOF?
Degree of PS
What do TOF PEDs experience?
TET - Hypoxic spells in older PEDs
What is a TET - Hypoxic spells?
Sudden - spon progressive cyanotic dyspnea
- loss of murmur
Resolves when - Squatting (increases Abd pressure)
TOF sounds like?
I-III Rough systolic LUSB (aka PS)
TOF w/u?
CBC - Polycythemia (Thombosis)
CXR - RVH - boot shaped heart
EKG - RAD/RVH
TXT of TOF?
PGE if cyanotic at birth - keep PDA open
Surgery (TET spells is indication)
Bacterial endocarditis PRPH 6mo s/p surgery
2nd MC cyanotic heart defect is?
TGA
What is TGA?
Aorta begins at RV - Deoxy blood in circulation
Pulm artery begins at LV - Oxy blood cycles LV/Lungs
In TGA does peripheral circulation receive O2?
NO - not unless L>R shunt present (PFO, PDA, ASD, VSD)
Failure for baby to pink up at birth suggests what CHD?
TGA - cyanotic lesion
TGA W/U?
EKG - RAD, RVH
CXR - egg on string shaped heart
TXT of TGA?
PGE - keep L>R shunt open (PDA)
Surgery
Tricuspid atresia is essentially what?
Underdeveloped RV
What is required for life in Tricuspid atresia?
ASD - Systemic blood RA > LA
VSD - LV > RV into pulmonary arteries
Mgmt of Tricuspid atresia if VSD not present?
PGE in order to keep PDA open at birth
TXT of Tricuspid atresia?
PGE - keep PDA open
Surgery
What is the blood flow of Tricuspid atresia?
- IVC/SVC > RA > ASD > LA > LV > VSD > RV > Pulm arteries > Lungs
- NO VSD - LV > Aorta > PDA > Pulm arteries > Lungs
Truncus Arteriosus is essentially what?
Failure of septation of truncus causing no division of Pulmonary artery and Aorta
What CHD is also present w/ Truncus Arteriosus?
VSD
TXT of Truncus Arteriosus?
Surgery - septal creation (may require multiple surg)
AND close VSD
Total Anomalous venous return is essentially?
Pulmonary veins (Oxy-bld) doesn’t connect to LA but instead to Right side of heart (RA or SVC)
What is required for Total Anomalous venous return to be compatible w/ life?
ASD
TXT of Total Anomalous venous return?
Surgery - Pulm vein connected to LA
Hypoplastic Left heart syndrome is essentially?
Developmental failure of Aortic arch, Aortic valve, or MV - resulting in small LV
What is required for Hypoplastic Left heart syndrome to be compatible w/ life?
DA - R>L shunting
MC cause of cardiac deaths in 1st month of life?
Hypoplastic Left heart syndrome
TXT of Hypoplastic Left heart syndrome?
PGE - keep DA open
- surgery - multiple
Ebsteins Anomaly is essentially?
Malformed TV sits too low and leaflets are partly attached to RV causing it to act like the RA partially
AND
Fibrous TV annulus
Ebsteins Anomaly is ass/w what other HD d/o?
TR - leaky TV
Pathophys of Ebsteins Anomaly?
Blood leaks from RV into RA causing RAE >
RAE enlrg causes increased pressure in RA >
RA pressure causes R > L shunt through FO >
Cyanosis due to PFO (Patent foramen ovale)
Ebsteins Anomaly pts will present as?
Cyanosis
CHF
Dyspnea
Ebsteins Anomaly W/U?
CXR - Box haped heart, decreased pulm markings
EKG - RAD, RAH, Peaked/broad P-waves, RBBB
EKG reading of Ebsteins Anomaly?
Tall, peaked P-waves (L-2 and V-1)
RAH/RAD (L1 - aVL)
RBBB
What does cyanotic lesions generally require?
PGE1 to keep DA open (L>R shunt)
All CHD/lesions causing CHF or HTN require?
Diuretics +- digoxin until surgery/def TXT (cath)
Generally speaking when are acyanotic lesions corrected?
By 2yo w/ structural/developmental maturity
UN-Txt lesions will generally all lead to?
Pulm HTN
CHF
SBE
Trisomy 21 - downs is ass/w what CHD?
ASD, VSD, PDA
XO - Turners is ass/w what CHD?
COA, AS
Esophageal atresia is ass/w what CHD?
VSD - (VACTRL)
Rheumatic fever is?
GAS strep infection cross reacting w/ Cardiac antigens causing Valvular scarring
MC age of RF?
6-15yo
Labs ordered for RF?
Anti-streptolysin O titer
Dx of RF is based on what criteria?
Jones criteria (2 Major -or- 1 Maj + 2 minor) \+ evidence of GAS infection, Increased ASO lab, scarlet fever or POS throat culture
Major Jones criteria? (5)
Carditis (Murmur, CHF, Pericarditis) Polyarthritis Sydenhams chorea Erythema marginatum (pink serpiginous macs) Sub-Q nodules
Minor Jones criteria? (6)
EKG changes - Prolonged PR or Heart BLK Arthralgias Fever (101-102) Elevated ESR/CRP Increased WBC Hx of RF/RHD
TXT of RF?
ABX - strep infection (PCN G Benz or Erythromycin)
ASA/NSAIDs - anti-inflammatory
(PO) CCS - prednisone or methylprednisolone (Carditis)
RF prph?
PCN G Benz (IM) Q/28d
Pericarditis is?
Inflammation of parietal/visceral pericardium
MC etiology of pericarditis?
Viral
MC bacteria to cause pericarditis?
Strep. Pneumo -or- S.A
S/S of pericarditis?
SML effusion - well tolerated
LRG effusion BUT slow build - well tolerated
Rapid build of fluid = hemodynamic compromise
When does pericarditis effusion become a problem?
If effusion builds rapidly
Manifestations of PERICARDITIS?
Pulsus Paradoxus - >10mmHg w/ inspiration
Narrow pulse pressure
Kussmual sign
(CP, Dyspnea, Distended neck veins, Pericardial knock)
Edema/Ascites
Pericarditis Imaging?
Echo - effusions
CXR - Rounded globular silhouette cardiomegaly
EKG
Pericarditis Labs?
ASO titers - Viral titers
Cardiac Enzymes
EKG results of pericarditis?
St elevation
Tachy-C
Electrical alternans - swinging heart in effusion
Pericarditis TXT?
Pericardiocentesis - drain fluid
Viral - NSAIDs
Bacteria - Abx
CHF txt PRN
When is pericarditis poor prognosis?
<6o old
Recurrent S/S
Infective endoarditis is essentially?
Infection of the endothelial surface of heart resulting in vegetations MC on valve leaflets
MC cause of in PEDs for infective endocarditis?
Viridian streptococci - PEDs w/ CHD w/out surgery
OR
S.A or Coag-Neg Staph - PEDs s/p cardiac surgery w/ prosthetic material
Highest RF of infective endocarditis?
Hx of infective endocarditis
W/in 6mo - Prosthetic valves/material
Unrepaired congenital heart disease
Other RF of Infective endocarditis?
Dental/oral procedure recently
Respiratory, GU, GI surgeries
RHD
Neonate RF of infective endocarditis?
Central catheters or surgery
MC early S/S of infective endocarditis?
Fever, Malaise, Wgt loss
Tachycardia - new/changed murmur
W/U for infective endocarditis?
Blood Cx
Difference between Acute vs Subacute infective endocarditis?
Subacute infective endocarditis - slow process
Acute infective endocarditis - similar to sepsis
Acute infective endocarditis MC organism?
S.A.
Infective endocarditis criteria?
DUKES criteria
- HF
- Splenomegaly
- Petechiae
- Embolic phenomena (Osler nodes/Roth Spots/Janeway lesions/Splinter hemorrhages)
PVT of Infective endocarditis in High risk pts?
Prph Abx - all dental/resp/skin/muscle procedures
- (PO) Amoxicillin 30-60m before procedure
(Clindamycin or Azithromycin = PCN allergy)
NL correct BP check protocol of PEDs?
> 3yo - Child sitting quiet 5m prior
HTN - classified as?
Primary (Essential) HTN
and
Secondary HTN
MC type of HTN in adolescents?
Essential HTN
Obese children more likely to have what type of HTN?
Essential HTN
MC cause of 2ndy HTN in PEDs?
Renal disease
Which type of HTN is more severe?
2ndy HTN
Which type of HTN occurs MC in younger PEDs?
2ndy HTN
When to eval for 2ndy causes?
PEDs BMI is <85th%
BP >140/100
2ndy causes of HTN + Turners syndrome indicates?
COA
2ndy causes of HTN + Café-au-lait spots or Abd bruits indicates?
Renal Artery Stenosis
2ndy causes of HTN + Precocious puberty indicates?
Renal artery stenosis
2ndy causes of HTN + Edema indicates?
Renal disease
2ndy causes of HTN + Excess sweating indicates?
Pheochromocytoma
2ndy causes of HTN + Striae in boys indicates?
Drugs/Steroids
Pediatric HTN eval?
UA, CMP (BUN/Cr,Lytes)
Renal U/S
TXT of Stage 1 asymptomatic PEDs HTN?
Lifestyle mod only
Stage 1 HTN essentially means?
No organ damage or systemic disease
Indications for Rx in PEDs HTN?
Failed lifestyle Mod
Stage 1 HTN + symptomatic
Stage 2 HTN
DM
HTN Rx by order used?
1L - CCB or ACEI
- Then - ARB, BB, Diuretic