CV Evaluation of the Pediatric Patient Flashcards
Acyanotic lesions?
Increased volume/ left to right shunts
Increased pressure/ obstructive lsions
Increased volume/left to right shunts?
Severe lesions can present early with signs and symptoms of heart failure
milder lesions
left untreated can progress to Eisenmenger Syndrome
Increased pressure/Obstructive Lesions?
Typically identified by classic exam findings
Left untreated severe lesions can progress to heart failure
Maternal health concerns?
Diabetic Maternal SLE Maternal CHD Rubella CMV, HSV, Coxsackie B, Parvovirus HIV
Teratogens?
Fetal alcohol Lithium Phenytoin Retinoic acid Warfarin
Fetal alcohol cause?
VSD, ASD, TOF, PDA
Lithium can cause?
Severe right heart abnormalities (Ebstein anomaly)
Phenyoin can cause?
PS, AS, coarc, PDA
Warfarin can cause?
PDA, ASD
Characteristic features of fetal alcohol syndrome?
FAS Facial characteristics
- small eye openings
- smooth philtrum
- thin upper lip
Postnatal history, growth and development?
poor weight gain and delayed development are often seen with heart failure (HF)
Feeding patterns? Postnatal history
poor feeding can be an early sign of HF
fatigue, diaphoresis, or cyanosis during feeds
Unable to stay awake for the full feeding
Cyanosis? Postnatal history
Onset, severity, frequency, affected areas (lips, toes, fingers)
Respiratory distress? Postnatal history
tachnypnea, dyspnea, retractions, etc
**squatting during distress suggests TOF
Tet spells?
cyanotic spell in infants or young children with uncorrected TOF
caused by any even that decreases SVR and produces a large R to L ventricular shunt leading to decrease in pulmonary blood flow which is already compromised
Characterize a tet spell?
rapid and deep respiration worsening cyanosis disappearance of murmur restlessness gasping respiration possible syncope
Sometimes relieve a tet spell?
infant in knee-chest position which traps venous blood in legs to decrease venous return and calm child
treatment for tet spell?
oxygen and morphine
History, Exercise intolerance/fatigue?
infants- feeding patterns
preschool/school-keep up with other children
older- how many blocks can he run? how many flights before fatigue?
History, edema puffy eyelids or sacral edema?
signs of CHF, venous congestion, frequency of lower respiratory infections
Heart murmur history?
timing and circumstances discovered
what was done about it?
History syncope?
with exercise? arrhythmia (long QT)/ obstuctive lesion
while sitting? seizure, arrhythmia
prolonged standing? Vasovagal
with exertion and CP? possible cardiac etiology
History of palpitations?
SVT, hyperthyroidism, premature beats, MVP
Family history congenital heart disease?
Risk of CHD in 2nd pregnancy after previous child is 2-6%
Risk is up to 20-30% when having CHD in 2 first degree family members
Family history Hereditary diseases?
some associated with CV disease (marfans, aortic aneurysm)
Family history rheumatic fever?
often occurs in multiple family members, no known genetic factor but thought to be inherited susceptibilty
Vital signs?
heart rate
-poor heart function leads to tachy to maintain CO
respiratory rate
-tachypnea, hyperventilation to improve oxygenation
pulse ox
-hypoxemia
height/weight
-growth and development are key markers of cardiac health in children
Palpation of peripheral pulses?
R/L upper compared with lower
Strong upper/ weak lower pulses?
coarctation of aorta
Bounding pulses, wide pulse pressure?
PDA, AI, increased CO
Weak pulse?
HF, pericardial tamponade, decreased CO
Diaphoriesis?
cold sweat, can be seen in children with HF
Clubbing?
indicates chronic low arterial saturation
loss of nail bed angle and distal hypertrophy of the digit
Eisenmenger Syndrome?
Shunt becomes R to L due to pulmonary hypertension
initially L to R shunt
occurs long term in lesions with increased volume of blood on right side resulting in medial hypertrophy and/or intimal hyperplasia in the pulmonary vasculature
Symptoms Eisenmenger Syndrome?
2nd/3rd decade
cyanosis, dyspnea, fatigue, arrhythmias
Apical impulse?
PMI normally located at the 4th left intercostal space medial to the midclavicular line under age 7 yrs
Apical heave?
suggests LV hypertrophy
Substernal thrust?
suggests RV hypertrophy
hyperactive precordium?
suggests volume overload, but can be normal in very thin individuals
Silent precordium?
suggests severe cardiomyopathy or pericardial effusion
Thrills?
palpable equivalent of murmurs
correlate with area where the murmur is heard the loudest on auscultation
always pathological
best felt with palm of hand, finger over neck
thrills over the suprasternal notch suggest LV outflow tract stenosis
S1?
closing of AV valves
heard best at apex, lower left sternal border
slight splitting can be normal but not common
S2?
closing of aortic and pulmonary valves
heard best at the upper left sternal border
splitting is normal, increases in inspiration, and decreases in expiration
fixed splitting suggests a cardiac defect
Splitting can be hard to hear in neonates due to rapid heart rates, so obvious splitting should raise concern
S3?
heard in early mid diastole during initial phase of rapid passive ventricular filling
low frequency, it is heard best at the apex with the bell
can be heard in healthy kids/athletes at apex but loud s3 is abnormal
may be heard as gallop rhythm in patients with heart failure and tachycardia
S4?
heard in late diastole and usually pathologic
associated decreased ventricular compliance
Ejection clicks?
heard in early systole, may be confused with split s1
best heard at mid to upper sternal borders
associated with AS, PS, or conditions that cause aortic/ PA dilation
a midsystolic click heard best at the lower sternal border suggest MVP
Heart murmurs?
I: barely audible II: soft, but easily audible III: moderately loud, but no thrill IV: louder, with thrill V: audible with stethescope barely on chest VI: audible with stethescope off chest
Murmurs, Benign?
innocent, functional
common in children
all are accentuated during high output state, usually during febrile illness
all are associated with normal EKG and CXR findings
Classic vibratory murmur/ Still’s murmur?
Most common
typically detected btw 3 and 6 yo, may be present in newborn
midysytolic ejection murmur
Low-pitch, best heard with bell of stethescope, patient supine
grade 1-3/6, typically heard best LLSB
Vibratory, twaning string, musical
Intensity with fever, anemia, after exercise, during excitment
Pulmonary flow of murmur of newborns? (PPS)
premature and full term newborns, usually disappears by 3-6 months
midsystolic
grade1-3/6
maximal at upper left sternal border
Transits well to L and R chest, axillae, and back
Caused by turbulent flow through pulmonary arteries when ductus closes that are relatively hypoplastic b/c they didnt recieve much blood flow during fetal life
Pulmonary ejection murmur of childhood?
8-14 yo, early to midsystolic
grade 2-3/6, blowing quality
heard best at the upper left sternal border
represents exaggeration of normal ejection vibrations in pulmonary trunk
Venous hum?
typically noted at 3-6 months
heard only in upright position and disappears in supine position
Continous murmur
medium pitch, grade 1-3/6
best heard at L or R supra/infraclavicular areas
can be obliterated by rotating head
from turbulens in jugular venous system
Carotid bruit?
any age, early systolic murmur grade 2-3/6 R supraclavicular area over carotids Occasional thrill noted over carotis from turbulence in crachicephalic or carotid arteries
Features that suggest a pathologic murmur?
diastolic murmur loud systolic murmur (3/6 >) associated with a thrill long in duration transmit well associated with any other abnormal heart sounds associated with strong/ weak pulses other associated CV symptoms, general exam findings, or abnormal CXR/ ECG
ASD exam findings?
palpation - RV displaced PMI heart sounds -fixed, widely split S2, SEM at ULSB other -possible RVH on EKG/CXR
VSD exam findings?
Palpation -LV displaced PMI, Thrill at LLSB Heart sounds -possible wide split at s2, harsh or blowing holosys murmur at LLSB other - possible LVH on EKG/CXR
AV canal exam findings?
Palpation -hyperactive precordium Heart Sounds -Loud S1, Holosys murmur at LLSB, Diastolic rumble Other -Cardiomegaly, HF
PDA exam findings?
Palpation -Hyperactive precordium Heart Sounds -continuous machinery like murmur at LLSB Other -bounding pulses
PS exam findings?
Palpation -RV displaced PMI Heart sounds -Ejection click, SEM at ULSB Other -Possible RVH on EKG/ CXR
AS exam findings?
Palpation -LV displaced PMI Heart sounds -Ejection click, SEM at URSB, mid LSB other -Possible LVH on EKG/CXR
ABG on room air tells you?
can confirm or refute central cyanosis
elevated PCO2 could mean CNS or pulmonary problem
Pre and postductal ABG/saturation tells you?
Arterial PO2 from right upper extremity that is 10 to 15 mmHg higher than umbilical artery or lower extremity site is significant and suggests a R to L ductal shunt
Hyperoxia test?
way to diagnose right to left shunt
take an ABG on room air, place the infant on 100% oxygen for at least 10 min, recheck ABG
Hyperoxia test if PaO2 rises above 150 mmHg?
intracardiac shunts are likely
suggest pulmonary disease or other cause of hypoxemia
saturation increases of 15% or greater also suggestive of other causes
Hyperoxemia test if PaO2 remains < 150 mmHg?
suggest R-L shunt (cyanotic congential heart disease)
Chest xray?
evaluate cardiac size and shape as well as position of apex
asses pulmonary vascular markings
evaluate associated pulmonary and thoracic abnormalities
Trasposition of the great arteries on CXR?
Egg shaped or egg on a string appearance
Tatrology of fallow on CXR?
boot shaped heart
Total Anomalous Pulmonary venous return (TAPVR)?
Snowman sign
Echocardiography?
shows cardiac structure and function as (wall thickness, ejection fraction, cardiac output, blood flow, presecence of clots, pericardial fluid)
useful for assessment of suspected heart disease, endocarditis, concerning heart murmurs
usually transthroacic (TTE), but transesophagel (TEE) if suboptimal TTE
Signs of PDA?
classic heart murmur bounding peripheral pulses hyperactive precoridum hypotension respiratory deterioration
Close a pathologic PDA?
Nsaids
surgery/ transcatheter approach
2 drugs used to close PDA?
Indomethacin
Ibuprofen
Indomethacin?
prostaglandin synthase inhibitor
renal side effects: decreased UOP and GFR
decreased mesenteric blood flow
Ibuprofen?
effective as indomethacin
fewer renal side effect
does not decrease renal or mesenteric blood flow
