general Flashcards
What are cardiac issues associated with Lyme
AV block
myocarditis
pericarditis
LV dysfunction
What are the three clinical phases of Kawasaki
acute - d7-10- T, conjunctivtis, mucositis, rash, LN, edema, aseptic meningitis, hepatitis
subacute - d11-21 - coronary aneurysm + desquemation
convalescent stage - 6-8wks- ESR going back to normal
What is the treatment for Kawazaki
IVIG in fisrt 10 days - decreases risk of anurysm from 25% to 3-5%.
No vacc for 11 mo
ASA high dose - 80-100mg/kg until 48hrs post T resolution
ASA 3-5 mg/kg for another 6-8week, if aneurysm - ASA forlife
ECHO 6 wks
What is the treatment for Lyme carditis
IV ceftriaxone or pen G for 14 d
or PO if mild with Amox for young and doxy for old
Block responds to Abx
Wht are ECG findings for myocarditis
sinus tachycardia low QRS voltage ST changes PR and QT prolongations arrythmia
what is a PDA
connection between the Left pulm artery and the descending aorta distal to the origin of the subclavian artery
What are clinical findings in pericarditis
- Narrow pulse pressure
- Pulsus paradoxs: abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg.
When the drop is more than 10mm Hg, it is referred to as pulsus paradoxus.
> 20 mmHg - Tamponade - sharp stabby chest pain
What are the most common causes of myocarditis?
Entrovirus - coxsack adenovirus parvo CMV EBV
what is sarnat 1 stage?
*hyper alert normal tone normal posture *inc Rfx *myoclonus *strong moro Mydriasis no sz EEG normal less than 24 hrs and do well
what is sarnat 2?
lethargy hypotonia flexed posture inc rflx myoclonus weak moro miosis SZ are COMMON EEG - low voltage lasts 24n hr to 14 days
what is sarnat 3?
coma no tone decerebrate posture no rfx no myoclonus no moro poor pupil response EEG - burst suppression days to weeks
what are risk factors for neural tube defects
- insulin dep DM
- Sz treated with VPA or carbamezapine
- FHx of NTD
what is the risk of recurrence of NTD?
2-3 % if one sibling, 4-6% if 2 siblings
even if treat with folic acid, still 1%
what syndrome is associated with TEF?
VACTERL syndrome
what are 2 syndromes associated with long QT syndrome
- Jervell and Lange-Nielson syndrome - AR, + deafness
2. Romano-Ward syndrome - AD
what electrolyte abnormalities might prolong the QTc
Low Ca
Low K
Low Mg
what are the 3 most common types of LQTS
LQT1 - K channel issues, events occur during stress
LQT 2 - also K, mixed pattern
LQT3- Na channel, highest probability of sudden death
what are causes of PAC/PVCs?
idiopathic fever/infection electrolytes hyperthyroidism drug toxicity FB - catheter
when should you get worried if someone has PVCs?
do not disappear with exercise
>=2 PVCs in a row
multifocal origin
underlying heart disease
what are the features of WPW
- short PR intervals
- widened QRS by delta wave
- predisposition to arrythmias - SVT, a. fib, Vfib
what is Texidor’s twinge?
precordial catch
brief episodes of sharp localized pain - lateral
can occur with bending or slouching
takes breath away
reproduce by palpating bottom ribs inward
recurrent
grow out of
what is the management of pt with WPW
betablockers if SVT issues
catheter ablation if severe
MUST avoid Digoxin!!!!
who is at risk for aortic aneurysms?
marfan syndrome
Noonan’s
Turners
what is the most common type of ASD?
Ostium secundum - 80% - foramen ovale region
Ostium primum - inf portion, near AV val
Sinus venosus - post/sup, often assocated with anomalous pulm venous drainage
what are cardiac cause of chest pain?
- ischemic lesion - coronary blockage , HOCM
- severe obstructive lesion - aortic/pulm stenosis
- MVP
- inflammatory - peri/myocarditis
- arrythmia
- cardiomyopathy
- aortic disection*
- Cocaine, methamph, sympathomimetic decongestants
what is the murmur expected with ASD
wide, fixed split S2 during inspiration - more blood in RV so takes longer for RV to eject
What are CXR finding for ASD?
cardiomegaly
RA/RV dilation
prominent vascular marking
prominent PA
what are causes of coronary insufficiency?
kawasaki Williams anomalous origin of of coronary arteries coronary arteriovenous fistula coronary cameral fistula
what maneuvre could help you diagnose Hypertrophic cardiomyopathy
if murmur increase from lying to standing
what antibiotics are recommended for IE prophylaxis?
amoxicillin
if allergic - cephalexin, clindamycin, azithro or clarithromycin
what antibiotics would you start with if thinking of IE?
Vancomycin and Gent
Can you interpret an ECG if WPW present
No
What are pt with WPW at risk for?
SVT
Sudden death
if a patient is confirmed to have HTN, what else should you do after that?
- Echo for LVH
- AUS and renal WU - BUN, creat, lytes
- assess other CVS risk factors - lipids
what heart lesions will have a click (3)
- aortic stenosis
- pulmonary stenosis
- MVP - mid-systolic click
which lesions have a narrow pulse pressure?
AS
cardiac tamponade
CHF
which lesions have wide pulse pressure?
aortopulmonary connection
- PDA
- Truncus A
Volume depletion
why do you get a fixed split S2 in an ASD?
due to overload of the right ventricle with prolonged ejection into the pulmonary vasculature
what is rheumatic fever?
immunological reaction post GAS pharyngitis
in relations to GAS, when does RF occur
2-6 weeks but up to 3 mo
How do you Dx rheumatic fever?
revised jones criteria:
evidence of strep infection +
2 majors or
1 major and 2 minors
what are major jone criteria for RF
JONES
Joints -Migratory polyarthritis - lasts 2-4 weeks
Carditis (endocarditis for sure) - clinical, tachy, new M, pericarditis, cardiomegaly, CHF
Nodule - chronic and recurrent
Erythema marginatum-macular, serpiginous with central clearing, evanescent
Sydenham disease-Inc emotions, ANA +, emotional, lasts 8 wks up to 6 mon
How can we prevent RF?
Abx up to D 9 of symptoms of strep pharyngitis
what are minor jones criteria for RF
crITERIA Inflammatory cells (leukocytosis) Temperature (fever) ESR/CRP elevated Raised PR interval Itself (previous Hx of Rheumatic fever) Arthritis - cannot use if arthralgia used as major criteria
Which patients with a Hx of RF are at higher risk of carditis if get GAS again
only if had carditis for 1 st episode
what type of RF prophylaxis is recommended if had NO carditis?
until reaches 21 yr of age or until 5 yr have elapsed since the last rheumatic fever attack, whichever is longer
what type of RF prophylaxis is recommended if had carditis but no residual valve disease?
10 yr or until 21 yr of age, whichever is longer
what type of RF prophylaxis is recommended if had carditis and residual valve disease?
10 yr or until 40 yr of age, whichever is longer, sometimes lifelong prophylaxis
What are characteristics of the arthritis associated with RF?
earliest manifestation
large joins-knees, ankles, wrists, and elbows
Red
warm
swollen
exquisitely tender
respond very well to NSAIDS if don’t respond = not RF
Inverse relationship between the severity of the arthritis and the carditis
What are 4 clinical manoeuvre to assess for RF chorea
(1) demonstration of milkmaid’s grip (irregular contractions of the muscles of the hands while squeezing the examiner’s fingers),
(2) spooning and pronation of the hands when the patient’s arms are extended,
(3) wormian darting movements of the tongue upon protrusion
(4) examination of handwriting to evaluate fine motor movements
what is DDx for chorea?
CP Huntington's SLE wilson's tic disorder
what are CF of myocarditis in neonates and small children
fever CHF resp distress tachycardia out of proportion for fever weak pulse mitral insuff
what are CF of myocarditis in teens
CHF ventricular arrythmia pain easy fatigability syncope or near syncope
what are features of cardiac syncope
little or no prodrome prolonged LOC > 5 min exercise induced startle induced \+ chest pain \+ palpitations Hx of CVS issues: AS, pulm HTN \+ Fhx
what are important Hx questions when assessing pt for prolonged QT
- palpitations
- symptoms during exercise or when startled
- Sz that are unusual
- palpitations when swimming
- deafness
- FHx
- Syncope
when does torsade de pointe occur
in low Mg
in long QT
Low K
patients with long QT are predispositioned to what type of arrythmia?
polymorphic ventricular tach
= VF and torsade
when can you not interpret QT?
if abnormal depolarization is present
- BBB
- WPW
what are acquired causes of prolonged QTc
CVS: myocarditis, MVP
Drugs: TCA, antipsychotics, Septra, clarithro, azithro, fluconazole, domperidone
lytes: LOW K, LOW Ca, LOW Mg
how do you manage a pt with long QT syndrome
beta blocker
if too brady on beta - may need pacemaker
if no response to beta, or Hx of arrest - Defibrillator needed!
what 3 lesions have LEFT axis deviation?
AVSD
tricuspid atresia
Noonan syndrome
in Kawasaki, who gets lifelong ASA
if large aneurysm > 6mm or
if multiple segments or
if complex aneurysm
what are features of cardiac chest pain
short
sudden onset
occurs at rest too
no other symptoms
what are the 4 stages of pericarditis ECG findings
- ST elevation and PR depression
- T wave flattening
- T wave inversion
- Resolution
what can help you differentiate sinus tachy from SVT
if RP is longer than PR = not re-entry and therefore will not respond to adenosine
what is Cor pulmonale?
Right heart dysfunction secondary to pulmonary disease
what lesions have decreased pulmonary vasculature
TOF
Tricuspid atresia
pulmonary atresia
ebstein’s + anomaly of tricuspid V.
CXR of snowman?
TAPVD
who can be found to have second degree type I AV block?
Wenkeback
- athletes
- sleep
- in AN
- in hypothyroidism
- in head injury
when might you see second degree type II heart block?
random drop in QRS - myocarditis - endocarditis - lyme dis - congenital worrisome because can progress to complete HB
who gets 3rd degree HB?
maternal SLE
cardiac Sx
myocarditis
Lyme disease
what happens to the QT in a patient with QTc syndrome when they exercise?
does not change
normal person, gest shorter QTc
what proportion of population has asymptomatic PFO?
25%
what causes pulsus bigeminus?
2 beats close together HOCM Hypo or hyperkalemia Hypothyroidism Betablocker therapy Digoxin MI Destruction or degeneration of the cardiac conduction system or heart muscle cells Infection
unstable baby in SVT. Mgnt?
synchronise cardioversion
which CHD has cyanosis aggravated by crying?
PS
?TOF
doxorubicin causes what type of heart issues
dilated cardiomyopathy - months to yrs post
can get acute myocarditis
may see long QT
once get CHF - high fatality
what are ECG findings associated with hyperkalemia
- peaking of the T waves
- ST-segment depression, an
- increased PR interval,
- flattening of the P wave, and
- widening of the QRS complex
= VF
How do you manage hyperkalemia
- stop K intake
- ECG
- Protect the heart - Calcium gluconate
- Shift potassium into the cells
- IV Na HCO3
- IV insulin and glocuse
- Neb salbutamol - Get it out:
Loop diuretic
Kayexalate
if bad - DIALYSIS
what are features of digoxin toxicity?
Low Na Low Ca HIGH K Bradycardia and heart block nausea and vomiting pulsus bigeminus
How do you treat a digoxin overdose
antidote if called digibind
ECG finding of Hypokalemia
flat T waves
depressed ST
U waves
how do you Dx IE
2 major
1 major + 3 minor
5 minor
what are the DUKE major criteria for IE - 2
- positive bld culture
2. echo +
what are the 5 major criteria of IE - FIVE PM
Fever > 38 oC
Immunologic phenomena (glomerulonephritis, Osler’s nodes, Roth’s spots, Rheumatoid factor)
Vascular phenomena (major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjuntival hemorrhage, Janeway lesions)
Echocardiography findings (suggestive but not definitive)
Predisposition (heart condition or IV drug user)
Microbiologic evidence (Positive blood culture but not meeting major criteria)
what criteria are necessary for possible IE
1 major + 1 minor
or
3 minor
what are factors associated with dev of coronar artery disease in Kawasaki?
fever > 14 d recurrence of fever after a 48 hr period fever free Cradiomegaly male < 1 yr > 8 yrs
AVSD ECG
aVF inverted
HLHS ECG
no R in V6
TA ECG
LVH - looks like adult ECG
baby should not have LVH, usually Right dominant
ECG of LVH
S in V1
R in V6
deep Q
RVH ECG
R axis
R is V1
S in V6
If see M in left lead
L bundle branch = myocarditis
if M on the right,
Right bundle branch block = VSD repain
HOCM ECG
LVH
abn T waves
Single S2 - all end in A
TGA
PA
aortic atresia
Truncus
what is the WU for ? prolonged QT
Scwarts score serial ECG parental ECG Holter exercise test ECHO -some cardiomyopathies have long QT
baby with cyanosis and an ejection click. Dx
truncus ateriosus
