Paediatric Cardiology Flashcards
Diagnostic criteria of acute rheumatic fever
Jones Criteria (SPACE CAFE) 2 major OR 1 major + 2 minor MAJOR: Subcutaneous nodules Pancarditis Arthritis (poly-) Chorea Erythema Marginatum MINOR: CRP/ESR raised Arthralgia Fever ECG: prolonged PR
Circulatory changes after birth
Activation of breathing - distension of lungs - dilation of pulmonary vasculature - reduced resistance - reduced RA pressure - LA pressure forces septum primum closed - functional closure of foramen ovale in first few minutes (complete closure by 12m)
Clamping of cord + temperature fall - contraction of Wharton’s jelly - high resistance in umbilical vein and artery - blood ceases to flow through umbilical vein and ductus venosus by few days after birth
Increased O2 saturation + rapid fall in PG levels (after placenta removed) - contriction of smooth muscle in ductus arteriosus and imbilical arteries within first few hours - complete obliteration after a few weeks (ligamentum arteriousus)
Red flags for pathological mumurs
Holosystolic Diastolic Grade 3 or higher Harsh quality Abnormal S2 Maximal murmur intensity at ULSB Systolic click Increased intensity on standing
7 S’s of innocent murmurs
Systolic
Short duration (not pansystolic)
Single (no clicks or added HS)
Small (limited to small area, non-radiating)
Soft (low amplitude)
Sensitive (changes with position or respiration)
Sweet (not harsh sounding)
The 8 benign murmurs
5 systolic:
- Stills (vibratory murmur) - 2-6, rare in infants
- Pulmonary flow (young kids - adults)
- Peripheral pulmonary arterial stenosis (kids under 1, or older kids recovering from RTI)
Supraclavicular or brachiocephalic systolic murmur (any age)
Aortic Systolic flow murmur (high output states - fever, anaemia, hyperthyroid)
3 Continuous:
Venous hum (3-6y)
Patent ductus arteriosus (physiologic in first few months)
Mammary souffle (late pregnancy and lactating women)
Acyanotic Congenital Heart Lesions (6)
Atrial septal defect Ventricular septal defect Patent Ductus Arteriosus Pulmonic Stenosis Coarctation of the Aorta
Cyanotic Congenital Heart Lesions
Tetralogy of Fallot (most common after neonatal period)
Transposition of the Great Arteries (more common cause of cyanosis in first days of life)
Truncus Arteriosus
Congenital heart lesions associated with trisomy 21
atrioventricular septal defect Atrial septal defect Ventricular septal defect Patent ductus arteriosus Tetralogy of Fallot
Congenital heart lesions associated with Turner syndrome
Coarctation of aorta, aortic stenosis (due to bicuspid valve), left ventricular hypertrophy
Congenital heart lesions associated with Marfan syndrome
Mitral valve prolapse
Aortic root dilatation
Aortic regurgitation
(Aortic dissection develops in later life)
What are the components of the Tetralogy of Fallot?
- Pulmonic stenosis (subvalvular)
- RV hypertrophy
- Overriding aorta
- Ventricular septal defect
Due to abnormal anterior cephalad displacement of infundibulur portion of interventricular septum
CXR in patient with tetralogy of Fallot
“Boot-shaped” heart - prominent RV with small pulmonary artery
+ Reduced pulmonary vascular markings
Management of acute rheumatic fever
Oral antibiotics (benpen or amoxyl first line - macrolides, cephs or clindamycin if allergic to penicillins)
Symptom/complication management:
Arthritis: NSAIDs or aspirin
CHF: frusemide, ACE-i (if severe), steroids
A Fib: digoxin
Severe Chorea: CBZ
Complications of acute rheumatic fever
Rheumatic heart disease (30-50%)
Typically affects mitral valve, may have mixed mitral and aortic disease
Jones criteria
Space cafe
Diagnostic criteria for acute rheumatic fever
Jones Criteria: evidence of GAS + 2 major OR 1 major and 2 minor SPACE CAFE Subcutaneous nodules Pancarditis Arthritis (poly) Chorea Erythema Marginatum
CRP/ESR elevated
Arthralgia
Fever
ECG: Prolonged PR interval
Presentation of heart failure in children of different ages
(Basically a sick child presentation) Infants: tachypnoea and diaphoresis during feeds + reduced volume of feeds and poor weight gain Easy fatigability Irritability
Young children:
GI symptoms (abdo pain, n+v, reduced appetite), FTT
easy fatigability
Recurrent cough with wheeze
Older children:
similar to adult
Causes of heart failure in utero
foetal hydrops due to anaemia (most commonly haemolysis due to blood group incompatibility)
Management of Heart failure in children
Similar to that of adults + increased caloric intake
High-flow O2, diuretics, ACE-i, inotropes, non-invasive positive pressure ventilation, correct metabolic acidosis, hypolygaemia or anaemia if present
ASD: symptoms, murmur, management, complications
2nd most common CHD
Usually asymptomatic OR SOBOE, fatigue, recurrent LRTI
Murmur: systolic at ULSB (+/- mid-diastolic rumble at LLSB), RV heave and wide, fixed split S2
Should be repaired by school-age if asymptomatic
Indications for repair earlier: significant shunt, symptomatic
Complications: Heart failure (less commonly than VSD), pulmonary vascular disease, Stroke
VSD: symptoms, murmur, management
Presentation: either asympotmatic or will develop heart failure (10% by 12m)
Murmur: harsh pansystolic, best heart at LSB +/- mid-diastolic rumble at mitral area
Mx: Closure indicated if CHF or pulmonary vascular disease (50% will close spontaneously by 2y, therefore leave until that point unless symptomatic)
Patent ductus arteriosus presentation, murmur, management
Symptoms: asymptomatic OR tachycardia, poor feeding, FTT, recurrent LRTI, fatigue, SOB, palpitations
Murmur: continuous machine-like murmur, heard best at subclavicular region
Mx: indomethacin in premature infants, surgical repair or ligation by minimally invasive techniques
Causes of heart failure in neonates and infants
o Congenital heart disease o Sepsis o Anaemia o Inborn errors of metabolism o Respiratory illness
Causes of heart failure in children older than 2m
o L sided obstructions (often missed earlier in life) Aortic stenosis Coarctation of aorta o Renal failure o Hypertension
Causes of heart failure in adolescents
o Cocaine, amphetamines
o Arrhythmia
o Cardiomyopathy
Congenital heart malformation associated with Noonan syndrome
Pulmonary stenosis
What kind of genetic abnormalities are NOT associated with pulmonary stenosis
Chromosomal defects e.g T21, T18 or T13
Causes of hypertension in children
Primary (uncommon in children)
Renal (75% of secondary) = glomerulonephritis, HUS, obstructive uropathy, VUR, polycystic kidneys)
CVS(15%) - coarctation
Endocrine (5%) - phaeo, hyperthyroid, CAH, Addison’s, Cushing’s
Other (5%) - neuroblastoma, neurofibromatosis, steroid therapy, raised ICP
Management of SVT in children
Valsalva (blow into blocked straw)
Ice pack held to face for few seconds
Adenosine
Possible causes for tachycardia in a child
Heart failure Hypovolaemia Hypoxia Hyperthyroidism Hyperglycaemia (DKA)
How to best hear a venous hum
Above the right clavicle with the child sitting upright
At what age is a VSD normally detected, why
Usually not until after 1 months, normal decrease in pulmonary vascular resistance allows left to right shunting to occur, causing murmur
How do you explain coarctation of the aorta with normal femoral pulses
Preductal coarctation of the aorta (femoral pulses normal because of blood flow from pulmonary artery to aorta through a patent ductus arteriosus)
Associated with other cardiac defects
Most valuable signs of heart failure in infancy
Hepatosplenomegaly is the most reliable sign
Oedema and ascites occur less commonly
Raised JVP is not reliable
Cardiac sequelae of congenital rubella
Persistent PDA
Pumonary stenosis
ASD
Fixed splitting of S2 + murmur =
ASD
