Paediatric CV/Resp Flashcards
What types of children have a poor prognosis with a RTI?
- Premature babies (less than 32 wks)
- Congenital anomalies
- Syndromes (genetic) ex. Down syndrome
- Chronic disease
- Neuromuscular weakness
- Age
A 4mth yr old presents to the emergency department due to a wheeze. The family describes a prodrome of URTI with fever and cough. Mom says that the baby has had difficulty feeding over the last 12 hrs. On exam the baby looks well nourished, there is nasal flaring and intercostal and subcostal indrawing. There are course crackles through the chest, mostly present on inspiration and there is an expiratory wheeze.
What investigations would your pursue at this point? What potential therapies are available for this baby?
Bronchiolitis: LRTI (RSV), inflammatory process, necrosis, sloughing off of cells contributing to airway obstruction
Investigations:
- NP swab: direct detection of viral antigen
- Capillary blood gas to assess for adequate ventilation
Consider further investigation in babies that will be admitted:
- CXR (in severe disease): air trapping, peribronchial thickening, atelectasis, increased linear markings
- CBC: WBC can be normal (elevated in bacterial pneumonia)
- Electrolytes
Therapy:
- Oxygen
- Supportive therapy; maintain hydration status
Additional therapies:
- Nebulized epinephrine
- Hypertonic saline
A 2 yr old child presents with a cough. You learn that the child is FTT, has greasy stools and had a rectal prolapse at birth. What is the inheritance pattern of this disease?
Cystic Fibrosis is autosomal recessive.
A 6yr old child presents with a persistent cough following a URTI and wheeze. The child has eczema. Mom has allergies to ragweed and nuts and has asthma. The child has previously been given a bronchodilator which provided relief for his symptoms. What would you expect to see on spirometry for this child? What is the first line therapy for this child?
Pediatri Asthma (>5 yrs old)
- FEV1 less than 80% predicted
- FEV1/FVC less than 80%
- FEV1 improvement 12% with a bronchodilator
Therapy:
- ICS + SABA + Asthma Action Plan
- First line therapy + LTRA
- ICS + SABA + LABA + Asthma Action Plan
A strongly atopic child with allergy as the main aggravator may be an especially good fit for a LTRA.
What is indicated by the following clinical presentation in a paediatric patient?
- Waxen or cyanotic appearance
- Gasping, anxious appearing child
- Fatigued appearance
- Marked retractions
- Nasal flaring
- Grunting
- Head bob
Respiratory Failure
A 2wk old male presents to the ED with a high pitched inspiratory sound. The sound becomes worse when the baby is supine, and crying and tends to improve once he is calm. On PE the baby has signs of increased WOB; indrawing and head bobbing. What investigation would provide a definitive diagnosis?
Laryngomalacia can be diagnosed by bronchoscopy (spaghetti scope). Differential diagnosis might include vocal cord dysfunction, laryngeal web, subglottic stenosis (biphasic stridor), vascular rings and slings.
Laryngomalacia will self resolve by approx. 12-18mths. However, babies with moderate/severe WOB are the ones that you want to scope.
A 2 yr old female presents with increased WOB starting yesterday. She has had a cough and runny nose for 10 days. Mom brought her into hospital today because she has started to gasp as if she can’t get air into her lungs. The child goes to daycare and many of the kids have colds. The cough is dry, and high pitched. Mom does not report a barking sound. The child is otherwise healthy. Immunizations are up to date. On PE the child appears toxic and is feverish. What bug is the most likely culprit in this case?
Bacterial Tracheitis
Bugs:
- S. aureus*
- H. influenza
- Alpha-hemolytic strep
- Pneumococcus
- M. catarrhalis
Presentation is similar to croup but the deterioration is much more rapid with a high fever. The baby appears toxic. It is a clinical diagnosis but definitive diagnosis can be made via scope. DO NOT touch these babies until you absolutely need to (do not want to risk decompensation esp. if suspicious of epiglottis as well).
Croup:
- Common prodrome: rhinorrhea, pharyngitis, cough +/- low grade fever
- Hoarse voice
- Barking cough
- Stridor
- Worse at night
A 5 yr old presents with drooling, dysphagia, dysphoria and is in distress. What is the diagnosis? Bug?
Epiglottitis
-Very rare as a result of haemophilus influenza B vaccine (may become more common due to anti-vaxxers :( )
Presentation: toxic appearance, rapid progression, 4 Ds (drooling, dysphagia, dysphoria, distress), stridor, tripod, sternal recession, anxious, fever>39
AVOID examining the throat to prevent rapid decompensation.
Trtmnt: intubation, antibiotics, prevented with vaccine
What is a Still’s murmur?
Still’s murmur
- One of the most common murmurs
- Ages 2-7 yrs
- Grade 1 or 2/6
- Vibratory SEM (often described as musical)
- Heard between the apex and LLSB
- Little radiation
- Increases with exercise, fever, supine position
- Decreases with sitting or standing or valsalva
What is a pulmonary flow murmur?
Pulmonary Flow murmur
- Most common murmur see in teens
- Vibrations produced in the RV outflow tract
- Ages 8-16 yrs
- Grade 1 or 2
- Vibratory or soft SEM
- Best heard at the L base
- Little radiation and increases with exercise, supine position
- Patients with thin or narrow chests
- Normal S2 (this same murmur can present with ASD so ensure other heart sounds are normal)
What is a venous hum?
Venous Hum
- Flow within the jugular venous system
- Age 3-8 yrs
- Grade 1 or 2
- Soft blowing continuous murmur with diastolic accentuation (diastolic murmurs are usually pathologic but this is an exception)
- Best heard in supra and subclavicular regions
- Radiation to neck and base
- Decreases with supine position or gentle pressure over jugular veins or with turning head
What is a carotid or brachiocephalic bruit?
Carotid/Brachiocephalic bruit
- From abrupt directional changes of blood flow from aortic arch to head and neck arteries
- Ages 2-10 yrs
- Grade 1 or 2
- Harsh SEM
- Supraclavicular region in the neck (>on right)
- Radiation below the clavicles
- Increases with fever or exercise, decreases with hyperextension of shoulders with chin upright
A 3 yr old female is referred to cardiology after her family physician noted a II/VI SEM at the LUSB with a widely split and fixed S2. What is your differential diagnosis for this type of murmur?
The ECG indicated RV overload, with a RBBB.
CXR: mildly increased pulmonary vasculature
What is the diagnosis?
ASD (foramen ovale does not close)= Increased pulmonary blood flow, RA, RV volume overload
Symptoms: mild, usually do not present until later in childhood, breathlessness with exercise, increased frequency of RTIs, rarely FTT
PE: RV heave, widely split, fixed S2, ejection systolic murmur at LUSB, diastolic murmur over TV if shunt is large
TRTMNT: surgical/device closure
A 9 week old male presents with laboured breathing, decreased feeding and feeding with difficulties. Mom says he is sleeping more than usual.
Vitals:HR 137, RR 61, BP 83/37, O2 Sat 95%., FTT
PE: mottled, anxious, tracheal tug, intercostal indrawing, tachycardia, crackles bilaterally. The cardiac apex is mid axillary at the 5th intercostal space. A harsh pansystolic murmur is heard at the LLSB and there is a RV heave and LV lift.The liver is enlarged.
What is the diagnosis?
VSD = increased pulmonary blood flow = dilation of LA, LV and increased pulmonary artery pressure = RV hypertrophy
- Small VSDs may be asymptomatic with normal growth and development of the child
- Moderate to large VSDs will result in delayed growth, decreased exercise tolerance, and PHTN if untreated
- Symptoms usually present in 4-6 wks in large VSDs
PE: cardiac apex displaced laterally, RV heave, LV lift, thrill at LLSB, harsh pan systolic murmur at LLSB
TRTMNT: small VSDs will close spontaneously, larger VSDs require surgical closure
A 4 wk old male with down syndrome presents with a systolic murmur radiating across the precordium. What is the most likely diagnosis?
AVSD
- RA and RV enlargement due to atrial shunt
- LA and LV enlargement due to ventricular shunt
- Increased pulmonary blood flow
Symptoms: FTT, feeding difficulties, recurrent RTIs
PE: cardiac apex displaced leftward, RV heave, LV lift, thrill over 2nd L intercostal space, normal S1, widely split S2, SEM of increased pulmonary blood flow, may be pansystolic murmur due to mitral regurgitation, signs of pulmonary and systemic congestion
TRTMNT: surgical closure at 4-6 months(~5kg)
