Paediatrics Flashcards
Name the 3 fetal shunts
ductus arteriosus
foramen ovale
ductus venosus
Describe the changes at birth that close the 3 fetal shunts
first breath expands alveoli, lowers pulmonary vascular resistant, lower pressure in right atrium closes foramen ovale -> fossa ovalis
Blood oxygenation causes decrease in prostaglandins, closes ductus arteriosus -> ligamentum arteriosum
Clamping of umbilical cord, ductus venosus-> ligamentum venosum
What is the purpose of the ductus venosus?
shunt connects the umbilical vein to the inferior vena cava and allows blood to bypass the liver
what is the purpose of the foramen ovale ?
shunt connects the right atrium with the left atrium and allows blood to bypass the right ventricle and pulmonary circulation
What is the purpose of the ductus arteriosus?
shunt connects the pulmonary artery with the aorta and allows blood to bypass the pulmonary circulation
What are the typical features of an innocent murmur?
Soft
Short
Systolic
Symptomless
Situation dependent, particularly if the murmur gets quieter with standing or only appears when the child is unwell or feverish
What features of a murmur would prompt further investigation ?
Murmur louder than 2/6
Diastolic murmurs
Louder on standing
Other symptoms such as failure to thrive, feeding difficulty, cyanosis or shortness of breath
What are the key investigations to establish the cause of a murmur and rule out abnormalities in a child?
ECG
Chest Xray
Echocardiography
What are 3 differentials for a pan-systolic murmur ?
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Where can the murmur be heard with a ventricular septal defect?
left lower sternal border
Name 3 differentials for an ejection-systolic murmur
Aortic stenosis
Pulmonary stenosis
Hypertrophic obstructive cardiomyopathy
What murmur does an atrial septal defect cause?
mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border
fixed split second heart sound
What murmur does patent ductus arteriosus cause?
continuous crescendo-decrescendo “machinery” murmur
What murmur does tetralogy of Fallot cause?
ejection systolic murmur loudest at the pulmonary area
Name 4 cyanotic heart diseases
Ventricular septal defect (VSD)
Atrial septal defect (ASD)
Patent ductus arteriosus (PDA)
Transposition of the great arteries
When does the ductus arteriosus usually stop functioning and close?
normally stops functioning within 1-3 days of birth, and closes completely within the first 2-3 weeks of life
Give 2 risk factors for patent ductus arteriosus
Rubella
Prematurity
Describe the pathophysiology of heart failure in patent ductus arteriosus
Left to Right shunt leading to pulmonary hypertension which causes right sided heart strain and hypertrophy
What are the symptoms of patent ductus arteriosus?
SOB
Difficulty feeding
Poor weight gain
LRTI
How is patent ductus arteriosus diagnosed?
Echo
How is patent ductus arteriosus managed?
monitoring with echo
Surgical or trans-catheter closure
Describe the pathophysiology of atrial septal defects
left to right shunt -> right sided strain -> right heart failure -> pulmonary hypertension
what are the 2 walls that form the atrial septum?
septum primum and septum secondum
What are the 3 types of atrial septal defect?
Ostium secondum
Patent foramen ovale
Ostium prinum
State 4 complications of atrial septal defects
Stroke in the context of venous thromboembolism (see below)
Atrial fibrillation or atrial flutter
Pulmonary hypertension and right sided heart failure
Eisenmenger syndrome
What symptoms may be present in a child with an atrial septal defect?
Shortness of breath
Difficulty feeding
Poor weight gain
Lower respiratory tract infections
What are the management options for an atrial septal defect?
watch and wait (small)
transvenous catheter closure or open heart surgery
anticoagulants (in adults)
Name 2 genetic conditions associated with ventricular septal defects
Down’s syndrome
Turner’s syndrome
What are the typical symptoms of ventricular septal defects?
Poor feeding
Dyspnoea
Tachypnoea
Failure to thrive
What are the examination findings of a ventricular septal defect?
pan-systolic murmur more prominently heard at the left lower sternal border in the third and fourth intercostal spaces. There may be a systolic thrill on palpation.
what are patients with a ventricular septal defect at increased risk of?
infective endocarditis
what is the management of a ventricular septal defect?
watch and wait
transvenous catheter closure or open heart surgery
What are the 3 underlying lesions that can result in Eisenmenger syndrome
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Describe the pathophysiology of Eisenmenger syndrome
defect in heart causes left to right, over time pulmonary hypertension develops when it exceeds systemic pressure the shunt reverses and is right to left, deoxygenated blood bypasses lungs and causes cyanosis
What examination findings are associated with pulmonary hypertension ?
Right ventricular heave: the right ventricle contracts forcefully against increased pressure in the lungs
Loud P2: loud second heart sound due to forceful shutting of the pulmonary valve
Raised JVP
Peripheral oedema
What findings in Eisenmenger syndrome are related to the right to left shunt and chronic hypoxia ?
Cyanosis
Clubbing
Dyspnoea
Plethoric complexion
What is the only definitive treatment once Eisenmenger syndrome has developed?
heart-lung transplant
What is the medical management of Eisenmenger syndrome?
Oxygen
Treatment of pulmonary hypertension e.g. sildenafil
Treatment of arrhythmias
Treatment of polycythaemia with venesection
Prevention and treatment of thrombosis with anticoagulation
Prevention of infective endocarditis using prophylactic antibiotics
What is coarctation of the aorta?
narrowing of the aortic arch
What genetic condition is associated with coarctation of the aorta?
Turners syndrome
How may coarctation of the aorta present?
weak femoral pulses
systolic murmur
differences in blood pressure in limbs
tachypnoea
poor feeding
grey and floppy baby
legs and left arm may be underdeveloped
What is the management of critical coarctation of the aorta?
Prostaglandin E (to keep ductus arteriosus open) whilst waiting for surgery
What are the presenting symptoms of aortic valve stenosis?
fatigue, shortness of breath, dizziness and fainting.
Symptoms usually worse on exertion
What are the key examination findings in aortic valve stenosis?
ejection systolic murmur
crescendo-decrescendo that radiates to the carotids
ejection click
palpable thrill
slow rising pulse and narrow pulse pressure
What is the gold standard investigation for aortic valve stenosis?
echocardiogram
What are the treatment options for aortic valve stenosis?
Percutaneous balloon aortic valvoplasty
Surgical aortic valvotomy
Valve replacement
what are some complications of aortic valve stenosis?
Left ventricular outflow tract obstruction
Heart failure
Ventricular arrhythmia
Bacterial endocarditis
Sudden death, often on exertion
what conditions are associated with congenital pulmonary valve stenosis?
Tetralogy of Fallot
William syndrome
Noonan syndrome
Congenital rubella syndrome
What are some symptoms of severe pulmonary valve stenosis?
fatigue on exertion, shortness of breath, dizziness and fainting
What are some signs of pulmonary valve stenosis?
Ejection systolic murmur heard loudest at the pulmonary area (second intercostal space, left sternal border)
Palpable thrill in the pulmonary area
Right ventricular heave due to right ventricular hypertrophy
Raised JVP with giant a waves
what is the gold standard diagnostic investigation in pulmonary valve stenosis?
echocardiogram
What are the 4 defects present in tetralogy of fallot?
Ventricular septal defect (VSD)
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy
What are the risk factors for tetralogy of fallot?
Rubella infection
Increased age of the mother (over 40 years)
Alcohol consumption in pregnancy
Diabetic mother
What is the investigation of choice for diagnosing tetralogy of fallot?
echocardiogram
What is the characteristic CXR finding in tetralogy of fallot?
“boot shaped” heart due to right ventricular thickening
what are some signs and symptoms of tetralogy of fallot?
Cyanosis
Clubbing
Poor feeding
Poor weight gain
Ejection systolic murmur heard loudest in the pulmonary area
“Tet spells”
What are some precipitating factors for a tet spell?
waking, physical exertion or crying
what are the symptoms of a tet spell?
irritable, cyanotic and short of breath
What are the conservative measures for managing a tet spell?
Older children may squat when a tet spell occurs. Younger children can be positioned with their knees to their chest. Squatting increases the systemic vascular resistance. This encourages blood to enter the pulmonary vessels.
what are the medical options for managing a tet spell?
O2
bblockers
IV fluids
morphine
sodium bicarbonate
phenylephrine infusion
what are the management options for tetralogy of fallot?
neonates - prostaglandin infusion to maintain ductus arteriosus
definitive - open heart surgery
what is Ebstein’s anomaly?
congenital heart condition where the tricuspid valve is set lower in the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle
what conditions are associated with ebstein’s anomaly
right to left shunt via atrial septal defect
Wolff-Parkinson-White syndrome
What are the presenting features of Ebstein’s Anomoly ?
Evidence of heart failure (e.g. oedema)
Gallop rhythm heard on auscultation characterised by the addition of the third and fourth heart sounds
Cyanosis
Shortness of breath and tachypnoea
Poor feeding
Collapse or cardiac arrest
How is ebstein’s anomoly diagnosed?
Echocardiogram
what is the management of ebstein’s anomoly?
treating arrhythmias and heart failure.
Prophylactic antibiotics
Surgical correction of defect
what is transposition of the great arteries?
condition where the attachments of the aorta and the pulmonary trunk to the heart are swapped
what defects are associated with transposition of the great arteries?
Ventricular septal defect
Coarctation of the aorta
Pulmonary stenosis
How does transposition of the great arteries present ?
usually picked up on antenatal scans
cyanosis
within a few weeks of life they will develop respiratory distress, tachycardia, poor feeding, poor weight gain and sweating
what is the management of transposition of the great arteries?
prostaglandin infusion to maintain ductus arteriosus
balloon septostomy
open heart surgery
what is bronchiolitis?
inflammation and infection in the bronchioles
what is the most common cause of bronchiolitis?
Respiratory syncytial virus
What are the presenting features of bronchiolitis?
Coryzal symptoms
signs of respiratory distress
dyspnoea
tachypnoea
poor feeding
mild fever
apnoeas
wheeze and crackles on auscultation
what are the signs of respiratory distress?
raised respiratory rate
use of accessory muscles (sternocleidomastoid, abdominal and intercostal)
Intercostal and subcostal recessions
nasal flaring
Head bobbing
tracheal tug
cyanosis
abnormal airway noises
children how have had bronchiolitis as infants are more likely to have what during childhood?
viral induced wheeze
When should you admit a child with bronchiolitis?
Aged under 3 months or any pre-existing condition such as prematurity, Downs syndrome or cystic fibrosis
50 – 75% or less of their normal intake of milk
Clinical dehydration
Respiratory rate above 70
Oxygen saturations below 92%
Moderate to severe respiratory distress, such as deep recessions or head bobbing
Apnoeas
Parents not confident in their ability to manage at home or difficulty accessing medical help from home
what is the management of bronchiolitis?
Ensuring adequate intake
Saline nasal drops and nasal suctioning
Supplementary oxygen if the oxygen saturations remain below 92%
Ventilatory support if required
what are the most helpful signs of poor ventilation on capillary blood gas?
Rising pCO2
falling pH
respiratory acidosis
what can be given as prevention against bronchiolitis?
Palivizumab
typical features of viral-induced wheeze (as opposed to asthma) are:
Presenting before 3 years of age
No atopic history
Only occurs during viral infections
how does viral-induced wheeze present ?
Presenting before 3 years of age
No atopic history
Only occurs during viral infections
how does an acute asthma exacerbation present?
Progressively worsening shortness of breath
Signs of respiratory distress
Fast respiratory rate
Expiratory wheeze on auscultation heard throughout the chest
The chest can sound “tight” on auscultation, with reduced air entry
what are the features of a moderate asthma attack?
peak flow >50% predicted
Normal speech
What are the features of a severe asthma attack?
peak flow <50% predicted
saturations <92%
Unable to complete sentences in one breath
signs of respiratory distress
resp rate >40 (1-5yrs), >30 (>5yrs)
heart rate >140 (1-5yrs), >125 (>5yrs)
What are the features of a life threatening asthma attack?
peak flow <33% predicted
Saturations <92%
Exhaustion and poor respiratory effort
hypotension
silent chest
cyanosis
altered consciousness/confusion
What is the stepwise treatment using bronchodilators in acute asthma and viral induced wheeze?
Inhaled or nebulised salbutamol (a beta-2 agonist)
Inhaled or nebulised ipratropium bromide (an anti-muscarinic)
IV magnesium sulphate
IV aminophylline
What is the stepwise management of acute asthma or viral induced wheeze?
Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
Nebulisers with salbutamol / ipratropium bromide
Oral prednisone (e.g. 1mg per kg of body weight once a day for 3 days)
IV hydrocortisone
IV magnesium sulphate
IV salbutamol
IV aminophylline
when can discharge be considered following an acute asthma exacerbation?
he child is well on 6 puffs 4 hourly of salbutamol
what presenting symptoms suggest a diagnosis of asthma?
Episodic symptoms with intermittent exacerbations
Diurnal variability, typically worse at night and early morning
Dry cough with wheeze and shortness of breath
Typical triggers
A history of other atopic conditions such as eczema, hayfever and food allergies
Family history of asthma or atopy
Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
Symptoms improve with bronchodilators
what are some typical triggers of asthma?
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens (e.g. peanuts, shellfish or eggs)
What investigations can be carried out to aid with the diagnosis of asthma?
Spirometry with reversibility testing (in children aged over 5 years)
Direct bronchial challenge test with histamine or methacholine
Fractional exhaled nitric oxide (FeNO)
Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
What are the stages of medical therapy of chronic asthma in children under 5?
Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
Add the other option from step 2.
Refer to a specialist.
What is the medical therapy of chronic asthma in children 5-12yrs?
Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
Add a regular low dose corticosteroid inhaler
Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
Titrate up the corticosteroid inhaler to a medium dose. Consider adding:
Oral leukotriene receptor antagonist (e.g. montelukast)
Oral theophylline
Increase the dose of the inhaled corticosteroid to a high dose.
Referral to a specialist. They may require daily oral steroids.
Describe inhaler technique with a spacer
Assemble the spacer
Shake the inhaler (depending on the type)
Attach the inhaler to the correct end
Sit or stand up straight
Lift the chin slightly
Make a seal around the spacer mouthpiece or place the mask over the face
Spray the dose into the spacer
Take steady breaths in and out 5 times until the mist is fully inhaled
what investigations may be done in a child with recurrent lower respiratory tract infections?
FBC
CXR
serum immunoglobulins
Immunoglobulin G to previous vaccines
Sweat test
HIV test
what age group is typically affected by croup?
6 months to 2 years
What is the classic cause of croup that typically improves in less than 48hrs and responds well to dexamethasone?
Parainfluenza virus
name 4 causes of croup
Parainfluenza
Influenza
Adenovirus
Respiratory Syncytial Virus (RSV)
what is croup?
upper respiratory tract infection causing oedema in the larynx
what are the presenting features of croup?
Increased work of breathing
“Barking” cough, occurring in clusters of coughing episodes
Hoarse voice
Stridor
Low grade fever
What is the management of croup?
oral dexamethasone
Oxygen
Nebulised budesonide
Nebulised adrenalin
Intubation and ventilation