Paediatrics 3 Flashcards
1
Q
Ventricular septal defect- symptoms
A
- Small- asymptomatic, normal growth
- Moderate- poor feeding, failure to thrive (FTT), short of breath (SOB)
- Large- poor feeding, FTT (falls down centiles), SOB, sweaty and pale with feeds
- Most common congenital heart defect, associated with downs syndrome, all require echo
2
Q
VSD- time of presentation
A
- Antenatal diagnosis at 16-18 weeks
- Presentation at 6-8 weeks
- Defect in the membranous portion of the ventricular septum is more common than the muscular portion
- Congestive heart failure typically presents after 4-6 weeks
- Persistent pulmonary hypertension of the newborn (PPHN) may become established by 6-12 months
3
Q
VSD- clinical findings
A
Auscultate: Pan-systolic murmur heard loudest at the lower left sternal border. Loud P2 suggests the presence of pulmonary hypertension
4
Q
VSD- investigations
A
- Basic obs
- Echocardiography
- CXR – cardiomegaly and pulmonary oedema (increased pulmonary vascular markings) if severe VSD (presence of heart failure), enlarged pulmonary artery
- ECG: In patients with moderate or large VSD, the ECG may demonstrate LV hypertrophy. May have Right ventricular hypertrophy as well
5
Q
VSD- management
A
- Small lesion: < 5mm usually close spontaneously, no repair required (30-40%)
- Moderate lesion: Diuretic therapy (furosemide and spironolactone). Feeding with high caloric feeds (Infantrini)
- Large lesion: Manage as per moderate lesion. Optimise weight gain for surgery. Schedule for surgery before 12 months to prevent persistent pulmonary hypertension of the newborn (PPHN). Either transvenous catheter closure or open heart surgery
6
Q
ASD symptoms and time of presentation
A
- Typically asymptomatic, some children will have recurrent chest infections
- The mean age of diagnosis is 4.5 years from an incidental finding of a murmur. Symptomatic presentation is usually before the age of 40 with arrhythmias, dyspnoea
7
Q
ASD- ascultate
A
- Ejection systolic murmur heard loudest at the upper-left sternal border (ULSB)
- Widely fixed splitting of the second heart sound
8
Q
ASD investigations
A
- Pulse oximetry
- ECHO – shows dilated RV and increased RV filling and ejection time
- CXR – usually no findings
- ECG – incomplete RBBB
9
Q
ASD management
A
- Most children are asymptomatic and rarely require congestive heart failure (CHF) therapy
- Spontaneous closure in lesions smaller than 7-8mm
- Large defects require repair – percutaneous (catheter closure) or open surgery
10
Q
Patent ductus arteriosus (PDA) symptoms
A
Symptoms
- Small – asymptomatic
- Moderate – congestive heart failure with failure to thrive (poor feeding)
- Large – poor feeding, severe failure to thrive, recurrent lower respiratory tract infections (preterm infants may experience failure to wean from ventilation)
- More common in preterm infants
- Symptoms usually present 3-5 days after birth when the duct begins to close
11
Q
PDA clinical features
A
- Bounding pulses and wide pulse pressure
- Auscultate: Continuous machinery murmur typically heard at the upper-left sternal border (best heard below left the clavicle). Check for the presence of a thrill at the upper left sternal border
12
Q
PDA investigations
A
- 2D echocardiography and Doppler
- CXR and ECG are less useful in diagnosing PDA
13
Q
PDA management
A
- If preterm – good probability of spontaneous closure
- If term – less likely to close spontaneously
- Medical – indomethacin/ibuprofen (not effective in term infants)
- Surgical – catheter closure or PDA ligation (left lateral thoracotomy incision) when weight is at least 5kg
14
Q
Coarctation of the aorta pathophysiology
A
- Obstruction to the left ventricles outflow tract leads to an increase in left ventricular afterload which causes left ventricular hypertrophy
- Associated with Turners syndrome, can develop heart failure
- Symptoms present 3-5 days after birth when the duct begins to close as the PDA and foramen ovale allows blood to bypass the outflow obstruction
15
Q
Coarctation of the aorta clinical features
A
- Palpate: Systolic blood pressure is high when measured with BP cuff. Absent femoral pulses or radio-femoral delay. Cold extremities (especially feet). Hepatomegaly in heart failure due to severe coarctation
- Auscultate: Murmur heard at the back between the scapulae
16
Q
Co-arctation of the aorta investigations
A
- 2D echocardiogram and Doppler – direct visualisation of defect
- CXR and ECG are less useful in the diagnosis
17
Q
Co-arctation of the aorta management
A
- Medical therapy: Continuous intravenous infusion of prostaglandin E1 to keep the ductus arteriosus open. Dopamine or Dobutamine to improve contractility in those with heart failure.
- Supportive care for metabolic acidosis, hypoglycemia, respiratory failure, and anaemia
- Surgical repair: Balloon angioplasty. Resection with end-to-end angioplasty. Bypass graft. Subclavian flap
18
Q
Different shunts in the infants heart
A
- Ductus arteriosus: this shunt moves blood from the pulmonary artery to the aorta
- Foramen ovale: bypasses the lungs and moves blood from the right to left atrium
- Ductus venosus: shunts a portion of umbilical blood flow directly to the inferior vena cava. Allows oxygenated blood from the placenta to bypass the liver
19
Q
Cyanotic heart disease
A
- Decreased pulmonary flow: Tatralogy of fallot, Tricuspid atresia, other univentricular heart conditions with pulmonary stenosis
- Increased pulmonary flow: Transposition of the great arteries, Total anomalous pulmonary venous return
- Cyanotic heart conditions have a right to left shunt which causes low levels of oxygen in the systemic circulation. Acyanotic heart conditions can become cyanotic over time
20
Q
Acyanotic heart disease
A
- Left-right shunt lesions: Ventricular septal defect, Atrial septal defect, Atrio-ventricular septal defect, Patent ductus arteriosus
- Obstructive lesions: Aortic stenosis, Pulmonary valve stenosis, Coarction of the Aorta
Louder murmurs are caused by smaller defects. The cardiothoracic angle is often larger in children/neonates.
