Paeds CARDIO Flashcards
What is Acrocyanosis?
peripheral cyanosis around the mouth + extremities
Often seen in healthy newborns, occurs immediately after birth
What causes acrocyanosis?
benign vasomotor changes resulting in peripheral vasoconstriction + increased tissue O2 extraction
What are the 6 features of innocent cardiac murmurs?
Sensitive to changes in position + breathing
Short duration (not pansystolic)
Single (no associated clicks/ gallops)
Small (in limited area + doesn’t radiate)
Soft (low amplitude)
Systolic
What is a ‘breathless baby’ presentation indicative of?
L-R shunt
Acyanotic heart defect
Recall the 3 types of L-R shunt from most frequent to least frequent
VSD
ASD
PDA
Give 3 risk factors for VSD
Maternal diabetes
Downs, Edwards, Patau syndrome
IUI- TORCH
Give 2 risk factors for ASD
Down syndrome
Fetal alcohol syndrome
Give 3 risk factors for PDA
Fetal alcohol syndrome
Congenital RUBELLA
Down syndrome
What murmur is heard in VSD?
Harsh pansystolic at lower LSB
Louder in smaller defects
MDM over cardiac apex
When can VSD be detected?
20w scan
What are the signs and symptoms of VSD?
Small: Asymptomatic
Med-large:
Heart failure by 2-3 months
failure to thrive
recurrent bronchopulmonary infections
Exercise intolerance
How are VSDs classified?
By size:
small <3mm
large >3mm
How should small VSDs be managed?
Self-limiting: they close over time
What is the medical management for large VSDs?
Diuretics for HF
ACEi to reduce afterload e.g. Captopril
High-energy feeds
(CDC: Calories, diuretics, Captopril)
What is the surgical management for large VSDs?
Patch repair
At 3-6 months to prevent permanent lung damage from pulmonary HTN + high blood flow
List 5 complications of VSD
Aortic regurgitation
Infective endocarditis
Eisenmenger’s complex
RHF
Pulmonary HTN
What is Eisenmenger syndrome?
Where a long-standing L-R shunt causes pulmonary HTN + eventual reversal of the shunt into a cyanotic R-L shunt
How should Eisenmenger be managed?
Early intervention for pulmonary blood flow
Heart transplantation not easy but can be done
What murmur is heard in ASD?
Ejection systolic
ULSE: 2nd ICS LSB
Widely split S2 (fixed- no change with respiration)
What are the types of ASD and which is more common?
Secundum (more common): defect in atrial septum (failure of closure of foramen ovale)
Primum/ Partial (AVSD): defect of AV septum
What are 3 signs and symptoms of ASD?
Asymptomatic (small)
Exertional dyspnoea
Recurrent bronchopulmonary infections
How will the different types of ASD appear on ECG?
Secundum: RBBB + RAD
Partial: superior QRS axis
How quickly after birth does AVSD present?
Typically 4-8w
May be earlier
How should the different types of ASD be managed?
Secundum: transcatheter device closure at 3-5y
Partial: surgical correction at 3-5y
What investigation is diagnostic of ASD or VSD?
Echo
Where is the ductus arteriosus?
Between the aorta + pulmonary artery
What connection allows underdeveloped lungs to be bypassed by the fetal circulation? What keeps this patent in utero?
Ductus Arteriosis
(R-L shunt)
Kept patent by PGE + low O2 tension
What happens to the ductus arteriosus after birth?
Pulmonary vascular resistance decreases + allows reversal of shunt from R-L to L-R
Give 5 features of PDA on examination
Continuous ‘machinery’ murmur
Left subclavicular thrill
Large volume, bounding, collapsing pulse
Wide pulse pressure
Heaving apex beat
What is the management of PDA in premature infants?
Indomethacin/ Ibuprofen infusion
Inhibits prostaglandin synthesis, induces closure
Surgical: Transcatheter closure or surgical ligation
If PDA associated with another CHD, what is the management?
Prostaglandin E1 infusion to keep the PDA open
When do cyanotic and acyanotic heart defects present generally?
Left-to-Right shunts = LateR cyanosis
Right-to-Left shunts = eaRLy cyanosis
Give 3 features of heart failure
Hepatomegaly
Tachypnoea
Pallor (low CO, low BP)
What is a ‘blue baby’ presentation a red flag for?
R-L shunt
Cyanotic heart defect
What are 5 causes of cyanotic congenital heart disease?
Tetralogy of Fallot (most common)
Transposition of the great vessels
Tricuspid valve atresia
Total anomalous pulmonary venous return
persistent Truncus arteriosis
What is the tetralogy of fallot?
VSD
Overarching aorta
Right outflow tract obstruction: pulmonary stenosis
RV hypertrophy
When does Tetralogy of fallot present?
~1-2 months,
May be later e.g. 6m
How does ToF present?
Tet spells: hypercyanotic hypoxic episodes (peak 2-4m)
a/w stress: crying, feeding, defecation
When does the ductus arteriosus close?
Functional closure within 24-48h if born at term
Complete by 2-3w
What would be heard on auscultation in tetralogy of fallot?
ESM at ULSE
due to pulmonary stenosis
What investigations should be done in suspected tetralogy of fallot?
Echo: confirmatory
CXR: Boot shaped heart
How is tetralogy of fallot managed?
Medical: PGE1 infusion until surgery to maintain PDA
Surgical by 6m: VSD repair- patch closure
How are acute tet spells managed in ToF?
100% FiO2 via NRB
Knee to chest position, squatting
What palliative procedure may be performed for severe ToF in the first week of life?
Blalock Thomas Taussig shunt
What determines the degree of cyanosis and clinical severity in ToF?
Severity of right outflow tract obstruction
What is the basic anatomical pathology in ToGA?
Aorta leaves the right ventricle
Pulmonary trunk leaves the left ventricle
When does ToGA present?
When ductus arteriosus closes at 2-4 days old
Give 2 signs of ToGA
Tachypnoea
Postnatal cyanosis- not affected by supplemental O2
What is heard upon auscultation in ToGA?
Single loud S2
Often NO MURMUR
Diminished femoral pulses
What investigations are used for ToGA?
Echo: confirmatory
CXR: Egg on a string
How can ToGA be managed?
PGE1 infusion to keep DA open
Balloon atrial septostomy
Urgent surgery (within 2w)
What surgical procedures may be used for ToGA?
Arterial switch procedure
or
Rastelli procedure
When do aortic problems (coarctation or stenosis) present?
First few weeks of life depending on presence of other abnormalities + patency of DA
What test is used to diagnose heart disease in a cyanosed neonate, and how is it done?
Nitrogen washout test
Give 100% oxygen for 10 mins
Measure right radial artery blood gas oxygen
If it stays low (<15kPa) = positive for CHD
What are the differentials for cardiac outflow obstruction and how can you clinically differentiate between them
If child is otherwise well: P or A stenosis
If child is also in CV collapse + shock: coarctation
Recall the medical and surgical management of PDA
Medical: Indomethacin (NSAID): to prompt duct closure
Surgical: at 1 year
How can cyanosis be tested for?
Hyperoxia nitrogen washout test
How should cyanosis be immediately managed?
ABCs
Prostaglandin infusion (to maintain PDA patency)
Recall the timeline of presentation of the different types of cyanotic heart disease after birth
<10 mins: Tricuspid atresia
Few hours: ToGA
Up to 3w: AVSD
Any age (at a few days, often): ToF
10-15y: Eisenmenger
What is Ebstein’s abnormality?
Malformation of tricuspid valve leading to severe tricuspid regurgitation
What maternal medication is associated with Ebstein’s abnormality?
Lithium
What would be heard on auscultation in Ebstein’s abnormality?
split 1st + 2nd heart sounds
What is Ebstein’s abnormality also referred to?
atrialisation of the right ventricle.
How should Ebstein’s be managed?
Prostaglandin infusion
Tricuspid valve repair
What is tricuspid atresia?
Complete absence of tricuspid valve:
No blood flow between RA + RV
Describe the presentation of tricuspid atresia
Cyanosis + SOB within first 10 mins of life
What is the murmur in tricuspid atresia?
ESM at LSE due to VSD
Recall the management of tricuspid atresia
IV PGE1 infusion
Balloon atrial septostomy
Stage 1: to maintain a secure supply of blood to the lungs
Blalock-Taussig shunt insertion
or
pulmonary banding to reduce pulmonary blood flow
Stage 2: Bidirectional Glenn procedure
Stage 3: Fontan procedure
Why is ToGA not instantly fatal?
Usually found alongside ASDs/ VSDs/ PDAs which aid mixing
What is the most common association with AVSD?
Down’s syndrome
How should AVSD be managed?
Treat heart failure medically + surgery at 3 months
What is the cause of congenital aortic/ pulmonary stenosis?
Aortic: fusion of valve leaflets (2 instead of 3)
Pulmonary: fusion of valve leaflets
What are the most likely co-existent conditions with aortic/ pulmonary stenosis?
Coarctation of aorta
What are the signs and symptoms of aortic/ pulmonary stenosis?
NO CYANOSIS
AS: ESM. Palpable thrill. Ejection click
PS: ESM, split S2
How should a/p stenosis be managed?
Transcatheter balloon dilatation
When does coarctation of the aorta present?
3 days - a few weeks of life
Depends on severity
Recall signs and symptoms of coarctation of the aorta depending on severity
Critical: shock + heart failure- dyspnoea, pale, irritable, poor femoral pulses, hepatomegaly
Less severe: Asymptomatic, weak femoral pulses, High BP in arms, low BP in legs
Ejection systolic murmur
How should coarctation be managed?
Critical: ABC, PGE1 infusion + inotropes. Once stabilised surgical repair
Non-critical: surgical repair OR balloon angioplasty + stenting
Recall 4 signs and symptoms of hypoplastic left heart syndrome
Cyanosis
Tachypnnoea
NO murmur
How should hypoplastic left heart syndrome be managed?
1st = ABCs + PGE1
2nd = Blalock-Taussig (BK) shunt or Norwood Stage 1
3rd = BK shunt removal –> Glenn/ hemi-Fontan –> Fontan/ Total Cavo-Pulmonary Connection
What is a BK shunt?
Arterficial ductus arteriosus
What HR is expected in SVT?
250-300bpm
Recall the main symptom of SVT in neonates
Hydrops fetalis
What would be seen on an ECG in SVT?
Narrow complex tachycardia + T wave inversion due to ischaemia
How should SVT be managed?
- Circulatory + respiratory support (correct any tissue acidosis)
- Vagal stimulating manoevres - 80% success
- IV adenosine
- Electrical cardioversion with synchronised DC shock if adenosine fails
What is the common cause of rheumatic fever?
Group A beta-haemolytic streptococcal throat infection
Acute rheumatic fever presents 2-4w after
What age child can get rheumatic fever?
5-17y
What is the long term risk of rheumatic fever?
Mitral stenosis
What are the 5 major Jones criterion for rheumatic fever?
CASES
Carditis
Arthritis (Polyarthritis)
Subcutaneous nodules
Erythema marginatum (map-like outlines)
Sydenham’s chorea
What are the 5 minor criteria for rheumatic fever?
FRAPP:
Fever
Raised ESR >30 / CRP >3
Arthralgia
Prolonged PR
Previous RF
What criteria are necessary to diagnose acute rheumatic fever?
2 Major or 1 Major + 2 minor
With evidence of preceding streptococcal infection e.g. elevated ASOT or +ve throat culture
How should rheumatic fever be managed?
Bed rest
IV Benzylpenicillin STAT
PO Penicillin V for >,10d
High dose aspirin (suppresses inflammatory responses in heart + joints)
Corticosteroids (if not resolved rapidly/ signs of mod-severe carditis)
What should be done following resolution of rheumatic fever?
Prophylatic monthly IM benzylpenicillin until age 21
May need surgical valve repair
Recall the signs and symptoms of infective endocarditis in a child
Necrotic skin lesions: from infected emboli
Splinter haemorrhages
Changing cardiac signs
Fever, aneamia, pallor
Splenomegaly
Arthritis/ arthralgia
Clubbing
How is infective endocarditis diagnosed in children?
Multiple blood cultures (before ABx) + echocardiography to identify vegetations
What is the most common pathogen implicated in paediatric IE?
Streptococcus viridians
How should infective endocarditis be managed in children?
6 weeks IV Abx
Strep viridians (native/prosthetic valve) = amoxicillin + gentamicin/vancomycin
Staph aureus (native valve): Amoxicillin/ vancomycin/ daptomycin
Staph aureus (prosthetic valve): nafcillin/ oxacillin
How is the liver affected by cardiac failure?
May see hepatomegaly
How is the respiratory system affected by cardiac failure?
Increased RR
Recurrent chest infections
What basic investigations are necessary in cardiac failure?
O2 sats
BP
FBC
U+Es
calcium
BNP/ANP
Recall systematically the management of paediatric cardiac failure
Decrease preload: diuretics (furosemide)/ GTN
Enhance contractility: eg digoxin, dopamine, dobutamine
Reduce afterload: ACE inhibitors
Improve oxygen delivery: B-blockers (eg carvedilol)
How should cyanosis be managed?
Prostaglandin infusion
