Paeds Cardio

Question 1

What are the 4 defects in the tetralogy of Fallot?

Answer 1

• Pulmonary valve stenosis
• RV hypertrophy
• VSD
• Overriding aorta (takes blood from both the RV and LV)

Mnemonic is PROVe
- Pulmonic, RV, Overriding, VSD

Question 2

How does squatting reverse a “Tet spell”?

Answer 2

Tet spells occur when vasodilation (ie with exercise) leads to a drop in systemic vascular resistance, leading to worsening of the R) to L) shunt
Can also occur with increase pulmonary resistance such as with crying, hyperventilating, straining (ie with defecation) valsalva and feeding
Other causes include infection, pain, dehydration and on waking from sleep

Squatting reduces overall 02 consumption by resting, and occludes the arteries supplying the legs leading to sudden increase in SVR, reversing the shunt back to L) to R)

Opiates such as Morphine are also used (0.1mg/kg IV). They suppress respiratory drive, reduce pulmonary resistance, reduce tachycardia and overall 02 demand

Question 3

What other defects must be present for a neonate with TGA to survive?

Answer 3

PDA
VSD

Question 4

Cardiac issues presenting to ED by age in infants

Answer 4

<1 month likely duct dependent
>1month likely heart failure

Question 5

What clinical features are red flags for cardiac defects?

Answer 5

Persistent cyanosis
Murmurs and active praecordium (praecordial thump)
Absent femoral pulses
Faltering growth
Persistent tachypnoea/tachycardia
Palpable liver edge
Gallop rhythm

Question 6

What are the causes of ischaemic looking ECG’s in young children (STD and STE)?

Answer 6

Ischaemia!
ALCAPA (Anomalous left coronary arising from pulmonary artery)
Peri/Myocarditis
Hypotension with global hypoperfusion

Question 7

How can you treat a child having a tet spell?

Answer 7

Ketamine for sedation
morphine to reduce RR
metaraminol increase SVR
Squat patient
02
cautious fluids

Question 8

What are the main causes of syncope in kids <6yo?

Answer 8

seizures
breath holding spells
cardiac disorders

Vasovagal uncommon <6yo

Question 9

How is acute rheumatic fever diagnosed (ARF)?

Answer 9

two major criteria
or
One major and two minor criteria

+

Evidence of preceding strep A infection

Question 10

What are the Major criteria for ARF?

Answer 10

• Carditis
• Polyarthritis (Aseptic monoarthritis in high risk groups)
• Sydenham chorea
• Subcutaneous nodules
• Erythema marginatum

Question 11

What are the minor criteria for ARF

Answer 11

• Fever >38.5C
• Polyarthralgia or aseptic monoarthritis
• Prolong PR interval on ECG
• CRP >30
• ESR >30 high risk, >60 low risk

Question 12

When should juvenile t waves begin to resolve?

Answer 12

Appears about 7 days old
Disappears approx 7 years of age

Unclear why newborns <7 days old don’t have this

Question 13

What is a rough guide to evaluating paeds ECG’s?

Answer 13

Rate
Rhythm
Axis
Intervals
Evaluate juvenile t waves
Assess for LVH and RVH

Question 14

When does the paeds heart rate roughly equate to an adults heart rate?

Answer 14

After 6yo

Question 15

What are the most common causes of sinus bradycardia in children?

Answer 15

Aerobically fit child (most common)
Hypothyroidism
Long QT syndrome

Question 16

What is the most common cause of 2nd degree AV block in infants?

Answer 16

Babies of mothers with SLE (self limiting)
Primary SLE
Post congenital heart disease surgery

Question 17

What is the most common causes of junctional rhythms (firing from AV node) in infants?

Answer 17

infection
desaturation
vagal stimulation
diving reflex (ie ice bath)

Question 18

What is the most common cause of VT in paeds?

Answer 18

Very uncommon in paediatrics, most of the time a wide complex tachycardia is SVT with aberrancy (95%)

Most common causes
Congenital heart disease
Drugs
Myocarditis

Question 19

What is the most common causes of 1st degree HB in kids?

Answer 19

PR interval shorter in paeds, approx 120msec (3 small boxes)

Normal variant
myocarditis
Acute rheumatic fever
hyperkalaemia
ASD
Ebsteins anomaly

Question 20

What is normal for the QRS axis in paeds?

Answer 20

• QRS normally positive in AVF
• QRS may or may not be down in I
• R) axis deviation normal until about age 6yo, should be adult axis >6yo

Question 21

What is the most common signs of RVH in paeds?

Answer 21

Lack of juvenile T waves
Larger terminal R’ wave in V1 (rSR, compared to RSr)

Question 22

What are the normal findings in a paeds ECG?

Answer 22

RSr pattern in V1
Juvenile T waves
Rightward axis
Dominant R waves in V1-3
Marked sinus arrhythmia
Rapid heart rate compared to adults
Longer Qtc (<490msec)
Q waves in the inferior and L) precordial leads
Slightly peaked p waves (<3mm)
Shorter PR (<120msec) and QRS (<80msec) durations

Question 23

What is the typical cardiac abnormality in down’s syndrome?

Answer 23

Atrioventricular septal defect 37%
Isolated VSD 31%

Question 24

How does dextrocardia appear on an ECG?

Answer 24

Northwest (extreme axis)
All S waves dominant in precordial leads

Question 25

How should a Tet Spell be treated?

Answer 25

• High flow 02
• IV fluids 10ml/kg
• Reassurance/calming from parents
• Knee to chest position
• Morphine 0.1mg/kg or IN fentanyl 1.5mcg/kg
• Resus, monitoring, call for help
• Metaraminol 10mcg/kg IV
• Sodi Bic 1mmol/kg IV to treat acidosis
• Phenylephrine (increase SVR) and beta blockers (decrease Hr)
• Ketamine for sedation

Question 26

What are the causes of acute tet spells?

Answer 26

• Pain/anxiety/distress
• Waking up from nap
• Sepsis/fevers
• Anaphylaxis
• Exercise
• Feeding
• Defecation
• Dehydration
• Tachycardia/hypoxia of any cause
• ACE-I

Question 27

What are the indications for inpatient referral for syncope in children?

Answer 27

• Atypical history
• Abnormal CVS/CNS exam
• Abnormal ECG
• Suspected seizure
• Suspected eating disorder
• Suspected CVS causes
• Recurrent or problematic syncope