Paeds Cardio Flashcards
What is the most common congenital heart defect?
Ventricular Septal Defect (VSD)
The majority of VSDs are caused by a defect in which part of the ventricular septum?
membranous top bit
as opposed to muscular bottom bit
Which way do most VSDs shunt?
left to right
Which are the three types of CHD which shunt left-to-right? (breathless)
VSD, ASD, PDA
Which are the two types of CHD which shunt right-to-left? (blue)
Tranposition of Great Arteries
Tetralogy of Fallot
What is main symptom of left-to-right shunts?
breathless
What is main symptom of right-to-left shunts?
blue
Auscultation of VSD?
pansystolic murmur @LLSE
radiating to axilla
What proportion of VSDs close spontaneously?
50%
In later childhood, some VSDs can start shunting right-to-left instead, causing deoxygenated blood from the right heart to flow around the body, causing cyanosis. What’s this called?
Eisenmenger’s
happens due to gradual increase in pulmonary vascular resistance
Name 4 risk factors for VSD.
foetal alcohol
Down’s
maternal diabetes
rubella
Why does VSD cause an increased risk of endocarditis?
turbulent flow
advise good oral hygeine!
What might ECG show in VSD?
LV hypertrophy (left-to-right shunt)
or biventricular
CXR can normal in small VSD. What would CXR show in large VSD?
cardiomegaly
pulm oedema
What is the medical management of VSD? (x3)
buy time and reduce symptoms
diuretics + ACE inhibitors + extra calories
furosemide, captopril
What drug is used when a child has congestive HF?
digoxin
What is the surgical management of VSD?
surgical or catheter repair
Why is it important to remain good dental hygeine if you’re a child with a VSD (repaired or not)?
risk of infective endocarditis
7 week old infant presents with poor weight gain, shortness of breath, and poor feeding. On auscultation, pansystolic murmur on lower left sternal edge, radiating to axilla. What investigations?
suspect VSD:
- ECG
- Echo
- consider CXR
also septic screen (bloods)
What is the gold standard investigation for diagnosis of VSD?
Echo
The main causes of heart problems in neonates are to do with obstructed systemic circulation. For example (x2)
coarctation of the aorta
hypoplastic left heart syndrome
The main causes of heart problems in infants are to do with high pulmonary blood flow. For example (x3)
VSD, ASD, PDA
The main causes of heart problems in older children are to do with actual heart failure. :( For example (x3)
Eisenmengers
Cardiomyopathy
Rheumatic heart disease
We can split congenital heart defects into left-to-right (VSD, ASD, PDA) or right-to-left (ToF, TGA) shunts….
But in which defect is there “common mixing”?
AVSD
atrioventriuclar septal defect
2 causes of outflow obstruction in well child.
aortic stenosis
pulmonary stenosis
What is cause of outflow obstruction in collapsed neonate?
coarctation of the aorta
Most ASDs are as a result of which bit of atrial septum failing to close?
ostium secundum
Ausculation of ASD.
ejection systolic murmur @ULSE
radiating to back
+ fixed second heart sound
(extra flow thru pulm valve + pulm valve can’t close)
What is the risky complication of ASD?
paradoxical embolism (crosses from pulm to systemic circ via ASD) --> stroke
Most ASDs are ASYMP. But some ASDs present late with breathlessness, big right heart and palpitations. True or false?
true
most ASDs are asymp tho
Apart from ASD, what else can cause hole in atrial septum?
patent foramen ovale
When is the foramen ovale usually meant to close?
when baby takes her first breath
Where is the foramen ovale and why is it a thing?
hole in atrial septum
allow oxygenated blood from placenta to go from right to left
bypassing the fetal lungs, which don’t work until first breath
Where is the ductus arteriosus?
pulm artery to aorta
Why is the ductus arteriosus a thing?
bypassing the foetal lungs
catches any right to left that the foramen ovale has missed
What is management of ASD?
surgical or catheter repair
Auscultation of PDA.
continuous machinery murmur @ULSE
Which babies does PDA usually affect?
preterms
A preterm baby has cyanosis only in the lower extremities. What do you suspect?
PDA
Why does PDA only cause cyanosis in lower extremities?
ductus arteriosus is downstream from subclavian arteries (which supply head and upper limbs)
Which hormone keeps ductus arteriosus patent? :(
prostaglandin E2
Which drug can do pharmacalogic closure of a PDA?
IV indomethacin
or ibuprofen
What is a AVSD (atrioventricular septal defect)?
the centre of the heart is missing :(
Which kids are affected by AVSD?
those with Down’s syndrome
In which congenital heart defect would they be breathless AND blue, with rapid symptoms?
AVSD
In general, what is the management for left-to-right shunts?
stabilise
increase calorie intake (NG feeds?)
diuretics + ACE inhibitors
…surgical or catheter repair
The aorta swaps places with the pulmonary artery. What’s this called?
Transposition of Great Arteries
What happens in Transposition of the Great Arteries?
Aorta swaps places with the pulmonary artery
(blood from right heart goes out to body via aorta, never oxygenated)
(blood from left heart goes out to lungs via pulm artery, never deoxygenated)
:/
Where is ductus venosus?
umbilical vein to IVC
In which congenital heart defects do the pulmonary and systemic circulations stay separate? :(
Transposition of the Great Arteries
(blood from right heart goes out to body via aorta, never oxygenated)
(blood from left heart goes out to lungs via pulm artery, never deoxygenated)
What is the cause of death in Transposition of the Great Arteries
deep hypoxia and lactic acidosis
What is the most common CYANOTIC congenial heart defect?
Tetralogy of Fallot
What is the definitive investigation for Transposition of the Great Arteries?
Echo
shows aorta and pulm artery wrong way round
What sign might CXR show in Transposition of the Great Arteries?
“egg on a string”
narrowed superior mediastinum
Describe the management of Transposition of the Great Arteries.
Balloon Sepostomy (to allow emergency mixing) then surgical correction
(long term complications of dodgy heart and neuro-dev abnormalities)
Within the first 24hrs of birth, a baby boy is cyanosed and has really low sats. ABG shows resp acidosis. He then collapses. What is the likely cause and how would you confirm this?
Transposition of the Great Arteries
Echo
(hypoxia and lactic acidosis)
What are the four abnormalities in Tetralogy of Fallot?
- Pulm stenosis
- RV hypertrophy
- VSD
- Aorta overriding VSD
Which chromosomal abnormality is associated with Tetralogy of Fallot?
DiGeorge syndrome
also CHARGE syndome
(also foetal alcohol syndrome)
What is the chromosome deletion in DiGeorge syndrome?
22q11 deletion
A 5 week old presents with clubbing, feeding difficulty and weight faltering. He deteriorates and starts going blue. You hear a pansystolic murmur at the lower left sternal edge, and an ejection systolic murmur at the upper left sternal edge. What do you suspect?
Tetralogy of Fallot
pansystolic LLSE = VSD
ejection systolic ULSE = pulm stenosis
Sepsis should be on the differential for any infant with resp distress and hypoxia. True or false?
true
What causes “Tet spells” in Tetralogy of Fallot? (this is when they become hypercyanotic when active)
hypoxia
they squat down to kink femoral arteries, change pressure and reverse shunt.
What are the symptoms of a “tet spell”?
sudden breathlessness
increasing cyanosis
lots of crying
What bloods might you do if you suspect genetic abnormality causing Tetralogy of Fallot?
chromosomal microarray
What would ECG show in Tetralogy of Fallot?
RV hypertrophy (right-to-left shunt)
What would CXR show in Tetralogy of Fallot?
boot-shaped heart
What causes the boot shaped heart sign on CXR in Tetralogy of Fallot?
RV hypertrophy
What is gold standard for confirming diagnosis of Tetralogy of Fallot?
Echo
What drug can be given in “tet spells” ?
Propanolol
What is the management of Tetralogy of Fallot?
manage tet spells (propanolol, squatting, BT shunt)
then perhaps definitive surgical repair
BT shunt can help reduce tet spells from hypoxia before definitive repair of Tetralogy of Fallot. What does it stand for?
Blalock-Taussig
85% children with surgically repaired Tetralogy of Fallot now survive to adulthood. How long do they need follow up?
lifelong
What are the three main causes of outflow obstruction in kids?
aortic stenosis
pulm stenosis
coarctation of the aorta
Blood gets to top half of body but not bottom half, causing radio-femoral delay. What is this?
coarctation of aorta
What does coarctation mean?
narrowing
A newborn has weak femoral pulses. What should FLASH across your mind?
coarctation of the aorta
narrowing is usually downstream of subclavians
Which congenital heart defect is associated with Turner’s syndrome?
coarctation of aorta
Asymptomatic murmurs in otherwise well neonates. What outflow obstructions do you think of?
aortic stenosis
pulm stenosis
What kind of pulse would you feel in a child with aortic stenosis?
slow rising pulse (parvus + tardus)
What would an ECG/Echo show in aortic stenosis?
LV hypertrophy
Ausculation in aortic stenosis.
ejection systolic murmur in upper right sternal edge
radiating to carotids
Ausculation in pulm stenosis.
ejection systolic murmur in upper left sternal edge
radiating to back
What would an ECG/Echo show in pulm stenosis?
RV hypertrophy
sometimes felt as heave in pulm stenosis
Which other congenital heart defects can result in pulm stenosis?
ASD
Tetralogy of Fallot
Pulmonary stenosis is associated with which genetic disorder?
Noonan syndrome
Noonan syndrome can be a cause of pulmonary stenosis. Which chromosome is usually the problem?
chromosome 12
As well as Tetralogy of Fallot, DiGeorge syndrome can also cause Truncus Arteriosus. What is this?
aorta and pulm artery don’t properly separate
Which congenital heart defects are most strongly associated with foetal alcohol syndrome?
ASD
VSD
Which congenital heart defect is most strongly associated with Down’s syndrome?
AVSD
also Tet Fallot, VSD
Which congenital heart defect is most strongly associated with Turner’s syndrome (45,X)?
Coarctation of the aorta
What is a thrill?
THIS REVISION! JOKE.
A palpable murmur
What is a heave?
hypertrophy
There is ejection systolic murmur at the upper left sternal edge, radiating to the back, and parasternal heave. Suspect?
pulm stenosis
heave is from RV hypertrophy
Pulmonary stenosis might be a defect on its own, or a part of which other congenital heart defects?
ASD
Tetralogy of Fallot
Aortic stenosis is ejection systolic murmur at upper right sternal edge. Where might this radiate to?
carotids
Slow rising pulse in….
aortic stenosis
You feel a thrill over the carotids. What FLASHES across your mind?
aortic stenosis
Pansystolic murmur at lower left sternal edge. What might this be and where might it radiate?
VSD
radiating to axilla
Ejection systolic murmur at upper left sternal edge. What might this be and where might it radiate?
pulm stenosis
radiating to back
(+ parasternal heave: RV hypertrophy)
Differentials for strawberry tongue?
KAWASAKI
SCARLET FEVER
(oral allergy syndrome!)
(toxic shock)
What are the criteria called for diagnosing Kawasaki?
Crash and Burn!
Tell me the Crash and Burn criteria for diagnosing Kawasaki.
Conjunctivitis Rash Adenopathy (lymph) Strawberry tongue (+red throat, cracked lips) Hands and feet
Burn = fever (lasting >5ds)
Describe me the conjunctivitis in Kawasaki.
Bloodshot eyes with limbus sparing
Describe me the ‘hands and feet’ in Kawasaki.
red and swollen palms + soles
peeling of fingers + toes
Does the fever in Kawasaki typically resolve with anti-pyretics?
Nope.
To get a diagnosis of Kawasaki, how many of the Crash and Burn criteria do you need?
4 symptoms + fever lasting >5ds
doesn’t meet all criteria = ‘incomplete Kawasaki’
What would urine show in Kawasaki?
sterile pyuria
increased WCC but no obv infection
Tell me what Kawasaki disease actually is please thank you :)
Vasculitis
of coronary arteries
but also large/medium size arteries throughout body
immune system attacks artery endothelial cells
Which age group does Kawasaki disease affect?
under 5s
esp 1yr olds
Kawasaki disease is one of the few indications for the use of aspirin in children. Why is aspirin not normally used?
risk of Reye’s syndrome
(brain and liver injury)
(after viral illness during which aspirin was administered)
In Kawasaki disease, kids often have raised WCC, with ‘shift to the left’. What does this mean?
more immature WBCs than normal
What is the investigation to diagnose Kawasaki?
clinical diagnosis only!
raised WCC, ESR/CRP, liver enzymes, plts
You’ve diagnosed Kawasaki clinically. What investigations would you want to check out?
bloods - (raised WCC, ESR/CRP, liver enzymes, plts)
urine - (sterile pyuria)
echo - (coronary artery involvement?)
What is the management of Kawasaki?
IV immunoglobulin
aspirin
Why do you follow up Echo of Kawasaki six wks later?
check for coronary artery aneurysm/clots, may need warfarin
Kawasaki may resolve untreated. But 25% of children get…
coronary artery aneurysms
