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Paeds cardiology: Flashcards

1
Q

List the 3 acyanotic paediatric heart diseases:

A
  • Ventricular septal defect
  • Atrial septal defect
  • Patent ductus arteriosus
    (pulmonary stenosis, aortic stenosis, co-arctation)
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2
Q

List 2 cyanotic paed heart diseases:

A
  • Tetralogy of fallot

- Transposition of the great arteries (TGA)

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3
Q

What change in heart sound is heard in ASD?

A

Wide fixed splitting of the second heart sound?

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4
Q

What cardiac abnormality can cause a pansystolic murmur?

A

VSD “burrrr” (no gap between murmur and S2)

Heard on the left sternal edge

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5
Q

What cardiac abnormality causes ejection systolic murmur?

A

Aortic stenosis

Pulmonary stenosis

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6
Q

What cardiac pathology can produce a continuous murmur?

A

Patient Ductus Arteriosum (PDA)

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7
Q

At what point can a VSD be auscultated from?

A

Tricuspid region

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8
Q

What does a soft ejection systolic murmur indicate and where would it normally be heard?

A

Innocent murmur

Heard best at left sternal edge

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9
Q

What are the 7 S’s? What are they used for?

A 
Short
Soft
Systolic
S1 & S2 normal
Standing and sitting variation
Symptomless
Special tests normal (ECG, CXR, Echo)

Diagnosis of innocent murmur.

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10
Q

In a foetus, where do the two umbilical arteries come from?

A

Internal iliac arteries

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11
Q

Where does the umbilical vein join?

A

IVC

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12
Q

Where does the Ductus venosus exist in foetus’?

A

At the umbilicus between the umbilical vein and the umbilical arteries

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13
Q

What two structures allow oxygenated blood from the mother to bypass the lungs and where are these structures present?

A 
Foramen ovale (from RA to LA)
Ductus arteriosus (from Pulmonary artery to aorta)
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14
Q

What additional features allows blood to bypass the lungs?

A

High pulmonary pressure

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15
Q

What stimulates the first breath in a child?

A

Hypoxia secondary to cord clamping

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16
Q

At birth, what allows blood to be redirected into the lungs?

A

After first breath, oxygen is drawn into the lungs and acts as a strong vasodilator. This drops pulmonary pressure allowing blood to flow into the lungs.

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17
Q

How long does it take for the ductus artiosus to close?

A

1-2 days (shrink and contracts)

Baby <24hrs = murmur - if clinically well review later

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18
Q

What is the most common congenital malformation and what 2 commonest conditions included in it?

A

Congenital heart disease (CHD) -

  • VSD
  • PDA
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19
Q

What makes congential abnormality cyanotic vs. acyanotic?

A

Cyanotic - R->L shunt

Acyanotic - L-> R shunt

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20
Q

At what oxygen saturation does blueness typically manifest?

A

85%

when there is >5g/dl of deoxygenated haemoglobin

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21
Q

What percentage of CHD are represented by VSD?

A

30%

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22
Q

What effect does size have upon the sounds of the murmur?

A

Loudness of murmur is inversely proportional with size (small = ^ turbulence = ^noise).

(size can vary from small hole to missing septum)

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23
Q

How do VSD typically resolve?

A

Often close spontaneously before age 5 if small.

If large then repair may be needed due to risk of pulmonary hypertension.

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24
Q

How may a patient with a large VSD present?

A
  • Heart failure at 4-6 weeks
  • Breathless or sweaty on feeing or crying
  • faltering growth
  • Recurrent chest infections (due to pulmonary congestion)
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25
Q

What are those with VSD more at risk of?

A
  • Chest infections

- Bacterial endocarditis

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26
Q

On examination, what might be observed in a large VSD?

A
  • Left parasternal heave (due to right ventricular hypertrophy)
  • Pulmonary ejection murmur
  • Quiet or absent pansystolic murmur

(in other words: sings of pulmonary hypertension)

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27
Q

What does pulmonary plethora mean?

A

Increase dilation of the pulmonary vasculature typically due to pulmonary hypertension

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28
Q

What would the investigation results show in those with VSD?

A

ECG - right ventricular hypertrophy (dominant R wave in V1)
CXR - cardiomegaly, prominent pulmonary artery and plethoric lung fields
Echo - size of lesion and doppler flow may indicate size of shunt

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29
Q

What is the treatment for those with VSD?

A
  • Most spontaneously close
  • Repair if large
  • Diuretics and ACEi for heart failure
  • Use of Abx prophylaxis is controversial
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30
Q

What may an ASD cause if large enough?

A

Left to right shunt at atrial level

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31
Q

What may indicate a ASD?

A
  • Recurrent chest infections
  • Heart failure
  • AF and SVT common in 30s and 40s (as AV node near defect)
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32
Q

What murmur si typically heard in ASD?

A

A wide splitting S2 sounds (murmur not produced by flow across the defect its self)

33
Q

What is the treatment for ASD?

A

Closure (ideally before 5th birthday as less to repair):

  • Open heart surgery with patch repair
  • Trans-catheter closure
34
Q

What is the second commonest CHD?

A

Patient ductus arteriosus (PDA)

35
Q

In whom is PDA common in?

A

Premature babies - kept open by hypoxia ( decreased surfactant = pulmonary pressure is higher)

36
Q

What is seen upon examination in those with PDA?

A
  • Collapsing pulse due to more blood flowing through the lungs and hence extra blood returning to the left of the heart
  • wide pulse pressure (due to high systolic and low diastolic)
  • Continuous ‘machinery’ murmur
  • Loudest below left clavicle and radiates to back
37
Q

What is the treatment for PDA?

A

1) Prostaglandin synthetase inhibitor (e.g. ibruprofen infusion)
2) Surgery:
- Trans-catheter occlusion
- Surgical ligation

38
Q

What characterises Fallots tetralogy?

A

P - Pulmonary stenosis causing..
R - Right ventricular hypertrophy
O - Over-riding aorta; R to L shunt across the
V - VSD
E - Ejection systolic murmur (from pulmonary valve)

39
Q

What buzz words are typically used to describe Fallots tetralogy?

A
  • ” Right ventricular outflow obstruction”
  • “Infundibular pulmonary stenosis” (i.e. not just the valve that is narrow, the outflow tract just below the valve is affected)
40
Q

What is typically found upon examination in Tatralogy of fallot?

A
  • Clubbing
  • Cyanosis
  • Right ventricular hypertrophy (left-parasternal edge)
  • Ejection systolic murmur
41
Q

In tetralogy of fallot when does cyanosis typically become apparent and why?

A

Around day 2 to 3 when ductus closes.

In tetralogy of fallot, the patient ductus arteriosus allows blood to bypass the pulmonary stenosis and flow back to pulmonary artery from the aorta. This means that those with a patent ductus arteriosus typically live longer than those without if they also have tetralogy of fallot.

42
Q

What is the treatment of tetralogy of fallot?

A

Surgical, two staged:
1) Shunt operation to increase pulmonary flow in order to help develop the pulmonary arteries = improved oxygenation and reduced pulmonary pressure

2) Followed by definitive correction - repair VSD + over-riding aorta

43
Q

What acronym can be used to remember Downs facial features?

A 
R- Round face
O - Occipital flattening  (and nasal)
S - Speckled iris (Brushfield spots)
E - Epicanthic folds
O - Open mouth with protruding tongue
L - Low set ears
A - Almond (oval) upwards slanting eyes
44
Q

List 3 other features seen in downs:

A
  • Single transverse palmer crease
  • Duodenal atresia (double bubble)
  • Sandal gap between big toes and other digits
45
Q

What should everyone with downs have at the time of diagnosis and why?

A

Echocardiogram - 40-50% of those with downs have a cardiac abnormality

46
Q

What cardiac abnormalities is downs associated with?

A
  • ASD
  • VSD
  • Atrioventricular canal defect
  • Mitral and tricuspid valve regurgitation
47
Q

What the the ‘buzz words’ for cardiac abnormalities in downs?

A

‘Endocardial cushion defect’ which leads to ‘ failure of septation’ of the heart, which results in atrioventricular septal defect (AVSD).

48
Q

What is Eisenmnegers syndrome?

A

Refers to the process of shunt reversal. This occurs due to L->R shunt causing pulmonary hypertension. As this develops/gets worse the degree of left to right shunting gets less causing improvement of heart failure symptoms. Finally, the right sided pressures are so high that right to left shunting occurs causing cyanosis. This is Eisenmengers syndrome. it is an acquired cyanotic heart disease.

49
Q

What is the treatment of Eisenmengers syndrome?

A

Heart/lung transplant

50
Q

What is Duckett Jones criteria used for?

A

Diagnosis of rheumatic fever

51
Q

What acronym can be used to remember the Duckett Jones major criteria?

A

Careys: Carry Coombs mitral diastolic murmur
Red - erythema marginatum
Nodule (painless, subcutaneous, rare)
Ruined ( just a verb)
Arthur - Arthritis (typically medium and large joints)
Career - Chorea (Sydenhams Chorea - St. Vitus’ dance)

52
Q

What is the minor criteria for Duckett Jones’?

A
  • Arthralgia (pain in joint)
  • Fever
  • Raised ESR
  • Heart block
53
Q

Where is the narrowing typically present in co-arctation of the aorta?

A

Just below the origin of the left subclavian.

54
Q

What syndrome is co-arctation of the aorta associated with?

A

Turners Syndrome

55
Q

How may co-arctation of the aorta present?

A
  • Shock in neonatal period when the ductus closes

- Or later, heart failure or hypertension

56
Q

List 3 signs on examination present in a patient with co-arctation of the aorta:

A
  • Weak femoral pulses with radio-femoral delay
  • Arm BP>leg BP
  • Systolic murmur over back
57
Q

What is transposition of the great arteries (TGA)?

A
  • Aorta comes off RV

- Pulmonary artery comes of LV

58
Q

What allows the patient to stay alive in TGA?

A

The patient ductus arteriosus is the only way which oxygenated blood can reach the systemic circulation

59
Q

What is the management for TGA?

A
  • Prostaglandins infusion to keep duct open
  • Arterial septosomy to encourage further mixing
  • Then definitive ‘switch’ operation
60
Q

What usually causes subacute bacterial endocarditis?

A

Strep. Viridans (dental)

61
Q

What is the treatment for subacute bacterial endocarditis?

A

Penicillin and gentamicin for 6 weeks

62
Q

List 4 signs of subacte bacterial endocarditis:

A
  • Clubbing
  • Splinter haemorrhages
  • Variable murmurs
  • Splenomegaly
63
Q

In ASD, why is there a wide second heart sound?

A

It is due to delayed pulmonary valve closure due to increased volume of blood passing through the right ventricle and pulmonary artery

64
Q

Why does the over-riding aorta develop in Fallots tetralogy?

A

Due to unequal partitioning of the truncus arteriosus by the aortico-pulmonary septum

(basically results in a large aorta and smaller PA).

65
Q

What triggers the closure of the ductus arteriosus?

A

Reducing circulating prostaglandins (PG) from the placenta

66
Q

When does the ductus arteriosus close by?

A

Physiological closure by 10 days (usually less than 3)

67
Q

Why is PDA more common in preterm babies?

A
  • Preterm heart less sensitive to reduction in prostaglandin levels
  • Hypoxia more common in preterms leads to increased pulmonary blood pressure = more blood flow through the DA thus keeping it open
68
Q

What is the diagnostic criteria for Kawasakis disease?

A

Fever and 4/5 features required:
M(y) - Mucosal involvement
H - Hands/feet reddening with oedema, followed by desquamation
E - Eyes: non-puralent bilaternal conjunctivitis
A - LymphAdenopathy
R - Erythematous rsh
T - Temp: non-relenting fever for >5days

69
Q

What can Kawasakis cause?

A

20% develop cornonary aneurysms (detected on echo)

70
Q

What investigation results would be present in Kawasakis?

A
  • ^ WCC
  • ^ ESR
  • ^ CRP
  • Thrombocytosis
71
Q

What is the Rx for Kawasakis?

A
  • early Immunoglobulins

- Asprin for at least 6 weeks

72
Q

What type of blood vessel does Kawasakis effect?

A

Medium sized arteries

73
Q

List 4 signs heart failure in children:

A
  • Tachypnoea
  • Tachycardia
  • Cardiomegaly
  • Extra heart sounds
74
Q

List 4 symptoms of heart failure in children:

A
  • Poor feeding
  • Sweating
  • Poor weight gain
  • recurrent chest infections
  • Breathlessness
75
Q

When does Rheumatic fever typically develop?

A

Occurs after a 2-6 week gap following infection with strep. pyogenes

76
Q

What group is Strep. Pyogenes a member of?

A

Group A beta- Haemolytic streptococcus

77
Q

Why does strep. pyogenes contribute towards rheumatic fever?

A

Molecular mimicry - strep. pyogenes have similar antigens to the heart antigens = antibodies cross react

78
Q

What can chronic rheumatic fever lead to?

A

Mitral stenosis or aortic regurgitation

79
Q

What is diagnosis of rheumatic fever based on?

A

Evidence of Strep. (throat swab or Anti-streptolysin O (ASO) titre) plus major or minor criteria

Paeds (13 decks)

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