Peads Resp, ENT, Opthalmology and Cardio Flashcards
What is an atrial septal defect
-Hole in the wall between the two atria
-This allows blood to flow from the right to the left atria
What normally separates the two atria in the middle of the heart?
Fusion of the two walls with the Endocardial cushion
What is the hole called in the septum secondum during foetus development?
Forman ovale - which closes during birth
How can an atrial septal defect lead to right sided heart failure?
- atrial septal defect leads to a shunt
-from L atria to the R atria due to pressure gradient
-blood flows to the pulmonary vessels and lungs
-but increased flow to RHS leads to overload an therefore RHF
-leads to pulmonary hypertension
What is eisenmenger syndrome? (3)
-pulmonary pressure is greater than systemic pressure
-reversing the shunt so now is R to L across the atrial septal defect
-so blood skips the lungs and patient become cyanotic
What are the three types of atrial septal defect?
-Ostium secondum - septum secondum fails to close
-patent foramen ovale - foramen ovale fails to close
- ostium primum - where the septum primum fails to fully close - leads to AV valve defects
What are some complications of atrial septal defects (4)
-stroke - due to Venus thromboemboli
-AF/ atrial flutter
-pulmonary hypertension
-Eisenmengers syndrome
Why can ASD cause strokes (3)
-because the shunt allows the clot to pass into left ventricle from vena cava
- the clot travels through to the left atria and ventricle
-through the AORTA up to the brain
-(in normal patients would become PE)
What are the sounds of ASD (2)
-MID systolic crescendo decrescendo murmur
-Fixed split second heart sound (heart sound doesn’t change in inspiration or expiration)
Management of ASD?
-if small and Asx then watch and wait
-transvenous catheter closure
-open heart surgery
-prevent clots - give anticoagulants
What conditions are ventricular septal defects associated with?
-Downs syndrome
-turners syndrome
How does ventricular septal defects lead to RHF?
-blood flows from Left to right ventricle through the defect hole
-leads to right side blood flow overload
-RHF
- and Pulmonary HTN —> eisenmengers syndrome
Sx of VSD and ASD
-Poor feeding (both)
-Dyspnoea (both)
-Tachypnoea (VSD)
-Failure to thrive (VSD)
-LRTI (ASD)
Tx of VSD?
-Same as ASD - watch and wait if Asx
-Transvenous catheter closure
-Open heart surgery
- Antibiotic prophylaxis- increased infective endocarditis risk
Causes of croup?
-Parainfluenza
-Influenza
-Adenovirus
-Respiratory Syncytial Virus (RSV)
-used to be caused by diptheria but now vaccinated against
Presentation of croup (5)
-Increased work of breathing
-Barking cough, occurring in clusters of coughing episodes
-Hoarse voice
-Stridor
-Low grade fever
Management of croup (3)
- most cases - FLUID AND REST
- Oral dexamethasone/prednisolone -150mcg/kg
- then add nebulised adrenaline (and monitor)
What’s the stepwise approach for severe croup management? (5)
1.Oral dexamethasone
2.Oxygen
3.Nebulised budesonide (reduces inflammation)
4.Nebulised adrenalin
5.Intubation and ventilation
What is croup?
-URTI
-causes oedema in the larynx
What are the bacterial causes of pneumonia (8)
- streptococcus pneumonia
- group A strep (s.pyogenes)
- group B strep
- staph. Aureus
- haemophilias influenza
- mycoplasma pneumonia - atypical
-legionellae - atypical
-chlamydophilia - atypical
Viral causes of pneumonia (3)
-respiratory syncytial virus (RSV)
-parainfluenza
-influenza
Investigations for pneumonia
- CHEST X-RAY
- Sputum culture / throat swabs
- Capillary blood gas - (for acidosis)
Presenting findings of pneumonia (7)
-cough (usually wet and productive)
-Fever
-tachypnoea
-tachycardia
-increased work breathing
-lethargy
-delirium
Give three characteristic chest signs of pneumonia?
-bronchial breath sounds - loud caused by consolidation
-focal coarse crackles - caused by air passing through sputum
-dullness to percussion- due to lung tissue collapse and consolidation
What is pneumonia?
Fluid exudation into alveoli due to inflammation; from infection of the lower respiratory tract and lung parenchyma
Fungal causes of pneumonia
Pneumocystis jiroveci but only in immunocompromised patients
What are the common pneumonia causing bacteria in NEONATES (4)
-S.aureus
-Klebsiella
-E.coli
-Group B strep
Most common pneumonia causing bacterial agents in INFANTS? (2)
-strep pneumoniae
-chlamydia
Most common pneumonia causing bacterial agents in school aged children? (4)
-strep pneumoniae
-s.aureus
-Group A - s.pyogenes
-mycoplasma pneumonia
Tx for pneumonia in children
Antibiotics:
-under 5yrs: 1st line - amoxicillin
alternative is coamoxiclav for typical
erythro/clarithro/azithro for atypical
-over 5yrs: 1st line - amoxicillin + macrolide if atypical
-severe pneumonia - co amoxiclav/ cefotaxime/cefuroxime
Tx for pneumonia if causative bacteria is S.aureus (2)
-macrolide,
-combination of flucloxacillin with amoxicillin
Other than AbX what are some other measures to manage pneumonia in children? (5)
- antipyretics for fever
- IV fluids
- Oxygen so >92%
- chest drain reduce fluid
- chest physiotherapy
How do you diagnose empyema?
Fluid sample - pH<7.2,
- glucose<3.3mmol/l
-Protein>3G/L
-pus cells present
Ultrasounds - location of fibrin strands
Most common cause of bronchiolitis
RSV
What is bronchiolitis?
inflammation and infection in the bronchioles
Most common age group for bronchiolitis diagnosis?
Children under 1 year
Why does bronchiolitis normally only affect infants?
-adults airways are larger, so when there is welling and mucus build up proportionally has little difference on breathing
-in infants the airways are smaller so it has a big impact on air circulation
Presentation of bronchiolitis? (6)
-Coryzal symptoms
-Dyspnoea
-tachypnoea
-Wheeze and crackles
-poor feeding
-fever
what are coryzal symptoms? (4)
-snotty nose
-sneezing
-mucus in throat
-watery eyes
What are signs of paediatric respiratory distress? (8)
-raised resp rate
-tracheal tug
-use of accessory muscles
-nasal flaring
-head bobbing
-cyanosis
-abnormal airway noises
-intercostal and subcostal recession
Management of bronchiolitis
Usually supportive:
-ensure adequate intake - but not too full stomach as can restrict breathing
-saline nasal drops/nasal suctioning - to help clear nasal secretion
-supplementary oxygen -if below 92%
-ventilation
Three types of abnormal airway noises and what they are caused by ?
-Wheezing - caused by narrowed airways during expiration
-grunting - exhaling with the glottis partially closed
-stridor- high pitched inspiration noise caused by obstruction of upper airway e.g CROUP
What the best way to assess childrens ventilation?
Capillary blood gas
- rising pC02 - airways cant clear CO2
- falling pH - acidosis due to CO2
What can be given to prevent RSV
Palivizimuab (Monoclonal antibody)
-monthly injections for those are vulnerable
-provides passive protection
What are typical features of a viral induced wheeze? (3)
-Presenting before 3 years of age
-No atopic history
-Only occurs during viral infections
Management of viral induced wheeze?
Same as ACUTE asthma
Mild cases can be managed as an outpatient with regular salbutamol inhalers via a spacer (e.g. 4-6 puffs every 4 hours).
Moderate to severe cases require a stepwise approach working upwards until control is achieved:
Salbutamol inhalers via a spacer device: starting with 10 puffs every 2 hours
Nebulisers with salbutamol / ipratropium bromide
Oral prednisone (e.g. 1mg per kg of body weight once a day for 3 days)
IV hydrocortisone
IV magnesium sulphate
IV salbutamol
IV aminophylline
If you haven’t got control by this point the situation is very serious. Call an anaesthetist and the intensive care unit. They may need intubation and ventilation
What is poiseuilles law?
flow rate is proportional to the radius of the tube to the power of four
What is asthma?
A chronic reversible airway disease caused by an IgE hypersensitivity reaction leading to
-reversible airway obstruction
-airway hyper responsiveness
-inflammation of the bronchioles
-mucus hypersecretion
What is a life threatening asthma attack categorised by? (7)
-peak flow <33%
-O2<92%
-cyanosis
-confusion
-silent chest - inability to move in air
-poor respiratory effort
-hypotension
What is the management approach in moderate/severe cases of asthma
O SHIT ME
-oxygen get above 94%
-salbutamol
-hydrocortisone
-ipatropium bromide
-theophylline
-magnesium sulphate
-Escalate - intubation/ventilation
How can mild cases of acute asthma be managed?
-as an outpatient with regular salbutamol inhalers via a spacer
-4/6 puffs every 4 hours
Stepwise approach in acute asthma or Viral induced wheeze with bronchodilators? (4)
-Inhaled or nebulised salbutamol (a beta-2 agonist)
-Inhaled or nebulised ipratropium bromide (an anti-muscarinic)
-IV magnesium sulphate
-IV aminophylline (combo of theophylline and ethylenediamine)
Side effects of salbutamol (2)
Tachycardia
Fine Tremor
How do you normally discharge a child after acute asthma exacerbation?
-prescribe a reducing regime of salbutamol to continue at home
-finish steroid course if started
-provide information about when to seek help
-individual asthma plan
What is the atopic triad
Hay fever
Asthma
Eczema
Give some typical triggers of asthma (6)
-Dust (house dust mites)
-Animals
-Cold air
-Exercise
-Smoke
-Food allergens (e.g. peanuts, shellfish or eggs)
What are the presentations suggesting asthma diagnosis?
-diurnal variability - typically worse at night and morning
-dry cough
-wheeze
-SOB
-Hx or FHx of atopic conditions such as eczema/ hay fever
- bilateral polyphonic wheeze
-improved condition with bronchodilators
Investigations used to diagnose asthma (4)
-Spirometry with reversibility test (5 yrs+)
-direct bronchial challenge test with histamine
-fractional exhaled nitric oxide
-peak flow variability diary
Medical therapy for chronic asthma in UNDER 5 years?
1.SABA (salbutamol)
2.ICS low dose /LRTA (monteleukast)
3.other of low dose ICS / LRTA
4.refer to specialist
Medical therapy for children aged 5-12 years with chronic asthma? (6)
- SABA inhaler (e.g. salbutamol) as required
2.Add low dose ICS
3.Add a LAB2A inhaler (e.g. salmeterol). Continue salmeterol if the patient has a good response.
4.Titrate up the ICS to medium dose. Consider adding:
Oral LRTA (e.g. montelukast)
Oral theophylline
5.Increase the dose of the ICS to a high dose.
6.Referral to a specialist. They may require daily oral steroids.
What’s the medical therapy for children with chronic asthma aged 12 years and over? (6)
- SABA
- SABA + low dose ICS
- SABA + LABA + low dose ICS
4.increase ICS dose to medium and consider
-oral LRTA
-oral theophylline
5.titrate up ICS to a high one
- Add oral steroids at lowest dose, maintain high dose ICS
Side effects of long term/high dose steroids usage? (4)
-impaired growth
-adrenal suppression
-oral candidiasis - fungal infection of tongue
-altered bone metabolism
With asthma when is a nebuliser used?
-use in emergency treatment for delivery of bronchodilator
-more likely a spacer is used though
Give examples of drug delivery devices for asthma? (4)
-nebuliser
-spacer with MDI
-dry powder device
-propellant metered dose inhaler (PMDI)
What are the steps of correct inhalation technique for >3yrs?
-child standing to allow use of full diaphragm
-shake MDI
-place MDI in the inhaler
-place device in mouth
-firm seal around the mouth piece of spacer
-breath in and out tidally (normally) and then activate device
-continue breathing in and out 5 times
-if second dose needed then shake the MDI again and repeat
What are the characteristics of infrequent episodic asthma?
Makes up 75% of asthmatics
-less than 4 episodes a year
-symptom free between acute episodes
-no regular treatment needed
Management for infrequent episodic asthma?
-treat acute episodes with SABA
-more severe episodes use nebulised prednisolone
Characteristics of frequent episodic asthma?
**20% of asthmatics
-episodes every 2-4 weeks
-regular treatment needed
Management for frequent episodic asthma? (2)
-SABA/LABA as required
-use regular, low dose ICS
Persistent asthma characteristics?
-Less than 5% of asthmatics
-greater than 3 episodes a week
-cough at night/morning
-regular Tx is needed
Management of persistent asthma?
-use ICS prophylactic inhaled steroids
-LABA
-oral steroids
-oral LRTA can allow reduced steroid dose
Exercise induced asthma Management
Mild: use SABA/LABA before exercise
Severe: low dose ICS
What. Are the principles of the stepwise asthma ladder? (4)
-start at moist appropriate step for symptoms severity
-review at regular intervals
-step up and down ladder based off symptoms
-check inhaler technique and adherence
What is epiglottis?
-inflammation and swelling of the epiglottis caused by infection
What’s the main cause of epiglottiitis?
haemophilus influenza type B
Why is epiglottitis an emergency
It can cause the epiglottis to swell to the point of obscuring the airways within hours of symptoms
Presentation of epiglottitis?
-Patient presenting with a sore throat and stridor
-Drooling
-Tripod position, sat forward with a hand on each knee
-High fever
-Difficulty or painful swallowing
-Muffled voice
-Scared and quiet child
-Septic and unwell appearance
What investigations and findings should be used for epiglottitis?
-If the patient is acutely unwell dont perform investigations
- lateral X ray shows ** thumb sign** due to oedematous and swollen epiglottis
Management of epiglottitis? (4)
-Do not distress the patient - could cause closure of the airway
-alert senior paediatrician and anaesthetist
-prepare for intubation but only use if necessary
-once airway secured then use
IV antibiotics (cefatriaxone)
Steroids - (Dexamethasone)
Complications of epiglottitis? (2)
-Death
-epiglottic abcess (pus collects around epiglottis)
What is cystic fibrosis?
An autosomal recessive genetic condition affecting mucus glands making secretions thicker
What chromosome is affected in Cystic fibrosis?
Chromosome 7
What’s the pathology of cystic fibrosis?
-mutation on chromosome 7 gene that codes for CFTR protein
-which functions as a chloride channel
-chloride movement is disrupted and therefore so is Na
-reducing the amount of water in secretions
-causing decreased mucus clearance due to thickness
-This environment provides ideal conditions to protect bacteria from host immune system
Presentation of cystic fibrosis?
-meconium Ileus (first poo gets stuck)
-frequent LRTI
-failure to thrive
-pancreatitis - Pancreatic tubes become blocked with mucus
Sx of Cystic fibrosis (7)
-chronic cough
-Thick sputum production
-recurrent respiratory tract infections
-Steatorrhoea
-abdominal pain and bloating
-salty tasting skin
-Poor weight and height (failure to thrive)
Signs of CF (5)
-low weight or height gain on growth hairs
-nasal polyps
-finger clubbing
-crackles and wheeze
-abdo distension
What are causes of clubbing in children (7)
-Hereditary clubbing
-Cyanotic heart disease
-Infective endocarditis
-CF
-TB
-IBD
-Liver cirrhosis
What are the three main ways to diagnose CF?
-GOLD STANDARD - sweat test
-newborn blood spotting test
-genetic testing CFTR gene via amniocentesis or CVS
How does CF sweat test work?
-patch of skin chosen
-pilocarpine applied to skin
-electrodes placed either side of patch
-current applied
-causing sweating
-sweat is then tested for chloride concetration is over 60mmol
Diagnostic chloride concentration for CF?
more than 60mmol/L
Management of CF?
-chest physio - Several times a day
-Exercise
-Prohylactic flucloxacillin
-Bronchodilators e.g salbutamol
-nebulised DNase e.g do dornase alfa to break down DNA material in resp secretions making it thinner
-nebulised hypertonic saline - makes mucus less thick
-vaccinations e.g pneumococcal influenza and varicella
-high calorie diet to counter malabsorption
-CREON tablets to replace pancreatic enzymes ad help digest fats
What are the complications of CF (4)
-pancreatic insufficiency
-CF related diabetes
-liver disease
-infertility due to absent vas deferens
-frequent LRTI
What is glue ear?
It is otitis media with effusion, where the middle ear becomes full of fluid causing hearing loss in that ear
What are grommets used for?
-Tiny tubes inserted into the tympanic membrane surgically
-allowing fluid from the middle ear to drain through the membrane to the ear canal
Management of glue ear
- usually goes away on its own
-Audiometry to establish extent of hearing loss
-grommets
Investigations for glue ear?
Otoscopy - will show a dull tympanic membrane
- with air bubbles
- visible fluid level
What is otitis media?
-An infection in the middle ear
-normally the bacteria enter from the back of the throat through the Eustachian tube
What structures are found in the in the middle ear (3)
-cochlea
-vestibular apparatus
-vestibular nerves
What bacteria cause otitis media? (4)
streptococcus pneumoniae
Others include
-haemophilius influenzae
-mortadella catarrhalis
-Staph. Aureus
Presentation of otitis media?
-ear pain
-reduced hearing
-fever
-cough
-coryzal symptoms
-sore throat
-when affecting the vestibular system it can cause vertigo and balance issues
Investigations of otitis media?
-otoscope to see tympanic membrane
- will be inflamed and red
- discharge in the ear canal
- hole in tympanic membrane
Management of otitis media
-In children less than 3 months admission if above 38 degrees
-in children 3-6 months admission if above 39 degrees
-Most cases resolve WITHOUT antibiotics give paracetemol, but in certain cases can give antibiotics
When can you give antibiotics in otitis media?
Patients with below give AMOXICILLIN:
-co morbidities
-immunocompromised
-children less than 2 years with bilateral otitis media
-they are producing discharge
Which antibiotics are used for otitis media?
First line: amoxicillin for 5 days
-Can use erythromycin and clarithromycin
What is a delayed prescription for antibiotics
-antibiotics that can be collected and used after 3 days if symptoms haven’t improved/ have worsened
Complications of otitis media? (6)
-Otitis medial with effusion
-Hearing loss (usually temporary)
-Perforated eardrum
-Recurrent infection
-Mastoiditis (rare)
-Abscess (rare)
-cholesteotoma
What can cause congenital hearing loss (3)
-maternal rubella/ cytomegalovirus during pregnancy
-genetic deafness
-associated syndromes Down syndrome
Perinatal causes of hearing loss? (2)
-prematurity
-hypoxia during or after birth
Post birth causes of hearing loss? (4)
-jaundice
-meningitis
-otitis media/glue ear
-chemotherapy
Presentation of hearing loss in newborns?
-Ignoring calls or sounds
-Frustration or bad behaviour
-Poor speech and language development
-Poor school performance
Investigations for hearing loss?
Audiometry
- children under 3 - basic response to sound e.g turning towards a sound
-older children- using headphones and specific tones and volumes
What is conductive hearing loss?
- where sound cant travel through air so is unable to pass through outer ear to inner ear
Causes of conductive hearing loss?
-ear canal atresia (narrowing)
-acute otitis media
-chronic otitis media
-secretory otitis media
Causes of sensorineural hearing loss?
Inherited: -ushers syndrome
-Waardenburg syndrome
Acquired:
Perinatal - birth asphyxia
- hyperbilirubinemia
- congenital infection e.grubella, CMV, syphilis
Postnatal - drugs e.g aminoglycosides
- Meningitis
- head injury
- labyrinthitis
- Acoustic neuroma
Management of hearing loss in children
-Speech and language therapy
-Educational psychology
-ENT specialist
-Hearing aids for children who retain some hearing
-Sign language
What are the readings of an audio gram in normal hearing
-At each frequency will be able to heard at 0-20 decibels
-Nearer the top of the chart
What will the audio gram look like in sensorineural hearing loss?
-both air (headphones) and bone (oscillator) conduction readings will be MORE than 20 dB
What will conductive hearing loss look like on audio gram
-Bone conduction will be normal (0-20dB)
-air conduction readings will be GREATER THAN 20dB
What will mixed hearing loss look like on an audiogram?
-BOTH air and bone conduction readings will be more than 20dB
-however there will a difference of 15dB between air and bone conduction
What is peri orbital cellulitis
-an infection of the soft tissues around the eye
-characterised by erythema and oedema
What time does periorbital cellulitis happen most?
-late winter/ early spring
-due to increased incidence of URTI
What are the two types of peri orbital cellulitis?
-pre septal - anterior to the orbital septum
-post septal - posterior to the orbital septum
How does peri orbital cellulitis commonly spread
ETHMOIDAL SINISITIS
- bacterial spread through paranasal sinuses into the orbit
Which organisms most commonly cause periorbital sinusitis? (4)
-staph aureus (most common)
-strep pneumonia
-H.influenzae
-group A strep
How does pre septal cellulitis present?
-eyelid oedema
-erythema of upper eyelid
-absence of orbital signs
How does orbital cellulitis present (6)
-proptosis- abnormal protrusion of eye
-opthamlmoplegia
-decreased visual acuity
-loss of RED colour vision
-chemo sis - swelling of conjunctiva
-painful diplopia
What is chandlers classification?
- a way to differentiate different types of periorbital cellulitis
Type 1 - pre septal
Type 2 - post septal/orbital cellulitis
Type 3 - subperiosteal abcess
Type 4 - intra orbital abcess - collection of pus around muscle cone
Type 5 - cavernous sinus thrombosis - can affect 3,4,5 cranial nerve
Investigations for periorbital cellulitis?
-Opthalmic history and exam
-rhinoscopy - shows discharge
-bloods - CRP
-CT to distinguish periorbital and orbital
Treatment of periorbital cellulitis?
Mild- pre septal
-oral antibiotics
Orbital cellulitis
-IV antibiotics
-nasal decongestants
-steroid nasal drops
Support with adequate IV fluid
Complications of peri orbital cellulitis?
-loss of vision
-intercranial abcess
-encephalomeningitis
-sepsis
-cavernous sinus thrombosis
Squint treatment?
-prescription glasses
-eye patch over good eye
Complication of squint?
-loss of/ underdeveloped binocular vision
-poor perception of depth
-abnormal head postures to compensate
-lazy eye
What investigations do you do for bronchiolitis?
-nasal pharyngeal swab
-throat swab
What is the ductus venosus
A shunt that connects the umbilical vein to the inferior vena cava
-allows the blood to bypass liver
what is the foramen ovale
Shunt that connects the right atrium with the left atrium
-allows blood to bypass the right ventricle and pulmonary circulation
What is the ductus arteriosus?
Shunt connects the pulmonary artery with the aorta
-allows blood to bypass the pulmonary circulation
What keeps the ductus arteriosus open?
Prostaglandins
What are the acyanotic heart diseases?
- 3 As
ASD and VSD
Patent ductus arteriosus
Coarctation of aorta
What are the cyanotic heart diseases
-Transposition of the great arteries
-tetralogy of fallot
- truncus arteriosus
What is cyanotic heart disease?
-When deoxygenated blood enters the systemic circulation
-so blood is bypassing the pulmonary circulation
What can cause pan systolic murmur (3)
-Mitral regurgitation - (fifth intercostal space, mid-clavicular line)
-Tricuspid regurgitation - (fifth intercostal space, left sternal border)
-Ventricular septal defect - (left lower sternal border)
What can cause an ejection systolic murmur (3)
-Aortic stenosis - (second intercostal space, right sternal border)
-Pulmonary stenosis - (second intercostal space, left sternal border)
-Hypertrophic obstructive cardiomyopathy - fourth intercostal space on the left sternal border
What causes a splitting of second heart sound
-When pulmonary valve closes slightly later than the aortic valve
-due to increase volume in RV
ASD heart sound
-Fixed split
-mid systolic crescendo - decrescendo
Tetralogy of fallot heart sound
-continuous crescendo decrescendo murmur
-during second heart sound
-due to pulmonary stenosis
Complications of eisenmengers
-heart failure
-infection
-thromboembolism
-haemorrhage
-death
Tx of eisenmengers syndrome
-underlying defect fixed surgically
-heart/lung transplant
Management of eisenmengers syndrome
-oxygen for Sx management
-treatment of arrhythmias
-sildenefil - for pulmonary hypotension
-venesection - treatment of polycythaemia
-anticoagulation - thrombosis prevention
-prophylactic antibiotics - infective endocarditis
How does eisenmengers lead to polycythaemia admin thrombosis?
-low oxygen saturation
-leads to bone marrow overproducing more RBCs and haemoglobin
-leads to more viscous blood and therefore increased clots
Examination findings of eisenmengers
related to pulmonary HTN
-right ventricular heave
-Loud P2
-raised JVP
-peripheral oedema
Related Septal defect
-ASD/VSD/PDA murmurs
-arrhythmias
Related to chronic hypoxia
-cyanosis
-clubbing
-Dyspnoea
-plethoric (Red) complexion
What is tetralogy of fallot?
-Ventricular septal defect (VSD)
-Overriding aorta
-Pulmonary valve stenosis
-Right ventricular hypertrophy
Risk factors for tetralogy of fallot (4)
-Rubella infection
-Increased age of the mother (over 40 years)
-Alcohol consumption in pregnancy
-Diabetic mother
Signs of tetralogy of fallot
-cyanosis
-clubbing
-poor feeding and weight gain
-Ejection systolic murmur heard loudest in pulmonary area
What murmur is heard in tetralogy of fallot and why
-ejection systolic murmur loudest in pulmonary area
-due to pulmonary stenosis
How to treat a TET spell (6)
-Oxygen - counter hypoxia
-beta blockers - increase blood flow to pulmonary vessels
-IV fluids - improve pulmonary vessels
-Morphine- improves breathing
-sodium bicarbonate - counter metabolic acidosis
-phenylephrine infusion - increase systemic vascular resistance
Management of tetralogy of fallot
-neonates - prostaglandin infusion to keep open ductus arteriosus and help pulmonary perfusion
-open heart surgery
What is coarctation of aorta
Narrowing of the aortic arch usually round the ductus arteriosus
Which genetic condition is associated with coarctation of aorta
Turners syndrome
Mx of coarctation of aorta
- prostaglandin E to keep ductus arteriosus open until surgery
-surgery to tie up the ductus arteriosus and fix the coarctation
Presentation of coarctation of aorta
- weak femoral pulse
- grey floppy baby
- tachypnoea
- lower blood pressure in limbs supplied after the narrowing
-higher blood pressure in limbs supplied before narrowing
What signs may develop over time in a patient with coarctation of aorta
-Left ventricular heave due to LVH
-Underdeveloped left arm where there is reduced flow to the left subclavian artery
-Underdevelopment of the legs
What are the most common cause of Infective endocarditis in children (4)
VSD
-PDA
-coarctation of aorta
-Bicuspid aortic valve
-Tetralogy of fallot
Common organisms that cause
-Staph aureus - most common
-strep viridens
Clinical features of infective endocarditis (9)
-low grade fever
-aneamia and pallor
-splenomegaly
-petechiae
-splinter haemorrhages, janeway lesions, osler nodes, Roth spots
-clubbing
Investigations for infective endocarditis
-blood cultures - three done before abx
-TOE/ECHO - to identify vegetations on valves
What criteria is used for infective endocarditis
Duke criteria
Triad requirement for Infective endocarditis
Microbial adherence
Platelet adhesion
Endothelial damage
Risk factors for infective endocarditis
-IV drug use
-CKD
-immunocompromised - cancer/HIV/medications
-history of IE
-structural heart pathology
What heart pathology can use infective endocarditis
-Valvular heart disease - stenosis or regurgitation
-Congenital heart disease - VSD, PDA
-Hypertrophic cardiomyopathy
-Prosthetic heart valves
-Implantable cardiac devices (e.g., pacemakers)
Mx of IE
-ABx
Usually IV amoxicillin with gentamicin
Surgery
-for abscesses or large vegetations
-to fix valve pathology
-keep good oral health
Complications of IE (4)
-Heart valve damage, causing regurgitation
-Heart failure
-Infective and non-infective emboli (causing abscesses, strokes and splenic infarction)
-Glomerulonephritis
What is rheumatic fever
A multi system Autoimmune condition triggered by strep bacteria
- affects joints, heart, skin and nerves
Typical causative organisms of rheumatic fever
- group A strep - strep pyogenes
How does rheumatic fever present
- 2-6 weeks after a pharyngeal infection
- mild fever, malaise and polyarthritis develop
What can happen if you have repeated attacks of rheumatic fever
Can cause valvular disease
Which valves are affected most by rheumatic fever?
- aortic
- tricuspid
Management of rheumatic fever
- Rest
- high dose aspirin for joint and heart inflammation
-if it doesn’t resolve then give corticosteroids
-AbX to treat persisting streptococcal infection
What is the criteria used to diagnose rheumatic fever?
- Jones criteria
- To make a diagnosis need TWO major, TWO minor - - plus evidence of a group A strep infection
What is given after acute episode of rheumatic fever
Monthly injections of Benzathine Penecillin
-if allergy to penecillin then oral erythromycin
Management of tricuspid atresia (2)
- palliation - making a disease less severe without curing by:
Blalock-Taussig shunt insertion - between the subclavian and pulmonary retry
Pulmonary artery banding - operation to reduce pulmonary blood flow if breathless
What is aortic stenosis?
-The aortic valve leaflets are partly fused together, causing reduced blood exit form the left ventricle
What other condition are associated with aortic stenosis (2)
-Mitral stenosis
-Coarctation of aorta
Physical signs of aortic stenosis (4)
-slow rising pulse
-carotid thrill - vibration herd in carotid
-ejection systolic murmur maximal at right sternal edge radiating to the neck
-delayed and soft aortic second sound
Investigations for aortic stenosis
Chest X ray - normal or prominent left ventricle with dilatation of the ascending aorta
ECG- show left ventricular hypertrophy
Management of aortic stenosis
-Balloon valvotomy
-Aortic valve replacement - but only done later on in life as complicated in neonates
Symptoms of heart failure (4)
• Breathlessness (particularly on feeding or exertion)
• Sweating
• Poor feeding
• Recurrent chest infections.
Signs of heart failure (7)
• Poor weight gain or ‘faltering growth’
• Tachypnoea
• Tachycardia
• Heart murmur, gallop rhythm
• Enlarged heart
• Hepatomegaly
• Cool peripheries.
Signs of right sided heart failure
Ankle oedema
Sacral oedema
Ascites
In the first week of life what is the most likely cause of heart failure
Any L to R shunt
Causes of heart failure in neonates?
- hypo-plastic left heart syndrome
-aortic valve stenosis
-coarctation of aorta
-interruption of the aortic arch - aortic arch doesnt form properly
Causes of heart failure in infants? (3)
-Ventricular septal defect
-Atrioventricular septal defect
-Large persistent ductus arteriosus
Causes of heart failure in older children (3)
• Eisenmenger syndrome (right heart failure only)
• Rheumatic heart disease
• Cardiomyopathy
Presntation of transpotion of the great arteries
- baby will have cyanosis
-will then after a few weeks will develop respiratory distress, tachycardia, poor feeding, poor weight gain and sweating
Management of transposition of the great arteries
-if there is a PDA then prostaglandin infusion to maintain it
-balloon septostomy - creat a large ASD
-open heart surgery - arterial switch
What associated conditon to transposition of Great arteries can provide immediate survival of the baby
-ASD
-VSD
-PDA
Allows the blood to go through to lungs and get oxygenated due to L to R shunt
What is classed as SVT
Heart rate between 250-300
Investigations for SVT
ECG - show a narrow complex tachycardia
Management of SVT (4)
restoration of sinus rhythm
- Circulatory and respiratory support – tissue
acidosis is corrected, positive pressure ventilation
• Vagal stimulating manoeuvres, e.g. carotid sinus
massage or cold ice pack to face
• Intravenous adenosine – the treatment of choice.
inducing atrioventricular. It is given incrementally in increasing doses
• DC Electrical cardioversion if adenosine fails.
What’s the management of SVT after sinus rhythm has been achieved
-sotalol/ flecainide
What antibodies is congenital complete heart block related
-Anti ro
-anti La
In the maternal serum
Inheritance pattern of long QT syndrome
Autosomal dominant
Which antibiotic can lead to long QT
Erthyromycin therapy
What is a squint
-misalignment of the eyes
-when the eyes are not aligned the images on the retina do not match so double vision
What concomitant squints
Squint due to difference in the control of the extra ocular muscles
What are paralytic squints
They are due to paralysis in one or more of the extra ocular muscles.
What is amblyopia
the affected eye becomes passive and has reduced function compared to the other dominant eye
What occurs if there is a squint in childhood
- the eyes in childhood haven’t fully established their connection with the brain
-so reduces the signal from the less dominant eye resulting in a lazy eye due to increased disconnection from the brain
Causes of squints (5)
- usually idiopathic
-Hydrocephalus - due to damage to nerve supplying ex ocular muscles
-Cerebral palsy - motor lesions disrupt vision
-Space occupying lesions, for example retinoblastoma
-Trauma
What tests are used for squint (2)
Hirschberg’s test: shine a pen-torch at the patient from 1 meter away. When they look at it, observe the reflection of the light source on their cornea. The reflection should be central and symmetrical. Deviation from the centre will indicate a squint. Make a note of the affected eye and the direction the eye deviates.
Cover test: cover one eye and ask the patient to focus on an object in front of them. Move the cover across to the opposite eye and watch the movement of the previously covered eye. If this eye moves inwards, it had drifted outwards when covered (exotropia) and if it moves outwards it means it had drifted inwards when covered (esotropia).
Management of squint
try to catch early before age of 8 to reduce chance of permanence:
-occlusive patch used to cover good eye forcing bad eye to develop
-atropine drops in the good eye causing vision in good eye to blur
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