Pedi Cardiology Flashcards
What is neurocardiogenic syncope?
“Vasovagal syncope” a hypersensitive autonomic response
heart rate slows, and the blood vessels in legs dilate, blood pools in LEs > BP drops. Lower HR and BP > diminished blood flow to your brain > syncope
Prodrome to syncope
nausea, palpitations, diaphoresis, tinnitus, pallor, dizziness, lightheadedness, blurred vision, weakness
Tx for near syncope
Lie down, elevate legs
increases blood return to brain
Classifications of syncope
Neurally mediated (vasovagal), Cardiovascular, Other (metabolic, neurologic, psychologic)
Causes of CV syncope
congenital HD (impaired CO), CAD, arrhythmia
Bezold-Jarisch reflex
paradoxical response of bradycardia, vasodilation, hypotension in vasovagal syncope
Syncope: when to worry
family Hx sudden death or seizure do (misdiagnosed long QT)
Myocardial dz
occurs w/exercise
associated palpations or CP
Work up for syncope
EKG to evaluate for: long QT, WPW, Complete Heart Block, Ventricular hypertrophy, myocardial ischemia
When to consult cardiology regarding syncope?
recurrent w/o identifiable cause
arrhythmia suspected or identified
occurs during exercise
Tx for vasovagal syncope
Volume & solute replacement
Mineralcorticoids (problematic & recurrent syncope)
BBs
Who is at risk for myocardial ischemia (as a cause of CP)?
Kawasaki dz, Transposition of the great arteries w/coronary switch operation, Ross operation
anomalies in coronary arteries (single coronary, ALCAPA, pulmonary atresia)
Sx of myocardial ischemia
pressure sensation +/- burning
radiation to neck, shoulder, arm
during or following exercise
improves w/rest
Sx pericarditis
severe substernal CP squeezing or tightening worse w/movement, breathing Lean forward, may refuse to lie down reproducible by sternal pressure Friction rub if small or no effusion
Tx pericarditis
NSAIDs 2-6weeks (always w/GI prophylaxis!), steroids if severe/recurrent
When to consult cardiology regarding CP
w/or after exercise w/syncope or near syncope known cardiac dz acute sudden onset w/marfan abnormal PE findings
Sx of hypertrophic cardiomyopathy
> 50% have murmurs r/t LVOT obstruction
exertional dyspnea, palpitations, syncope, CP
95% have EKG abnormalities
When to consult cardiology regarding palpitations
PACs and single monomorphic PVCs
Associated w/exercise, syncope, symptoms
asymptomatic generally no referral
How much of AP width does cardiac silhouette occupy on CXR?
50-55%
What are you looking for on CXR when assessing CV system?
size of heart (small, normal, large)
contours of heart (enlarged, absent, displaced)
pulmonary vascularity (diminished, normal, increased)
ASD on CXR
Prominent pulmonary vasculature and enlarged right heart
increased compliance LV, L-> R shunting
VSD on CXR
Enlarged pulmonary vasculature, left heart dilation
L-> R shunt, increased P blood flow & return to LA and LV
PDA on CXR
Left heart dilation and cardiomegaly
L–>R shunt at arterial level, inc P blood flow and return to LA and LV
AV canal defect on CXR
Prominent pulmonary vasculature, dilation all 4 chambers
often w/ASD & VSD, L–>R shunting, inc Pulm blood flow, regurgitation AV valves
AS on CXR
Dilated ascending aorta, LV dilated & hypertrophic, displaced downward and lateral
(increased velocity across narrowed LVOT, LV works harder)
ToF on CXR
small, hypo plastic or atretic Pas Mediastinum appears narrowed RVH d/t PS Uplifting of cardiac apes BOOT SHAPED HEART Diminished pulmonary vascular markings (PA restricts PBF)
TAPVR on CXR
Snowman appearance, pulmonary vasculature prominent
TAPVR–> vertical vein –> innominate vein –> SVC
Pathogenesis of IE
formation of small thrombus on abnormal endothelial surface > secondary infection w/bacteria transiently circulating > proliferation of bacteria > vegetations on endothelial surface
2007 changes in prophylaxis for IE?
More likely to get it w/daily activities than procedures. Good oral hygiene more important.
Who gets IE prophylaxis?
prosthetic cardiac valve / material for valve repair
Hx IE
cardiac transplant w/abnormal valves
CHD (unrepaired cyanotic HD, 1st mth after complete repair, repaired but w/residual defect, 1st 6mo after transcatheter device placement)
What procedures merit IE prophylaxis?
Dental procedures involving manipulation of gingival tissues, including routine cleaning
Respiratory/airway procedures: T&A, airway biopsy, bronchoscopy w/biopsy
NOT for GI, GU, orthodontic, vaginal procedures, c-section
What is given for IE prophylaxis
amox or ampicillin 1st line
ADHD meds: initial workup
patient & FH
PE for murmurs, HTN, irregular HR, stigmata of marfan
ECG baseline
What is kawasaki Dz?
idiopathic multisystem dz characterized by vasculitis of small and medium blood vessels including coronary arteries
Predisposing factors to KD?
age around 2.3 yrs, asian american, winter or spring
Diagnostic criteria for KD
R/o other origin
Fever 5+ days (high w/reduced response to antipyretics)
At least for of following: 1) changes in extremities (edema, erythema, desquamation, 2) polymorphous exanthem (typically truncal), 3) conjunctival injection (non purulent), 4) erythema +/- fissuring of lips and oral cavity, 5) cervical LSD
Lab finding supporting KD
Leukocytosis w/left shift mild normocytic, normochromic anemia thrombocytosis >450 Elevated ESR & CRP hypoalbuminemia elevated transaminases sterile pyuria mild hyponatremia
Phases of KD
ACUTE: 1-2w from onset (febrile, toxic appearing; oral changes, rash, erythema)
SUBACUTE: 2-8w from onset (desquamation, gradual improvement even w/o Tx)
CONVALESCENT: months to years (remaining sx resolve, lab criteria normalize)
Signs and Symptoms of KD
Respiratory (rhinorrhea, cough, pulmonary infiltrate)
GI (V/D, abd pain, gallbladder hydrops)
Neurologic (irritability, aseptic meningitis (IVIG))
MS (myositis, arthralgias, arthritis)
KD cardiac changes on EKG
EKG: arrhythmias, abnormal Q waves, prolonged PR and or QTc, low voltages, ST-T wave changes
KD cardiac changes on CXR
cardiomegaly
KD cardiac changes on PE
suggestive of myocarditis (tachy, m/g, CHF), pericarditis (distant heart sounds friction rub, tamponade), valvulitis (murmur, tachy)
When are aneurysms of KD more likely to occur?
8yrs Fever >14 days Male Thrombocytosis Evidence of cardiac involvement on exam (Mitral regurg or pericardial effusion)
Principle cause of death in KD?
MI, most often in 1st year, majority while at rest/sleeping
about 1/3 asymptomatic
Tx KD
IVIG 2g/kg as one time dose
Aspirin: high dose (80-100mg/kg/day div q6h) until afebrile + 48h; Low dose (3-5mg/kg/day) x 6wks or until normalization of acute phase reactants (CRP, ESR, PLT)
*repeat IVIG if failure to respond or recurrent fever after 24h after 1st dose
F/U for KD
lifelong. 6mo-5y depending on risk
What is WPW?
Wolff Parkinson White
abnormal accessory conduction pathways between atria and ventricles - risk for SVT
ECG changes associated w/WPW?
Delta wave, short PR interval, widened QRS complex
WPW associated w/structural HD?
Not usually, but Ebstein anomaly and HCM in some
Risks associated w/WPW
SVT, afib, SCD
Tx for WPW
transcatheter ablation
High risk for SCD w WPW
Male, less than 30 Hx afib Hx syncope Familial WPW CHD
Atypical KD
Less than 4 of 5 Dx criteria
Compatible labs
Coronary aneurysm risk
When is atypical KD more common
Less than 6mo
Older than 10 years
