Pediatric Cardiology Flashcards by Clyde Silverio

[Fetal Circulation]

Trace the flow of oxygenated blood

Placenta
IVC
RA
FO
LA
LV
Ascending aorta

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[Fetal Circulation]

Trace the flow of deoxygenated blood

IVC
RA
Tricuspid Valve
RV
Pulmonary artery
Ductus arteriosis
Descending aorta
Lower part of the body
2 umbilical arteries

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[Fetal Circulation]

Unique features in fetal circulation

Ductus venosus
Foramen Ovale
Ductus arteriosus

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Fetal cardiac output highly depends on ___

SV can be increased

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[Fetal Circulation]

What are the effect of interrupting the umbilical cord?

Increase SVR

2. Closure of ductus venosus

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[Fetal Circulation]

Lung expansion results in____

Reduction of the PVR
Functional closure of the FO due to increased pressure in the LA
Closure of PDA as a result of increased arterial O2 saturation

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Functional closure of the ductus arteriosus occurs by ____

Constriction of the medial, smooth muscle in the ductus within 10-15 hours after birth

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The anatomic closure of ductus arteriosus is completed by ____

2-3 weeks

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[Fetal Circulation]

Effect of removing the placenta in SVR

SVR increases

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[Fetal Circulation]

the closure of PDA is dependent of

Low O2 and High prostaglandins

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What is the strongest stimulus for contraction of the ductal smooth muscles in the ductus arteriosus?

Post natal increase in O2 saturation

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[Murmur]

Systolic ejection or blowing murmur are best heard on the ___

base or at the 2nd ICS through stenotic strucutres

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[Murmur]

Systolic regurgitant murmur is best heard in ____

apex or at the left lower sternal border

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PDA persisting beyond ____ life in a term infant rarely closes spontaneously or with pharmacologic intervention

1st week of life

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[Congenital Heart Disease]

What are your Acyanotic Heart Disease

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[Congenital Heart Disease]

What are examples of cyanotic heart disease with decreased pulmonary blood flow?

Pulmonary atresia
Pulmonary stenosis
TOF
Tricuspid atresia
Ebstein anomaly

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[Congenital Heart Disease]

What are examples of cyanotic heart disease with increased pulmonary blood flow?

TOGA
TAPVR
TA

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What is the most common type of ASD?

Ostium seccundum

which is present at the site of fossa ovalis

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[Congenital Heart Disease]

Acyanotic
Systolic ejection murmur
2nd LICS
Widely split S2

Right sided enlargement

ASD

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[Congenital Heart Disease]

Acyanotic
Systolic regurgitant murmur at LLSB
Loud and single S2

Left sided enlargement; biventricular hypertrophy if Eisenmenger Syndrome

VSD

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[Congenital Heart Disease]

Acyanotic

Continuous “machinery-like” at 2nd left infraclavicular area

Bounding pulses
Wide pulse pressure
Left-sided enlargement
Enlarged aorta

PDA

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Most common cyanotic heart disease

TGA

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What are the various mechanisms of hypoxic spell?

Increase SVR
RVOT obstruction
Decrease pulmonary blood flow, pO2, pH, pCO2
Increase SVR

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[Management of Hypoxic Spell]

How will you manage RVOT obstruction?

Propranolol

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[Management of Hypoxic Spell] How will you address systemic venous return?

Knee Chest Position

[Management of Hypoxia Spell] How will you address Increased systemic vascular resistance?

Vasoconstrictor

[Management of Hypoxic Spell] How will you address hyperpnea or hyperventilation?

Morphine

[Management of Hypoxic Spell] How will you address the decreased pBF, pO2, acidic pH

O2, NaHCO3

What is the dose of morphine sulfate to suppress the respiratory center?

0.2mg/kg/dose SC

[Treatment for TOF] Used to vasoconstrict and increase SVR

1. Phenyephrine 0.02 mg/kg IV Ketamine 1-3mg/kgIV over 60s increases SVR

[Treatment for TOF] stabilize vascular reactivity of the arteries preventing a sudden decrease in SVR

Propranolol 0.01-0.25 mg/kg

Surgical technique to augment pulmonary blood flow

Blalock-Taussig Shunt

(Not 2DE), method to distinguish CHD from pulmonary disease

Hyperoxia tes

How will you perform hyperoxia test?

100% FiO2 for 10-15 minutes

heart diseases associated with this syndrome Down

Endocardial Cushion Defect

heart diseases associated with this syndrome Marfan

MVP, Progressive enlargement of the aorta

heart diseases associated with this syndrome Hunter Syndrome

thickening of cardiac valves

heart diseases associated with this syndrome Noonan

Pulmonary stenosis 1. Facial anomalies 2. Short stature 3. Webbed neck 4. Chest deformities 5. Undescended testes 6. Pulmonary stenosis

[Diagnosis] Cyanosis manifesting within few hours at birth or within few days of life

TGA

[Diagnosis] Cyanosis manifesting after the first year of life, usually in an infant or a toddler

TOF

What are the heart defects that permit mixing of the 2 circulations for survival

1. ASD 2. VSD 3. PDA

What is the most common cause of cyanotic CH in newbornd

TGA Unresponsive to oxygen inhalation

What is the pathognomonic CXR finding of TGA

Egg-shaped cardiac sillouette with a narrow superior mediastinum

What are the components of tricuspid atresia?

1. Atretic TV 2. Hypoplastic RV 3. VSD 4. ASD 5. Pulmonary stenosis

What are the components of truncus arteriosos?

1. Pulmonary arteries arise from aorta 2. Truncal valve overrides the VSD 3. VSD, large

Most commonly associated congenital heart defect in Turner Syndrome/

CoA

How does CoA appear on X-ray?

1. Rib notching in children around 7 years old

Treatment of choice for neonates with severe CoA

PGE1 to reopen ductus

[Diagnosis] Weak or absent femoral pulses BP arms > legs Rib notching

CoA Tx: Primary anastomosis or patch aortoplasty

[Diagnosis] Systolic ejection murmur at LUSB with radiation to the upper back

Pulmonic stenosis Brock Procedure (balloon valvuloplasty)

[Diagnosis] Systolic ejection murmur at RUSB

Aortic stenosis

[Diagnosis: CXR Findings] boot-shaped heart / Coeur en sabot

TOF

[Diagnosis: CXR Findings] | Egg on string

TGA

[Diagnosis: CXR Findings] Snowman

TAPVR

[Diagnosis: CXR Findings] Figure of 8

TAPVR

[Diagnosis: CXR Findings] Rib notching

CoA

[Diagnosis: CXR Findings] Inverted E

CoA

[Diagnosis: CXR Findings] 3 sign

CoA

[Diagnosis] Child, exercise intolerance, easy fatigability late systolic murmur with an opening click

MVP

[Diagnosis] Child, exercise intolerance, easy fatigability Disparity in pulsation and BP in the arms and legs Weak popliteal, posterior tibial, and dorsalis pedis

CoA

[Diagnosis] Child, exercise intolerance, easy fatigability S2 widely split and fixed

ASD

[Diagnosis] Child, exercise intolerance, easy fatigability loud, harsh, blowing systolic murmur

VSD

[Diagnosis] Child, exercise intolerance, easy fatigability Wide pulse pressure, bounding peripheral arterial pulses, continuous murmur

PDA

[Diagnosis: Indication of Surgical Procedure] Blalock-Taussig Shunt with GoreTex Conduit

TOF

[Diagnosis: Indication of Surgical Procedure] Rashkind artrial septostomy

TGA

[Diagnosis: Indication of Surgical Procedure] Jantene arterial switch

TGA

[Diagnosis: Indication of Surgical Procedure] Senning ang mustart

TGA

[Diagnosis: Indication of Surgical Procedure] Fontan Procedure

[Diagnosis: Indication of Surgical Procedure] Norwood procedure

Hypoplastic Left Heart Syndrome

[Diagnosis: Indication of Surgical Procedure] Glenn anatomosis

Hypoplastic left Heart syndrome

[Diagnosis] RV pumping blood to the the lungs and out of the body via patent PDA

Hypoplastic Left Heart Syndrome

[Associated Heart Disease] Rubella

PDA

[Associated Heart Disease] DM

TGA

[Associated Heart Disease] Lupus

Complete heart block

[Associated Heart Disease] Aspirin

persistent pulmonary hypertension

[Associated Heart Disease] lcohol

1. VSD | 2. PS

[Associated Heart Disease] Lithium

Ebstein anomaly Tricuspid valve is displaced toward the apex

What are the major components of the Jones Criteria?

1. Joints/Polyarthritis 2. Carditis 3. Nodules, subcutaneous 4. Erythema marginatum 5. Syndeham chorea

What are the minor components of the Jones Criteria

1. Fever 2. RHD/RH previously 3. Arthralgia 4. Prolonged PR interval on ECG 5. Elevated acute phase reactants: EST/CRP/Leukocytosis

What is the most consistent feature of ARF?

Valvulitis

In RF, erythema marginatum spares what part of the body?

Face Nonpruritic serpiginous or annular erythematois evanescent rash prominent on the trunk and inner proximal portions of the extremities

[RF] ___ spontaneous purposeless movements followed by motor weakness

syndeham chorea

What is the set point fever for high risk patients with RF?

>38 deg C Low rislk, >38.5 deg C

ASO titers become elevated ___ weeks after strep infection

2 weeks Peaks at 4-6 weeks

What are the criteria to demonstrate evidence of preceding strep infection?

1. Increased or rising ASO or anti-DNAse B 2. Positive throat culture for GABHS 3. Positive rapid group A strep carbohydrate antige

What is the criteria to diagnose initial ARF?

1. >2 major manifestations | 2. 1 Major plus 2 minor manifestations

What is the criteria to diagnose recurrent RF?

Reliable history of ARF or established RHD 1. 2 major 2. 1 major + 2 minor 3. 3 minor

What is the DOC for for acute RF?

1. Oral Penicillin or Erythromycin x 10 dyas | 2. Single IM injection of benzathin penicillin

What are the drugs used to eradicate Streptococcus?

1. Penicillin VK 200-500mg QID x 10 days 2. Benzathine PCN 0.6-1.2 MU IM 3. Erythromycin 250mg TID x 10 days

What is the secondary prophylaxos for RF?

1. Pen VK 250mg BID PO | 2. Benzathin PCN 0.6-1.2 MU IM q 21 days

[Duration of prophylaxis for ARF] RF without carditis

5 year or until 21 years of age

[Duration of prophylaxis for ARF] RF with carditis but no residual heart disease

10 years or until 21 years old

[Duration of prophylaxis for ARF] RF with carditis and residual HD

10 years or until 40 years of age

What are the causative agents in Infective Endocarditis?

1. Viridans streptococci | 2. S. aureus

What is the echocardiographic finding in IE?

1. Oscillating mass vegetations 2 Regurgitant flow near a prostheisis 3. abscess 4. partial dehiscence of proshetic valve, new valve regurgitant

How will you collect samples for blood culture if you suspect IE?

1. 2 separate sites 12 hours apart | 2. 3 or more 1 hour apart

What are the minor criteria in IE?

1. Fever 2. Predisposing condition 3. Vascular 4. Immunologic 5. Microbiological evidence 6. Echocardiographical

[PE in IE] linear lesions beneath the nails

Splinter hemorrhages

[PE in IE] painless small erythematous hemorrhagic lesions on the palms and soles

Janeway lesions

[PE in IE] Tender, pea-sized intradermal nodules in the pads of fingers and toes

Osler nodes

What antibiotics will you give after a dental procedure with manipulation of the gingiva Patient allergic to amoxicillin

Clindamycin 600mg orally 30-60 minutes before the procedure

[Murmurs] Characteristics of innocent murmur

1. Soft 2. Systolic 3. Short 4. Musical/vibratory 5. Symptomless 6. Normal diagnostics

[Murmurs: Innocent or pathologic] Grade I to grade II sternal border soft systolic

Innocent

[Murmurs] Characteristics of pathologic murmur

1. Diastolic 2. Pancystolic 3. Late systolic 4. Continuous 5. Thrill

[Murmurs: Grades] Loud but no thrill

Grade III

[Murmurs: Grades] Loud, with thrill

Grade IV

[Murmurs: Grades] Thrill and audible with edge of the stethoscope

Grage V

[Murmurs: Grades] Thrill and audible with stethoscope just off the chest

Grade VI

[Infective endocarditis: organism] Normal person No underlying disease

Staphylococcus

[Infective endocarditis: organism] Underlying heart disease Dental procedure

viridans Streptococcus

[Infective endocarditis: organism] Gut or lower bowel manipulation

Group D streptococcus

[Infective endocarditis: organism] after an open heart procedure

fungal

[Infective endocarditis: organism] IV drug abusers

1. Staphylococcus and | 2. Pseudomonas

[Infective endocarditis: organism] + CVP + Prosthetic valves

Coagulase negative staph

[Diagnosis] Child with fever, arthralgia, myalgia, acutely ill looking new heart murmur Organism?

staphylococcus aureus

[Diagnosis] Child, known CHD, fever, fatigue, weight loss, painful skin lesions on the finger poor oral hygiene

viridans streptococcus

[Diagnosis] Child, known CHD, fever, fatigue, weight loss, painful skin lesions on the finger underwent root canal treatment

viridans streptococcus

[Diagnosis] Child, known CHD, fever, fatigue, weight loss, painful skin lesions on the finger recent repair of VSD

fungal

[Diagnosis] Child, known CHD, fever, fatigue, weight loss, painful skin lesions on the finger IV drug user

pseudomonas

Fishmouth buttonhole deformity

Mitral valve stenosis

What are the consequences of Mitral Stenosis?

LA MV LV 1. LA enlargement 2. Increased LA pressure 3. Pulmonary congestion 4. Pulmonary HPN 5. AF

How to differentiate VSD and MR since both have systolic regurgitant type of murmur

1. VSD - no transcmission to LAAL | 2. MR - with transmission to LAAL

[Diagnose] High pitched diastolic murmur loudest at 3rd to 4th LICS, more audible when sitting and leaning forward

Aortic Regurgitation 1. Diastolic thrill at 3rd LICS 2. Hyperdynamic precordium 3. Bounding water hammer puls 4. Wide pulse pressure