Review Important physical exam findings for the pediatric patient with a cardiac condition Clinical presentation of these patients Different differential diagnoses Differentiate transitional nursery murmurs vs. pathological murmurs Differentiate acyanotic lesions and associated clinical presentation Understand the clinical presentation of heart failure in pediatric patients Understand the chest pain and Kawasaki Disease Learn how to perform a pre-participation sports physical Transitional nursery murmurs: natural flip from pediatric to normal circulation that happens in babies

Valvular Insufficiency Abnormal ____flow of blood via ineffective/defective valve Turbulence occurs when it meets normal, ____ blood flow causing murmur Congenital Anomaly Atrial or Ventricular _____ defects Blood forced through congenital anomaly from one ____ to another = turbulence = murmur

Backflow (valves aren't closing properly and causes backflow) forward Septal defects (ASD, VSD) chamber

Increased Blood Flow Increased blood flow through a normal valve happens often in high output states: an____, s_____ Large v_____ passes through the cardiac valve, and the normal blood flow is disrupted ____'s murmur is a benign aortic flow murmur frequently heard in childhood that frequently dissappears over time

anemia, sepsis volume Still's example of a flow murmur - literally from too much blood flow

Causes of Systolic Murmur Turbulence caused by ventricular _____ ______ of aortic or pulmonary valve, aorta or pulmonary artery Increased _____ Ticuspid and mitral valve _______ Abnormal ventricular or arterial comm_____ Ventricular ____ defect or _ _ _

outflow Narrowing flow regurgitation Communications VSD, PDA

Causes of Diastolic Murmur Turbulence in ventricular ______ N______ Increased ____ Semilunar (____ and _____) valve regurgitation

inflow Narrowing flow aortic and pulmonary

Causes of Continuous Murmurs Abnormal systemic _____ artery communications Abnormal ar___v____ communications P _ _ (1): abnormal connection of arterial blood flow direct to vein (1): abnormal connection of a coronary artery and heart chamber or blood vessel

pulmonary artery communications arteriovenous communications PDA AV fistula Coronary artery fistula Continuous murmurs kind of rare dt abnormal communication for ex when blood mixes ex) when PDA doesn't close, fistulas

Common Murmurs in the First Few Days of Life Normal (1) Narrowing of pulm arteries in newborns develops in utero = less blood flow to ____ Post partum arteries are narrow until they grow and relax While slightly narrow before growth may hear a _____ Resolves sp______ (1) Transitional (1) Ductus arteriosus is a normal part of fetal blood circulation in _____ is an ____ blood vessel that connects the pulmonary artery to the ____ In utero the ductus arteriosus lets blood ____ the lungs bc oxygen is from the mother (1) Abnormal O_____ obstruction Aortic and Pulmonic _____ C_____ of aorta Abnormal comm_____ V _ _ , _ _ _ (if open for too long)

Normal Peripheral Pulmonary Stenosis lungs murmur spontaneously Pulmonary flow murmur Transitional murmurs Closing PDA utero extra blood vessel, pulm art to aorta bypass the lungs Transient tricuspid regurgitation Abnormal Outflow Stenosis Coarctation communications VSD, PDA Pulm stenosis most often benign but CAN be pathological, on this slide its benign bc baby in utero gets blood from placenta, so pulm arteries are narrow when baby is first born and will resolve when pressure from blood normalizes

Transitional Nursery Murmurs ____ left sternal border or left infra_____ area Systolic or continuous often louder as PDA gets ____ Occasional v_____ Typically 12-48 hrs of age then goes ____ Transient ______ Regurgitation ____ left sternal border regurgitant, systolic takes several days to resolve

Upper LSB, infraclavicular smaller vibratory away Transient Tricuspid Regurgitation Lower LSB

ASD Workup and Treatment Workup = Treatment Spontaneous ____ before 2 years of age possible, ____ based on clinical condition Cardiac c______ placement of closure device ____ heart surgery if Large ASD and/or complext heart anatomy, surgeons use stitches or ______ to close the hole

Refer to Cardiology Echocardiogram (sound waves create an image of the heart) EKG Chest X-ray closure, watchful waiting catheterization Open heart, patches Watchful waiting, usually asymptomatic as long as child is growing, eating, drinking

VSD Workup and Treatment Diagnosis of VSD may require? Treatment for VSD prn to prevent permanent cardiac damage Dependent on Child's ____ S___ of the VSD Watchful _____ to see if VSD will close on its own Many small VSDs will do so before child is __ yrs old Surgical repair may be postponed if possible to allow for ____ and _____ Higher _____ feedings to help with sx and growth

Echo, EKG, chest X-ray, Cardiac cath (could potentially repair via cath), cardiac MRI Tx health Size waiting 2 growth and development (better outcome for surgery) HIGHER CALORIC FEEDINGS

Coarctation of Aorta narrowing of aortic arch adjacent to the site of ductus _____ ejection murmur below left _____ Decreases pulse and BP in lower extremities If severe, causes _______ dt no output Often associated with _____ aortic valve (should be tricuspid)

Systolic, left scapula SHOCK Bicuspid aortic valve

Aortic Valve Stenosis Occurs in 5% of children with CHD May have _____ defect such as coarctation, VSD, or PDA Non obstructive isolated bicuspid aortic valve is the most common congenital defect and even then occurs in 1% of the population (pretty much is very rare) May be valvular, subvalvar or supravalvar Valvar AS usually cases a systolic ejection _____ at the apex (click is not present in most severe cases) Most common presentation is just a murmur BUT If very narrow valvular opening, needs the right to left shunting available through the ____ May present acutely with ____ or CHF if ductus closes Can progress over months Systolic ejection murmur begins in early systole after the click Click helps distinguish it from a pulmonary flow murmur medium to high pitched upper right sternal border to apex radiates to neck May have a _____ in suprasternal notch or ____ arteries area

associated CLICK PDA shock thrill, carotid

Pulmonic Stenosis Systolic ejection murmur _____ left sternal border Radiates to ____ Systolic ejection ____ at LLSB which varies with r_____ May have thrill at suprasternal notch

Upper left sternal border back click, respiration

PDA Presentation Infants and children tend to be completely _____ ___maturity May have pulmonary _____ (blood to lungs) Will present early If going to have pulmonary overcirculation, does so when pulmonary resistance ___ at 4-6 wks Single S2 = pulmonary _____ ____ pulse pressure _____ pulses (waterhammer pulse) - bounding and forceful pulse, rapidly increasing and subsequently collapsing Quinke pulse on finger tips =

asymptomatic prematurity overcirculation falls hypertension wide Bounding visualization of capillary pulsations with light compression to the tip of the fingernail bed

Pediatric Cardiology Flashcards by Felita Salim

Objectives

Review
- Important physical exam findings for the pediatric patient with a cardiac condition
- Clinical presentation of these patients
- Different differential diagnoses
Differentiate transitional nursery murmurs vs. pathological murmurs
Differentiate acyanotic lesions and associated clinical presentation
Understand the clinical presentation of heart failure in pediatric patients
Understand the chest pain and Kawasaki Disease
Learn how to perform a pre-participation sports physical

Transitional nursery murmurs: natural flip from pediatric to normal circulation that happens in babies

How well did you know this?

Not at all

Perfectly

Normal Heart

How well did you know this?

Not at all

Perfectly

Murmurs overview

Murmur sound is caused by?

Caused by disease/malformation of cardiac valves and structures 4 main causes (4)

turbulent blood flow

Valvular Stenosis
Valvular Insufficiency
Congenital anomaly
Increased blood flow

How well did you know this?

Not at all

Perfectly

Valvular Stenosis

Blood flow is forced through ____ area
Turbulent blood flow ensues
Increased stenosis = ______ murmur BUT
Development of heart failure may _____ pressure and turbulent flow; murmur may decrease or dissappear

tight
louder
decrease

How well did you know this?

Not at all

Perfectly

Valvular Insufficiency

Abnormal ____flow of blood via ineffective/defective valve
Turbulence occurs when it meets normal, ____ blood flow causing murmur

Congenital Anomaly

Atrial or Ventricular _____ defects
Blood forced through congenital anomaly from one ____ to another = turbulence = murmur

Backflow (valves aren’t closing properly and causes backflow)
forward
Septal defects (ASD, VSD)
chamber

How well did you know this?

Not at all

Perfectly

Increased Blood Flow

Increased blood flow through a normal valve happens often in high output states: an____, s_____
Large v_____ passes through the cardiac valve, and the normal blood flow is disrupted
____’s murmur is a benign aortic flow murmur frequently heard in childhood that frequently dissappears over time

anemia, sepsis
volume
Still’s
- example of a flow murmur - literally from too much blood flow

How well did you know this?

Not at all

Perfectly

Timing and Grading of Murmurs

Reference Slide

Systolic Murmurs
- Midsystolic (4)
- Holosystolic (2)
- Late systolic (1)
Diastolic Murmurs
- Early diastolic (3)
- Mid late diastolic (2)
- Other rare murmurs (1)
Grading generally the higher the grade =

Aortic stenosis, Pulmonic stenosis, ASD, HOCM
Mitral regurg, Tricuspid regurg, VSD
Mitral valve prolapse
Aortic regurg, Pulmonic regurg, Austin-flint
Mitral stenosis, Tricuspid stenosis
Patent ductus arteriosus
Higher the grade, the louder the murmur

How well did you know this?

Not at all

Perfectly

Where Murmurs are Heard

Reference Slide

Aortic area
Pulmonic area
Left Sternol border
Tricuspid area
Mitral area

Ejection type murmur (Aortic stenosis, flow murmur)
Ejection type murmur (Pulmonic stenosis, flow murmur)
Early diastolic murmur (Aortic regurgitation, Pulmonic regurgitation)
Pansytolic murmur (Tricuspid regurgitation, Ventricular septal defect), Mid to late Diastolic murmur (Tricuspid stenosis, Atrial septal defect
Pansystolic murmur (Mitral regurg), Mid-to late diastolic murmur (Mitral stenosis)

Ex) in mitral area usually a mitral valve issue

How well did you know this?

Not at all

Perfectly

Causes of Systolic Murmur

Turbulence caused by ventricular _____
______ of aortic or pulmonary valve, aorta or pulmonary artery
Increased _____
Ticuspid and mitral valve _______
Abnormal ventricular or arterial comm_____
Ventricular ____ defect or _ _ _

outflow
Narrowing
flow
regurgitation
Communications
VSD, PDA

How well did you know this?

Not at all

Perfectly

Causes of Diastolic Murmur

Turbulence in ventricular ______
N______
Increased ____
Semilunar (____ and _____) valve regurgitation

inflow
Narrowing
flow
aortic and pulmonary

How well did you know this?

Not at all

Perfectly

Causes of Continuous Murmurs

Abnormal systemic _____ artery communications
Abnormal ar___v____ communications
P _ _
(1): abnormal connection of arterial blood flow direct to vein
(1): abnormal connection of a coronary artery and heart chamber or blood vessel

pulmonary artery communications
arteriovenous communications
PDA
AV fistula
Coronary artery fistula

Continuous murmurs kind of rare dt abnormal communication for ex when blood mixes ex) when PDA doesn’t close, fistulas

How well did you know this?

Not at all

Perfectly

Common Murmurs in the First Few Days of Life

Normal
- (1)
  - Narrowing of pulm arteries in newborns develops in utero = less blood flow to ____
  - Post partum arteries are narrow until they grow and relax
  - While slightly narrow before growth may hear a _____
  - Resolves sp______
- (1)
Transitional
- (1)
  - Ductus arteriosus is a normal part of fetal blood circulation in _____
  - is an ____ blood vessel that connects the pulmonary artery to the ____
  - In utero the ductus arteriosus lets blood ____ the lungs bc oxygen is from the mother
- (1)
Abnormal
- O_____ obstruction
- Aortic and Pulmonic _____
- C_____ of aorta
- Abnormal comm_____
- V _ _ , _ _ _ (if open for too long)

Normal
- Peripheral Pulmonary Stenosis
  - lungs
  - murmur
  - spontaneously
- Pulmonary flow murmur
Transitional murmurs
- Closing PDA
  - utero
  - extra blood vessel, pulm art to aorta
  - bypass the lungs
- Transient tricuspid regurgitation
Abnormal
- Outflow
- Stenosis
- Coarctation
- communications
- VSD, PDA

Pulm stenosis most often benign but CAN be pathological, on this slide its benign bc baby in utero gets blood from placenta, so pulm arteries are narrow when baby is first born and will resolve when pressure from blood normalizes

How well did you know this?

Not at all

Perfectly

Transitional Nursery Murmurs

____ left sternal border or left infra_____ area
- Systolic or continuous
- often louder as PDA gets ____
- Occasional v_____
- Typically 12-48 hrs of age then goes ____
Transient ______ Regurgitation
- ____ left sternal border
- regurgitant, systolic
- takes several days to resolve

Upper LSB, infraclavicular
- smaller
- vibratory
- away
Transient Tricuspid Regurgitation
- Lower LSB

How well did you know this?

Not at all

Perfectly

Acyanotic Congenital Heart Disease

No cyanosis, no drop in O2, no blue lips

(2)

(2), (3)

Septal Defect

ASD, VSD

Obstruction to Ventricular Outflow

Valvar, Subvalvular or Supravalvar aortic or pulmonic stenosis

Coarctation (narrowing of aorta)

PDA

How well did you know this?

Not at all

Perfectly

Atrial Septal Defect (ASD)

Systolic ejection murmur
Upper left sternal border
Wide fixed split S2
Right ventricular impulse (p_____ palpation)
Diastolic r_____ at lower left sternal border
do we see CHF?
Subtle _____ intolerance may be noted

palpable palpation
rumble
no
exercise intolerance dt less oxygenated blood getting to body

Blood is mixing, but left side can still pump out blood

How well did you know this?

Not at all

Perfectly

ASD Workup and Treatment

Workup =

Treatment

Spontaneous ____ before 2 years of age possible, ____ based on clinical condition
Cardiac c______ placement of closure device
____ heart surgery if Large ASD and/or complext heart anatomy, surgeons use stitches or ______ to close the hole

Refer to Cardiology
Echocardiogram (sound waves create an image of the heart)
EKG
Chest X-ray
closure, watchful waiting
catheterization
Open heart, patches

Watchful waiting, usually asymptomatic as long as child is growing, eating, drinking

How well did you know this?

Not at all

Perfectly

Ventricular Septal Defect

Holosystolic murmur
H____, ___ pitched if VSD is small
Diastolic rumble at Apex for larger VSD
Will you see CHF?
Increased left arterial pressure
Pulmonary _____
Increased ____ of breathing
____ growth
Can lead to pulmonary ____ if not found

Harsh, high pitched
CHF if VSD is large
Edema
work of breathing
poor growth
pulm HTN

Pulm artery should have deoxygenated blood but its getting mixed w oxygenated blood*
CHF if large bc blood isn’t getting pushed out*
Pulm edema- to the point kids can’t eat while breathing -> poor growth*

How well did you know this?

Not at all

Perfectly

VSD

At birth
- Pulmonary Vascular Resistance __ Systemic Vascular Resistance bc
- Shunt is ___ to ____ or bidirectional
As PVR falls, then ___ to ___ shunt and murmur appears
- Murmur pitch depends on whether right to left or left to right
Diastolic rumble at Apex
- Caused by vibration of the ____ valve
- Large volume of flow from the lungs goes into the left ventricle
- much more likely to be moderate in intensity

At birth

PVR > Systemic vascular resistance
Right to left

PVR falls, then left to rigth shunt and murmur appears

Diastolic rumble at Apex

vibration of mitral valve

How well did you know this?

Not at all

Perfectly

VSD Workup and Treatment

Diagnosis of VSD may require?

Treatment for VSD prn to prevent permanent cardiac damage

Dependent on
- Child’s ____
- S___ of the VSD
- Watchful _____ to see if VSD will close on its own
- Many small VSDs will do so before child is __ yrs old
Surgical repair may be postponed if possible to allow for ____ and _____
Higher _____ feedings to help with sx and growth

Echo, EKG, chest X-ray, Cardiac cath (could potentially repair via cath), cardiac MRI
Tx
- health
- Size
- waiting
- 2
growth and development (better outcome for surgery)
HIGHER CALORIC FEEDINGS

How well did you know this?

Not at all

Perfectly

Coarctation of Aorta

narrowing of aortic arch adjacent to the site of ductus
_____ ejection murmur below left _____
Decreases pulse and BP in lower extremities
If severe, causes _______ dt no output
Often associated with _____ aortic valve (should be tricuspid)

Systolic, left scapula
SHOCK
Bicuspid aortic valve

How well did you know this?

Not at all

Perfectly

Aortic Valve Stenosis

Occurs in 5% of children with CHD
May have _____ defect such as coarctation, VSD, or PDA
Non obstructive isolated bicuspid aortic valve is the most common congenital defect and even then occurs in 1% of the population (pretty much is very rare)
May be valvular, subvalvar or supravalvar
Valvar AS usually cases a systolic ejection _____ at the apex (click is not present in most severe cases)
Most common presentation is just a murmur BUT
- If very narrow valvular opening, needs the right to left shunting available through the ____
- May present acutely with ____ or CHF if ductus closes
Can progress over months
Systolic ejection murmur begins in early systole after the click
- Click helps distinguish it from a pulmonary flow murmur
- medium to high pitched
- upper right sternal border to apex
- radiates to neck
May have a _____ in suprasternal notch or ____ arteries area

associated
CLICK
- PDA
- shock
thrill, carotid

How well did you know this?

Not at all

Perfectly

Pulmonic Stenosis

Systolic ejection murmur
_____ left sternal border
Radiates to ____
Systolic ejection ____ at LLSB which varies with r_____
May have thrill at suprasternal notch

Upper left sternal border
back
click, respiration

How well did you know this?

Not at all

Perfectly

Patent Ductus Arteriosus (PDA)

Blood from (1) into (1), ____ the lungs
Normally closes by __hrs after birth
Shunt direction depends upon the differential resistance between aorta and pulmonary artery
Right to left ductal shunting occurs with severe left heart obstructive lesions
- Severe co______
- _____ (underdeveloped) left heart
- Normally ____ to ____ shunting

right ventricle into descending aorta, bypasses
48
- coarctation
- hypoplastic
- left to right

How well did you know this?

Not at all

Perfectly

PDA Presentation

Infants and children tend to be completely _____
___maturity
May have pulmonary _____ (blood to lungs)
Will present early
If going to have pulmonary overcirculation, does so when pulmonary resistance ___ at 4-6 wks
Single S2 = pulmonary _____
____ pulse pressure
_____ pulses (waterhammer pulse) - bounding and forceful pulse, rapidly increasing and subsequently collapsing
Quinke pulse on finger tips =

asymptomatic
prematurity
overcirculation
falls
hypertension
wide
Bounding
visualization of capillary pulsations with light compression to the tip of the fingernail bed

How well did you know this?

Not at all

Perfectly

Complex Congenital Heart Disease Diagnoses (5) Big bad conditions - will usually cause cyanosis

**Common AV canal (truncus)** **Tetralogy of Fallot** **Hypoplastic left heart** **Transposition of the Great Arteries** **Ebstein's Anomaly of the Tricuspid Valve**

Common AV Canal (truncus) = * Abnormal valves * _____ of blood: backflow to \_\_\_\_\_ * Increased work = _______ of heart * Symptoms (4) * Work up (6) * Treatment =

**Large central septal hole where atria and ventricles meet** * Mixing, lungs * enlargement * Symptoms * Cyanosis * difficulty breathing * poor weight gain and growth * heart murmur * Work up * Echo, EKG, cardiac MRI, cardiac cath, pulse ox, CXR * Tx * 1-2 mths of life * Repair hole

Tetralogy of Fallot ## Footnote **4 Defining Characteristics**

**VSD** **Overriding aorta** **Pulmonary stenosis** **Hypertrophy of R ventricle**

Tetralogy of Fallot ## Footnote Symptoms (3) Workup? Treatment?

* Cyanosis * Heart murmur * Clubbing ECHO, EKG, Pulse ox monitoring, Cardiac MRI, Cardiac Cath Temporary repair then Full patch and opening

Hypoplastic Left Heart (3)

**Mitral valve is atretic** **Aortic valve is atretic** **Left ventricle is very small**

Hypoplastic Left Heart ## Footnote Symptoms (4) Workup Treatment

* Cyanosis * Difficulty breathing * Difficulty feeding * Lethargy (sleepy or unresponsive) ECHO, EKG, pulse ox monitoring, cardiac MRI, cardiac cath **Fatal if untreated, requires open heart surgery to re-direct the oxygen rich blood, post op right side of heart will do what is usually the job of the left side** (will flip the heart, bc less effort/work for the deoxygenated side) EMERGENCY- baby fine at first then all of a sudden will be lethargic

Transposition of the Great Arteries = Symptoms (3)

**Aorta is attached to R ventricle** **Pulmonary artery is attached to L ventricle** Cyanosis Tachypnea Difficulty feeding, poor appetite, poor weight gain

Transposition of the Great Arteries ## Footnote Workup Treatment

ECHO, EKG, Pulse Ox monitoring, Cardiac MRI, Cardiac Cath * 1/3 of newborns with TGA have **extreme hypoxia at birth** * Requires **urgent intervetion** = balloon atrial septostomy (BAS) * BAS creates or enlarges a hole between to allow blood to mix (temp fix just to oxygenate)

TGA Surgery: Arterial Switch Operation ## Footnote * Happens in _____ of birth * Reconstruct the heart * Attach the aorta to the (1) * Attach the pulmonary artery to the (1)

* days * L ventricle * R ventricle Later need 3 surgeries

Ebstein's Anomaly of Tricuspid Valve ## Footnote Description * Caused by malformation of a _____ in utero * 1-3 ______ missing/malformed * R atrium may be _____ and R ventricle \_\_\_\_ * Blood "leaks" back into (1) bc valve doesn't _____ completely * Severe cases may cause? * Some may have ASD * Some may have _ \_ _ and associate arrhythmias

* Valve * leaflets * enlarged, small * R atrium, close * heart failure * WPW ## Footnote Malformation of tricuspid valve - usually 3 leaflets hence tricuspid but could not have all three leaflets -\> backflow bc valve doesn't close properly may have wolfe-parkinson's syndrome

Ebstein's Anomaly of Tricuspid Valve ## Footnote Workup Treatment * If mild = * Severe = * WPW =

ECHO, EKG, Exercise Chest, Chest-X ray, Cardiac Cath less common * none * surgery to repair valve * ablation

Acute CHF in Children ## Footnote * End organ hypoperfusion causes symptoms * Decreased blood flow to \_\_\_\_\_ * Renin/angiotensin based salt and water _____ and increased circulating v\_\_\_\_\_ * **Results in \_\_\_\_\_** * Decreased perfusion to _____ -\> pallor and mottling, diaphoresis during feeding, due to catecholamine release * Increased systemic vascular resistance -\> increased myocardial ____ causing _____ or dilation

* Hypoperfusion * kidney * retention, volume * **edema** * skin * demand -\> hypertrophy

Causes of CHF in Children Contractility Reduction **Primary Cardiomyopathy** (3) **Secondary Cardiomyopathy** (3) **Inflammatory** (3) **Traumatic** (2)

* Types: dilated, hypertrophic, restrictive * Myocarditis, MI, Arrhythmogenic (complete heart block w bradycardia, SVT, or VT) * Kawasaki disease, Systemic Lupus, MIS-C with COVID (multisystem inflammatory syndrome) * Cardiac Tamponade, Myocardial contusion

Hypertrophic Cardiomyopathy ## Footnote * May have bi\_\_\_\_\_ outflow tract ______ in infancy * Older children are \_\_\_\_\_\_\_\_ * May have murmur * \_\_\_\_\_may be diminished as ventricular ejection is impeded * How to listen to the murmur? * MURMUR WILL greatly ______ IN INTENSITY as child stands

* biventricular, obstruction * Asymptomatic * Pulse * **squatting then stand** * **INCREASE**

Hypertrophic Cardiomyopathy ## Footnote Maneuvers that _increase_ the intensity and duration of the murmur * ______ preload - Strain of Valsalva * _____ contractility - Exercise * _____ afterload - stand suddenly Maneuvers that will _decrease_ the intensity and duration of the murmur * ______ afterload - squat or hand grasp * _____ preload - raise legs

* Decrease * Increase * Decrease * Increase * Increase

CHF History Findings ## Footnote Infant, Child, or Adolescent? 1. Decreased exercise capacity, fatigability, SOB, weight gain or loss 2. Poor weight gain, Cachexia, Malnutrition, Sweating when feeding 3. Fatigue, cold intolerance, exercise intolerance, syncope, dizziness

1. Child 2. Infant 3. Adolescent Syncope and dizziness are red flags Weight gain or loss (gain may be cuz activity intolerance)

CHF PE Findings ## Footnote * First sign + \_\_\_\_\_\_\_ * Infant heart is ____ and less distensible so they increase rate as they cannot stroke volume * Tachy\_\_\_\_ * Hepato\_\_\_\_ * Ed\_\_\_\_ * As\_\_\_\_\_ * Diminished per\_\_\_\_\_ * Pedal edema and neck vein distention are \_\_\_\_ * Listen for g\_\_\_\_\_\_

* Tachycardia * stiffer * Tachypnea * Hepatomegaly * Edema * Ascites * perfusion * rare * gallop

Chest Pain in Children ## Footnote Some Differential Dx include (6)

Musculoskeletal Pain Respiratory Conditions Psychogenic Disturbances Gastrointestinal Disorders Cardiac Disease Idiopathic = 20-45% in some studies *in order of prevalence bc most of the time is MSK then resp conditions*

Chest Pain - Common MSK Causes (3)

Strain of chest wall muscles ## Footnote New exercise, new activity, wrestling, heavy books, backpacks Chest wall trauma Bruise, fracture Costochondritis tenderness on palpation, worse with breathing, persistent

Chest Pain: Respiratory Causes (4)

Overuse of chest wall musculature from ## Footnote Persistent cough, asthma, PNA, new exercise Spontaneous pneumothorax Pulmonary emoblism Pleuritic pain/cough/back pain, hemoptysis, more common w h/o leg trauma Infection Fever and Dyspnea (PNA, bronchitis, COVID)

Chest Pain - Psychogenic Origin ## Footnote * **\_\_\_\_\_ common in males and females\*** * ______ may not be readily apparent * _____ history of anxiety, \_\_\_\_\_\_ * S\_\_\_\_\_ history * Family member/friend with chest pain as presenting sx of cardiac disease

* **Equally** * Anxiety * Family, depression * Social

Chest Pain - GI Origin ## Footnote * R\_\_\_\_\_/Es\_\_\_\_\_\_ * ______ body * Hiatal \_\_\_\_\_\_ * Sub-diaphragmatic ab\_\_\_\_\_\_

* Reflux, Esophagitis * Foreign body * hernia * abscess

Chest Pain - Cardiac Origin ## Footnote * Previously undiagnosed cardiac disease is \_\_\_\_\_\_ * Myocardial ischemia = ______ anomalies * K\_\_\_\_\_\_\_ Disease * ______ and other drug abuse * Arr\_\_\_\_\_\_ * Hypertrophic \_\_\_\_\_\_\_ * ______ Syndrome * Peri\_\_\_\_\_\_

* rare * coronary * Kawasaki * Cocaine * Arrhythmia * cardiomyopathy * Marfan * Pericarditis

Chest Pain: Myocardial Ischemia ## Footnote * _____ in children * Suspect if known history of coronary disease (2) * ______ of coronary arteries * P\_\_\_\_\_\_ sensation _+_ b\_\_\_\_\_\_ * ______ to neck, shoulder or arm * Occurs during or following \_\_\_\_\_\_\*\* * Improves with \_\_\_\_\_

* Rare * Kawasaki, Transposition of Great arteries * Anomalies * Pressure, burning * Radiation * exercise * rest

Chest Pain - Aortic Dissection ## Footnote * Pain is typically acute and sharp * Present where? (2) * Depends on the area of the aorta affected * Medical and surgical \_\_\_\_\_\_! * Suspect in patients with what diagnosis? * Autosomal \_\_\_\_ * Disorder of f\_\_\_\_\_ * Chromosome \_\_\_, _____ gene * May also occur in (1) syndrome (connective tissue dx)

* anterior chest or back * EMERGENCY! (bc basically bleed out in themselves) * Marfan Syndrome or Marfan body habitus * dominant * fibrillin * 15, FBN1 gene * Ehlers-Danlos Syndrome

Chest Pain - Pericarditis ## Footnote * May cause severe sub\_\_\_\_\_ chest pain * Described as s\_\_\_\_\_ or t\_\_\_\_\_ * Respiratory \_\_\_\_\_, C _ \_ * Precordial "\_\_\_\_" or ____ (like the sound of shoes walking on snow) * Classic signs include * exercise \_\_\_\_\_, fatigue * ______ distension * lower extremity \_\_\_\_\_ * hepato\_\_\_\_ * poor distal \_\_\_\_\_ * ______ heart tones * pulsus \_\_\_\_\_ * Pain worsens with movement, including \_\_\_\_\_\_\_ * Patients prefer to lean \_\_\_\_\_, may refuse to lie down * Pain is ______ by sternal pressure * Consider in post - ___ cardiac pts * Pericardial Effusion * Usually a friction rub if small or no effusion * if large effusion, no rub but distant/m\_\_\_\_ heart sounds * **t\_\_\_\_\_\_\_**

* substernal * squeezing, tightening * distress, CHF * "knock", rub * intolerance * jugular * edema * hepatomegaly * pulses * diminished * paradoxus * breathing * forward * reproducible * post-op * muffled * **tamponade**

Chest Pain Work-Up ## Footnote * _____ if MSK * ____ if cardiac concern * Exercise, palpitation * ____ if respiratory suspected * fever, cough, dyspnea * _____ is generally not indicated unless * rub * family hx of hypertrophic cardiomyopathy * congenital heart disease

* None * EKG * Chest radiograph * Echocardiogram ## Footnote If needs echo probably will refer to cardiologist

Chest Pain - When to Refer ## Footnote * Chest pain with or after \_\_\_\_\_ * Chest pain with or near \_\_\_\_\_ * Chest pain in pt with _____ cardiac _____ or hx of cardiac \_\_\_\_\_\_ * A\_\_\_\_\_, S\_\_\_\_\_ onset * ______ Syndrome

* exercise * syncope * previous cardiac disease or hx of cardiac surgery * Acute, sudden * Marfan

Marfan Syndrome Criteria (FYIs) ## Footnote Congenital ______ Tissue Disorder Ghent diagnostic criteria for marfan syndrome was revised and includes any of the following

Connective

Marfan Syndrome Systemic Criteria (FYIs)

Marfan Syndrome Craniofacial Features ## Footnote * Criteria for Marfan Syndrome = ___ of following Craniofacial features * Dolichocephaly * Downward-slanting palpebral fissures * Enopthalmos, retrognathia, and malar hypoplasia * Skin straie * Myopia * Mitral valve prolapse

Pre-Participation Sports Physica and Cardiac Problems Cardiac Causes of Sudden Death * Vary with Age: Younger than ___ years * \_\_\_\_\_\_\_\_ * Hypertrophic cardiomyopathy * Coronary anomalies * Aortic stenosis * Arrhythmia (WPW, long QT syndrome, etc * \_\_\_\_\_\_\_ * Myocarditis * Dilated Cardiomyopathy * Coronary Artery Disease * \_\_\_\_\_\_\_ * Commotio cordis (cardiac concussion)

* 35 * Congenital * Acquired * Trauma FAM HISTORY\*

Non-Cardiac: Causes of Sudden Death ## Footnote * Cerebral \_\_\_\_\_\_ * _____ Cell Disease * Bronchial \_\_\_\_\_\_ * ___ use (cocaine, amphetamines) * Unknown

* Aneurysm * Sickle * Asthma * Drug * Unknown

AHA Recommendations for Sports Physical ## Footnote Targeted History and Physical Exam * Identify (or raise suspicion of) ______ lesions known to cause sudden death in young athletes in all high school and college aged participants prior to training * Repeat full _____ every 2 years * Interval History and _ \_ yearly

* cardiovascular * history every 2 yrs * BP yearly

AHA 14 Point Pre-participation Recommendations ## Footnote 1. Chest ____ or pressure related to exertion 2. Unexplained s\_\_\_\_\_ or presyncope 3. Dy\_\_\_\_\_, fa\_\_\_\_\_\_, or pal\_\_\_\_\_ related to exercise 4. History of a heart \_\_\_\_\_ 5. Elevated _ \_ 6. Previous _____ from sports 7. Previous cardiac \_\_\_\_\_\_ 8. Family history of premature d\_\_\_\_\_ 9. Family history of dis\_\_\_\_\_ from heart disease 10. Family hx of hypertrophic or dilated \_\_\_\_\_\_, long __ syndrome, or other iron ch\_\_\_\_\_opathies, M\_\_\_\_\_ syndrome, significant arr\_\_\_\_\_, or specific gen\_\_\_\_ cardiac conditions 11. Heart _____ on examination 12. Feel the _____ pulses for aortic coarctation 13. Physical examination findings consistent with M\_\_\_\_\_ syndrome 14. _____ artery blood pressure (both arms)

1. pain 2. syncope 3. Dyspnea, fatigue, palpitations 4. murmur 5. BP 6. restrictions 7. testing 8. deaeth 9. disability 10. cardiomyopathy, QT, channelopathies, Marfan, arrhythmia, genetic 11. murmur 12. femoral 13. Marfan 14. Brachial

Expectations of Screening ## Footnote * Even the Best H and P won't detect everything! * Should Detect: * (1) - systolic ejection murmur * (1) - physical stigmata * May Not Detect: * Hy\_\_\_\_\_ \_\_\_\_\_\_ * ______ Artery \_\_\_\_\_\_ * Others

* Aortic Stenosis * Marfan's * Hypertrophic Cardiomyopathy * Coronary Artery Anomalies

The Athlete With Symptoms ## Footnote * Symptoms During Exercise Should be Evaluated Thoroughly * Chest pain or \_\_\_\_\_ * Palpitation or _____ Heart Beat * Syncope is _____ normal during exercise * Refer to a trained \_\_\_\_\_\_ * H/P * 12 lead ECG * Exercise ____ test * Echo

* tightness * Irregular * NEVER * Specialist * exercise stress test

"ITIS" and Infection Myocarditis = * _____ infection of the myocardium (e.g viral myocarditis) * ____ production (e.g diphtheria) * Immune response as a delayed sequela of an infection * \_\_\_viral or postinfectious myocarditis * Common type of myocarditis is acute _____ fever (ARF)

Inflammatory disease of the myocardium * Direct * Toxin * Delayed sequela * Postviral * Acute rheumatic fever

Acute Rheumatic Fever: Jones Criteria Revised 2015 ## Footnote * **(1)** * ****Clinical and/or subclinical traits * Seen on echo * Monoarthritis, polyarthritis and/or polyarthralgia * Chorea = * Erythema marginatum * Subcutaneous nodules * **(1)** * ****Prolonged PR interval * Monoarthralgia * Temp _\>_ 38C * Peak ESR _\>_ 30mm in 1 h and/or CRP _\>_ 3.0mg/dL

* **Major Criteria** * ****Chorea = jerky, involuntary movements * **Minor Criteria** * ****has to do with inflammatory markers

Endocarditis ## Footnote **= An infection of the endothelial ____ of the heart, with a propensity for the \_\_\_\_** * Increased risk in children with ____ valves and patches, and patients with ____ lines * 90% of cases are caused by **(1)** * ****Alpha strep, *\_\_\_\_ aureus,* pneumococcus, group A B hemolytic streptrococci * Clinical Features * F\_\_\_\_ * \_\_\_cardia, CHG, dys\_\_\_\_, cardiogenic \_\_\_\_ * History of recent cardiac ____ or indwelling vascular \_\_\_\_ * Heart \_\_\_\_ * P\_\_\_\_, septic em\_\_\_\_ dt DIC, splen\_\_\_\_\_\_

**infection of endothelial surface of the heart, propensity for the valves** * artificial valves, patches, central lines * **Gram positive cocci** * *****staph* * Clinical features * Fever * Tachycardia, dysrhythmia, shock * surgery, indwelling vascular catheter * murmur * Petechiae, septic emboli, splenomegaly *SEPTIC, in shock, hospitalized, super sick*

Kawasaki Disease = * Medium vessel vasc\_\_\_\_ * _____ etiology - toxin mediated? * Affects infants and children * Vasculitis = propensity for coronary _____ (develop in 20% if untreated) * May cause subsequently scar, resulting in coronary artery st\_\_\_\_\_ (early onset coronary artery disease) * Coronary artery th\_\_\_\_\_ and myocardial \_\_\_\_\_\_ * Myocarditis, dys\_\_\_\_\_\_ * Treatment (2)

Mucocutaneous Lymph Node Syndrome * **Vasculitis** * Unclear * aneurysms * stenosis * **thrombosis, infarction** * dysrhythmia * **IVIG, Aspirin if plts \> 1 million** * Platelets go up -\> thrombosis and MI* * Usually don't give aspirin to children dt reyes but don't want them to clot*

Kawasaki Disease ## Footnote Diagnostic Criteria * Fever \> __ days * Plus 4/5 of * Non-purulent c\_\_\_\_\_ * Oral _____ changes * Red fissured lips * _____ tongue * Phar\_\_\_\_\_ * Extremity changes ie \_\_\_\_\_ * Swelling or peeling * R\_\_\_\_\_ - often nonspecific, perineal in many * Cervical adenopathy

* Fever \> 5 days * + 4 out of 5 * Conjunctivitis * mucosal * Strawberry * Pharyngitis * edema * Rash

Prolonged QT ## Footnote 10% present with s\_\_\_\_\_ 15% of pts with prolonged QTc ___ during their first episode of arrhythmia 30% of deaths occur during the ____ year of life

seizures die first A lot of times we don't know they have it

Critical Concepts ## Footnote Consider (1) in all patients presenting with brief nonspecific changes in LOC Fainting, syncope, seizures, breath-holding, apparent (1) events * *Take home message* * *\_\_\_\_ murmurs go away* * *\_\_\_\_\_ may not pick it up, _____ bad need immediate intervention* * *\_\_\_\_ murmurs bad, ___ murmurs less bad*

cardiac arrhythmias life-threatening events * *Flow* * *Acyanotic, Cyanotic* * *Loud, quiet*