Pediatric Cardiology Flashcards
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
Normal Heart
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
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
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
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
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
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)
-
(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)
-
(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
-
Peripheral Pulmonary Stenosis
-
Transitional murmurs
-
Closing PDA
- utero
- extra blood vessel, pulm art to aorta
- bypass the lungs
- Transient tricuspid regurgitation
-
Closing PDA
-
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
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
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
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
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*
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
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
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
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
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
4 Defining Characteristics
VSD
Overriding aorta
Pulmonary stenosis
Hypertrophy of R ventricle
Tetralogy of Fallot
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
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
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
- 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
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
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
Marfan Syndrome Criteria (FYIs)
Congenital ______ Tissue Disorder
Ghent diagnostic criteria for marfan syndrome was revised and includes any of the following
Connective
Marfan Syndrome Systemic Criteria (FYIs)
Kawasaki Disease
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
- 4 out of 5
