Peds Cardio Flashcards
fetal circulation pathway of mothers oxygenated blood to fetal heart.
oxygenated blood to placenta via umbilical vein -> inferior vena cava -> right atrium -> foramen ovale to left atrium -> left ventricle -> aorta
Placenta accepts deoxygenated blood from the fetus through _________.
two umbilical arteries
Mother oxygenates the blood and returns it to the placenta to the fetus via _________.
one umbilical vein
What type of cyanosis most concerning?
central > peripheral
If you hear thrill what grade murmur?
4/6 or more
Define thrill
vibratory sensation associated with loud murmur
How does fetal blood bypass lungs and get oxygenated in placenta?
ductus arteriosus connects pulmonary artery to aorta and shunts blood
When and how does ductus arteriosus functionally close?
within 12 hrs of life
due to drop in prostaglandin levels and smooth muscle constriction
Progression from newborns first breaths to closure of foramen ovale and ductus arteriolus
Birth First breath decreased pulmonary resistance increased blood through lungs Increased PO2 tension closure of ductus arteriosus and more flow through the lung
Increased flow to lungs leads to increased flow to L atrium mechanical closure of the foramen ovale
What to do for congenital cyanotic heart disease?
Keep ductus arteriosus patent
Prostaglandins
Lower O2 sats (80-90%)
Trying to maintain high O2 saturations will increase pulmonary perfusion, but kill your baby!!
Define acrocyanosis
Peripheral cyanosis
Central trunk-pink
Benign
central cyanosis
Tongue, mouth, lips-(perioral)
Pathological
pectus excavatum indicates _____.
Marfan Syndrome
splinter hemorrhages, Janeway lesions, Osler Nodes indicate ________.
endocarditis
What may cause thrill? Where?
URSB/suprasternal notch: aortic stenosis
LLSB: VSD
How is normal pulse reported?
2+
1+ diminished, 3+ bounding and hyperactive
How to check perfusion of infant?
press firmly on skin for 5 seconds then release; should refill in < 2 sec
What is grade 6/6 murmur?
murmur heard with stethoscope off chest
What is grade 2/6 murmur?
murmur can be heard by trained ear
types of systolic and diastolic murmurs
systolic: ejection murmurs
diastolic: aortic regurg., Tricuspid or mitral stenosis
What causes artificially lower pulse ox readings?
severe anemia, hypotension, hypothermia, artificial nails or nail polish
How is the hyperoxia test done? Why is it done?
done for cyanotic/low O2 sat infants to determine if the problem is cardiac or pulmonary
breath 100% oxygen for 10 min
improved paO2 and pulse ox -> respiratory defect
no improvement in paO2 or pulse ox -> cardiac defect
Any time you don’t hear an S2 split it is a _______ until proven otherwise.
ASD
How to determine cardiomegaly on chest XR?
CT ratio > 60% in neonate and > 45% in infant or child
CT ratio = cardio/thoracic
EKG most effective for what heart conditions?
dysrhythmias
WPW
What normal kids can appear like LVH?
very thin athletic kids
What is S1 sound?
closure of mitral and tricuspid valves
What is S2 sound?
closure of aortic and pulmonary valves
normal physiological S2 splitting, increases with inspiration
Most common cardiology referral in pediatric patients?
murmurs; 60% not pathologic
mid-systolic vibratory, musical murmur
Stills murmur
When does systolic and diastolic murmurs occur?
systolic btwn S1 and S2
diastolic after S2
Abnormal S2 sounds
fixed: ASD
Single/no split: absence of aorta or pulmonary valve (ex. transposition, truncus, HLHS)
Most common benign pediatric murmurs in each age group: infants, child, adolescence?
newborn: peripheral pulmonary stenosis murmur (PPS)
Infant/child: Stills, Venous Hum
Adolescent: innocent pulmonary ejection murmur
When is murmur pathologic?
Grade 4 or more
Description: systolic-harsh, holosystolic, continuous, diastolic
Fixed sound (no changes with position)
When is murmur benign?
Grade 3 or less
Description: vibratory, twanging, musical
Intensity changes with position
When are congenital heart diseases dx’d?
within first 4 weeks of life
Two broad categories of congenital heart diseases:
acyanotic and cyanotic
Left- to-right diseases
ASD, VSD, PDA
Right-to-left heart diseases
Tetralogy of Fallot
Tricuspid atresia
Eisenmenger syndrome
low pulmonary resistance -> pulls blood to lungs -> pulm HTN -> increase pulm resistance/edema
left-to-right pathophysiology
low pulmonary resistance with higher systemic resistance
Complete congenital obstructions present in infancy/newborn as ______ and need to treat with ________.
shock
prostaglandins
Pearl: memorize 5 T’s and H of cyanotic heart disease using hand
1) Truncus Arteriosus
2) Transposition of great arteries
3) Tricuspid atresia
4) Tetralogy of Fallot
5) Total Anomalous Pulmonary Return
Hypoplastic Left Heart Syndrome
Prophylaxis for bacterial endocarditis required for patients with:
Prosthetic heart valves
H/O infective endocarditis
Dental procedures w/ gums
Congenital heart disease
Bacterial endocarditis prophylaxis treatment for children
amoxicillin 50mg/kg
Major cause of HTN 1-6 yo vs 12-18 yo
1-6 yo: renal and renal vascular disease
12-18 yo: essential HTN
percentile BP of normal, pre-HTN, HTN
Normal < 90
Pre-HTN > or = 90
HTN > 95 (stage 1 95-99 and stage 2 +99)
Most common cause of elevated BP in children
faulty measurement (wrong cuff size)
Red flags of HTN
Think secondary HTN!
- Prepubertal child
- Thin child with negative fhx
- Acute rise in BP above a previously stable baseline
- Severe HTN (Stage 2)
- Diastolic and/or nocturnal HTN
- Abnormal sx’s (chest pain, vision changes, urinary complaints, snoring, weight changes, cold/heat intolerance)
- Abnormal Exam findings (tachycardia, flushing, edema, goiter, rashes, joint effusions, masses, or murmurs)
Reasons for labs/dx testing in child with HTN
all < 12 yo, all with normal BMI
Labs/Dx testing for HTN child that isn’t obese and older than 12yo
UA, CBC, BMP (lytes, BUN/Cr, glucose), Lipid panel, renal u/s with flow dopplers
HTN treatment in child
lifestyle modifications first line: diet, exercise, stop tobacco exposure, family-based intervention
Pharm: ACEs, diuretics, beta blockers
- for stage I (>95%) if unresponsive to 4-6 mon of lifestyle changes
- for most stage II (>99%)
Most common causes of sudden cardiac death
1) HCM = hypertrophic cardiomyopathy (formerly called IHSS)
2) Arrhythmias: Long QT, WPW
How to differentiate athletic heart vs HCM?
HCM autosomal dominant, so get fhx!
HCM: +/- systolic ejection murmur (louder when upright), LVH, Q wave, ST strain
Characteristics of HCM murmur?
systolic ejection murmur
louder when upright
EKG findings of Wolff Parkinson White?
- Short PR interval
- Delta wave
- Widen QRS
Meds that cause long QT
quinolones, macrolides, antipsychotics, TCAs
commotio cordis
direct blow to chest at upstroke of T wave; leads to cardiac arrest
associated with ALCAPA - only true situation where child can have heart attack
How is sudden cardiac death prevented?
Most important is H&P
Trainers & school officials competent in basic CRP
AED devices at schools
Pre-Sports Physicals
AHA guidelines for sports participation
12 ELEMENT H&P
- Exertional chest pain or discomfort
- Presyncope/Syncope
- Unexplained exertional dyspnea or fatigue
- Prior recognition of heart murmur
- Elevated systemic blood pressure
Family history
- Unexpected/Sudden cardiac death
- Disability or early cardiovascular death in relative (< 50 yo)
- Known h/o cardiac anomaly in family member (HCM, Marfan, prolonged QT, etc.)
Physical Exam
- Heart Murmur
- Femoral pulses
- Physical stigmata of Marfan syndrome
- Elevated brachial artery BP when sitting
- Any YES to these, child does NOT play, until seen by cardiology or ECHO
Most common innocent murmur in childhood
Still’s murmur
Describe Still’s murmur
loudest in apex and LSB
musical or vibratory
systolic
diminishes with sitting/standing
Venous hum diminished with what?
turning of head, jugular compression, supine
Describe peripheral pulm stenosis murmur
soft, systolic ejection murmur
well localized to ULSB
When do innocent murmurs Still’s, venous hum, and peripheral pulm stenosis appear?
PPS: newborn
Still’s: 2-8 yo
Venous hum: 3-6 yo
Innocent murmurs are what grade?
Grade I-III
What does squatting from standing do to venous pressure?
squatting from standing -> increase venous return from lower body -> increase SVR -> increase LV filling
Why not increase O2 in cyanotic newborn with non-respiratory cause?
O2 sat will get worse and PDA will close up
PGE1 indication
cyanotic infant that is cardio-related; keep ductus arteriosus open for shunting
Indomethacin indication
close off PDA
Standing decreases intensity of all murmurs except _________ and ________.
HCM and mitral valve prolapse
Continuous murmur in 3 yo that is loudest when sitting. Normal exam.
venous hum murmur
fixed split S2 with increased pulmonary blood flow and pulmonary ejection murmur
ASD
continuous machine-like murmur, wide pulse pressure, tachypnea
PDA
How to treat PDA?
indomethacin
congenital obstruction in heart that’s seen in Turner syndrome.
Aortic coarctation
Congenital condition where femoral pulses are weaker than RIGHT radial and brachial pulses. Also find differential cyanosis with lower pulse ox in lower extremities.
Aortic coarctation
Describe pulses of aortic coarctation in upper and lower extremities
UE: normal or bounding 3+
LE: diminished 1+
How is aortic coarctation treated in newborns? Why?
prostaglandins to keep ductus arteriosus open
Newborn with SOB, cyanosis, and systolic ejection murmur. EKG shows RVH.
pulmonary stenosis
Most congenital cyanotic heart diseases treated with what med? Which you should NOT be treated this way?
prostaglandins to keep DA open
EXCEPT truncus arteriosus (no DA dependence)
Heart defect with single arterial trunk making loud single S2
truncus arteriosus
Heart defect that creates parallel circuits where there is tachypnea with no pulmonary findings
transposition of Great Vessels
Heart defect where there is no flow from RA to RV
tricuspid atresia
4 features of Tetralogy of Fallot
overriding aorta
pulmonary stenosis
VSD
RVH
CXR of Tetralogy of Fallot
boot-shaped (uplifted apex or egg on side)
decreased pulm blood flow
“Tet spell” management
squatting or knee to chest position high flow O2 morphine beta blockers (relax RV) phenylephrine (increase pulm circulation)
pink vs blue tetralogy
pink: mild pulm stenosis; some blood still goes to lungs for oxygenation
blue: severe pulm stenosis; all blood shunted to systemic circulation
How does “Tet spell” occur?
stress (i.e. heat, infection, exercise, acidosis) -> decreased systemic vascular resistance (SVR) -> increased shunting to systemic circulation -> decreased pulm perfusion -> increased cyanosis
Heart abnormality where all 4 pulmonary veins drain into right atria, so oxygenated blood never reaches LA
Total Anomalous Pulmonary Return
Marked hypoplasia of left ventricle and ascending aorta, leading to rapid cariogenic shock
HLHS (hypoplastic left heart syndrome)
How to treat HCM?
pacemaker
avoid isometric activities
genetic syndrome that presents with widened down-slanting eyes, pulmonary stenosis, short stature, and webbed neck.
Noonan syndrome
Fibrillin defect in Marfan syndrome causes what symptoms?
Hypermobile joints, arachnodactyly, pectus deformity, wingspan > height, ectopic lentis
Inheritance of Marfan syndrome
autosomal dominant
What should be monitored in Marfan patient? Why?
ophthalmology (watch for ectopic lentis)
Annual ECHO
Strict BP control
No isometric sports
High risk of aortic aneurysm!!!
Which murmur is loudest in supine position?
Stills
Benign murmur in ped patient that is loudest upright and disappears supine.
Venous hum
Harsh, crescendo murmur that is loudest squatting and softer standing
aortic stenosis
