Peds Cardiology (Exam 4) Flashcards
What is an innocent heart murmur?
One that occurs in the absence of anatomic or physiological abnormalities of the heart or circulation
Roughly ___ of kids will have a murmur at some point
50%
What are the 6 types of innocent murmurs?
- New born murmurs
- Vibratory systolic murmur (Still’s murmur)
- mc- L sternal boader/apex - Venous hum
- Pulmonary systolic murmur
- Peripheral pulmonic systolic murmur
- Supraclavicular systolic murmur
What useful HPI concerns for a murmur?
- Easily fatigable, including difficulty w/ feeding
- disinterest, diaphoresis, change in resp patterns, cynaosis
- Claudication
- Sx that worsen w/ exertion (feeding)!!
- Syncope (Babies passing out is never a good thing!)
- Sig. Fam hx
- CP IS NOT USEFUL
What are concerning PE findings with murmurs?
- Falling off growth charts
- Unequal pulses/pressures
- Hyperactive precordium, displaced PMI
- Murmur itself (diastolic or continuous, Grade IV+)
What type of murmur is almost always abnormal?
Diastolic
Are lab studies necessary in dx a peds murmur?
No if asymptomatic- It adds practically nothing to the initial evaluation of an asymptomatic kid with a murmur (refer to peds cardiology)
When do you need to order an echo on a peds?
If the kiddo is symptomatic or asymptomatic with: -suspected diastolic or continuous murmur -ejection clicks -radiate to back or neck -grade 3 or louder -murmurs ass. with abnorm ekg or cx
Rheumatic fever is an ________ dx that occurs after a ______ infection
autoimmune/inflammatory dx
GROUP A STREP
If a pt comes in with rheumatic fever sx when would you do a rapid strep test?
Only if the HPI is consistent with an acute strep infection
What is the time frame of RF onset after a group A strep infection?
1-5 weeks
What lab tests do you want to get for a RF pt?
ASO titer (rises 1-3 wks after strep infx, peaks 3-5 wks)
CBC
CMP
ESR + CRP (if neg=not RF)
What is the diagnostic criteria for rheumatic fever?
Jones Criteria
What is the Jones Criteria?
DX based on presence of known group Q strep infection PLUS:
2 major OR
1 major and 2 minor criteria
What are the 5 major criteria of the Jones Criteria?
- Migratory polyarthritis (MC-80%)
- insanely painful joint pain that jumps to a new spot every 3-10 days
- must have associated swelling and limited movement - Carditis (valvulitis, myocarditis, pericarditis)
- Most serious complication
- present 40%
- Tachy, new murmur, cardiomegaly, CHF
- MV and AV mc affected - Erythema marginatum (less than 5%)
- macular, red, non itchy rash on trunk - Chorea (Sydenham’s)
- less than 15%
- rapid, purposeless movement (like Huntington’s dx)
- delayed onset (mo to yrs) - Subcutaneous nodules (uncommon <5%)
- non-tender, freely moving, over a joint
What are the 6 minor criteria of the Jones Criteria?
- Arthralgia (no joint swelling)
- Fever
- Elevated acute phase reactants (ESR, CRP)
- Prolonged PR interval (can’t use if pt has carditis as a major)
- Leukocytosis
- Previous h/o RF
What is the treatment for acute RF?
Antibiotics ONLY if evidence of acute strep infx:
- Penicillin
- Erythromycin (if pen allergic)
Otherwise:
- ASA for sx
- (+/-) steroids
- (+/-) valve replacement
- Tx heart failure if present
What is the preventative treatment for pts w/ h/o RF or RHD?
H/o RF: very low threshold for ABX with c/o ST
RHD: 5-10 yrs or until 21 yo prophylatic abxs
-DOC: Pen G Q4 weeks
What is Reye Syndrome? What is it mc associated with?
Reyes syndrome: rapidly progressive encephalopathy
Sx: vomiting, AMS, seizures
90% of cases associated with ASA use
VERY RARE (less than one in a million kiddos per yr)
What is Kawasaki Dx?
AKA mucocutaneous lymph node syndrome
Systemic Vasculitis
MEDIUM sized blood vessels become inflamed (Coronary arteries!!)
Etiology: unknown
MC acquired heart dx- 9/100,000 kids <5
What is the criteria for diagnosing Kawasaki Dx?
Must have a FEVER plus 4 of the 5 other sx OR coronary aneurysms:
- Fever
- Conjunctivitis- bilateral w/o exudates, painless
- changes in hands and feet- erythema and swelling, followed by desquamation
- mucous membrane involvement: swollen lips, pharyngitis, “strawberry tongue”
- cervical adenopathy: often unilateral
If a question mentions “strawberry tongue” as an PE finding you should be thinking of??
Kawasaki disease
-mucosal membrane involvement
What are the complications of Kawasaki dx?
- fatal coronary artery aneurysms
- coronary lesions–thrombosis–MI
- myocarditis/pericarditis
- valvular dx
When do coronary artery aneurysms form during Kawasaki dx?
after day 10 of illness, peaks at 4 wks
Coronary artery aneurysms develop in ___ of kawasaki dx pts who go untreated
20-25%
What is the tx for Kawasaki Dx?
-IVIG
-Aspirin
high dose= acute phase
low dose= after acute phase
-Repeat ECHO’s (minimum: at 2wks and 6-8wks)
What is Infective Endocarditis?
An infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium or the septum
- may lead to intractable CHF and myocardial abscesses
- Fatal if left untreated
What are the 3 most common causes of infx endocarditis in PEDS?
- Streptococci Viridans
- staph aureus
- Fungal
What are the 3 most common causes of infx endocarditis in adults?
- streptococcus
- staphylococcus
- enterococcus
What is the most likely cause of acute endocarditis?
staph aureus
What is the most likely cause of subacute endocarditis?
streptococci viridans
What are the 5 major risk factors for IE?
- H/O congenital heart disease!!
- H/o prosthetic valve
- indwelling catheters
- h/o rheumatic heart disease
- IVDU (right sided valves)
What are the sxs of IE?
FROM JANE F- fever (97%) R- Roth spots (eye hemorrhages) O- Osler's nodes (Ouch! painful spots) M- esp if new!!
J- Janeway lesions (non-tender hem. macules on hands and feet)
A- Anemia
N- Nail hemorrhage (splinter hem.)
E- Emboli
What Duke’s Criteria is used to dx what disease? What does it include?
Used for infective endocarditis
Need 2 major OR 1 major and 3 minor OR 5 minor
Majors:
- 3 full sets of blood cultures positive with a typical microorganism
- positive ECHO
Minor:
- predisposing risk factor
- fever >38
- evidence of embolism
- immunological problems: glomerulonephritis, Osler’s nodes
- Positive blood culture (that doesn’t meet a major criterion)
What is the work-up for Infective Endocarditis?
CBC CMP Blood cultures x3 ESR CRP Lactate ECHO
Why are the valves most commonly affected by endocarditis?
Because they have no blood supply
-more likely to adhere to prosthetic or damaged valves
What is the treatment for IE?
- Start BS ABX immediately
- Hospitalization
- ID consult
- anticoagulation is NOT recommended
What is the prophylaxis tx for IE?
Oral amoxicillin 1 hr before the procedure
If pen allergic:
- Azithromycin
- clarithromycin
- Clindamycin
What is heart failure?
When the heart fails to meet the circulatory and metabolic demands of the body
-can result from volume/pressure overload (congestion) or from an abnormality of the ventricular myocardium (hypertrophic, restrictive, infiltrative)
What are the sx of HF in a peds pt?
- tires easily feeding
- periorbital edema, wg not consistent w/ growth chart
- rales and rhonchi
- dyspnea, orthopnea, tachypnea
- diaphoretic/sweating
- tachycardia
- failure to gain weight–late SX
What is the tx for pediatric HF?
no good standard approach
must be targeted at underlying cause
What are the 2 fetal shunts that exist to bypass the fetuses non-functioning lungs?
- Foramen ovale: b/w atria
2. Ductus Arteriosus: connects the pulm artery to the descending aorta
What fetal shunt allows oxygenated blood from the placenta to bypass the liver?
Ductus Venosus: shunts a portion of the left umbilical vein blood flow directly to the inferior vena cava
What type of shunt produces a cyanotic baby?
R–L shunt or parallel circuit
What type of shunt produces acyanotic baby?
L–R shunt or obstruction
What are the six types of acyanotic defects? (L–R shunts)
- Atrial Septal Defect (ASD)
- patent foramen ovale (PFO) - Ventricular spetal defect (VSD)
- Patient ductus arteriosis (PDA)
- Pulmonary stenosis (PS)
- Coarctation of the aorta (CoA)
- Aortic stenosis (AS)
What are the six types of acyanotic defects? (L–R shunts)
- Atrial Septal Defect (ASD)
- patent foramen ovale (PFO) - Ventricular spetal defect (VSD)
- Patient ductus arteriosis (PDA)
- Pulmonary stenosis (PS)
- Coarctation of the aorta (CoA)
- Aortic stenosis (AS)
What is an Atrial Septal defect?
- oxygenated blood is shunted from the L to R side of heart via defect
- Inc. in blood vl in right side of heart leads to R sided hypertrophy
- causes extra blood to pass through the pulm artery into lungs–pulm HTN–CHF
Do most peds with an ASD defect have sx?
No most are asymptomatic
However, roughlt 70% develop sx by 40 yos
What are the complications if an ASD goes unrecognized/untreated?
- CHF
- poor growth
- SOB - cor pulmonale is a rare and late occurrence (R heart failure due to pulm HTN)
What it is the MUST KNOW heart sound associated with an ASD?
Widely split and fixed S2 (duhhhhh)
What is the 1st line dx test for ASD?
ECHO
What is the tx for an ASD if the pt is symptomatic?
refer to cardiology
What is the tx for an ASD if the pt is asymptomatic?
Get an ECHO then discuss with cardiology
Roughly ___ of ASDs will spontaneously close within the 1st year
40%
ASDs present after ___ will not spontaneously close
2 yrs
What is the tx of an ASD plus CHF in a peds patient?
Same as adults:
-diuretics and ACEIs
When is surgery necessary for an ASD?
Immediately if larger–assoc. w/ HF
age 1-3 if stable
What is a foramen ovale defect?
Small flaplike opening b/w the atrial septa (ASD) that allows blood flow from R–L atria (too small to cause cyanosis)
Does a foramen ovale defect close on its own?
Generally yes, shortly after birth.
If not it is referred to as a patent foramen ovale (PFO) which is a type of ASD.
-about 25% of people have PFO
-rarely cause sx
What is the most common congenital heart disease?
Ventricle Septal Defect
Which way is blood shunted in a ventricle septal defect?
Left to Right
What is the result of the result of the increased amount of blood entering the right side of the heart due to a VSD?
right sided hypertrophy
With a VSD:
More blood is returning to the right side of the heart which also means more blood is going through the pulmonary artery into the lungs than usual…what does this cause?
Pulmonary hypertension which causes congestive heart failure
If a patient has a small VSD they will be?
Asymptomatic and 90% close spontaneously by age 6
How will a pt with a large VSD appear?
Sick! show up in ED by 6 mos
- not eating
- poor growth
- SOB
- recurrent respiratory infx
- Need surgery!
What is going to be the dx test of choice for all CHDs?
ECHO
What is the prognosis for a VSD?
Very good!
What is Eisenmenger syndrome?
Refers to any untreated congenital cardiac defect with in intracardiac communication that leads to pulm HTN, reversal of flow and cyanosis. L to R shunt is converted to R to L shunt secondary to elevated pulm artery pressures and associated pulm vascular dx
What is a patent ductus arterious?
- L to R shunt
- connection b/w the aorta and pulm artery
- causes right hypertrophy due to excess blood going through right side
- same with pulm art—pulm htn—CHF
PDA usually closes ___ after birth
1-5 days
Why in some cases do you want the PDA to remain open?
It is often present with more serious CHD’s and without it the baby would not be viable due to lack of oxygenated blood
What is the murmur associated with a PDA?
Rough, continuous machine-like murmur at left 2nd ICS
What medication keeps a PDA open?
Prostaglandin E1
What medication closes a PDA
NSAIDS (inhibits prostaglandins)
What is the general rule for treatment for all of these CHD?
Refer to cardiology
Surgery is necessary if symptomatic
If asymptomatic monitor closely with ECHOs
What is coarctation of the aorta (CoA)?
Narrowing in the aortic arch causing obstruction of left ventricular blood flow
This results in L ventricular hypertrophy and decreased systemic blood flow
What are sx of CoA?
Severe: CHF and CV collapse Mod: -absent or weak fem pulses**(I have this starred!) -leg cramps -chronic pulm congestion -HA -epistaxis -BP discrepancies -differential cyanosis (pink U and blue LE)
What is the murmur associated with a CoA?
Blowing systolic murmur that radiates to the back or left axilla. Ejection click if pt has concurrent bicuspid aortic valve (80%)
How can a CoA be clinically dx?
weak or absent femoral pulses
What is the tx for newborns in extremis with CoA?
- resuscitation
- prostaglandins (keep PDA open)
- inotropic drugs (increase squeeze)
Aortic stenosis causes?
left ventricle hypertrophy
What are the 3 types of aortic stenosis?
- valvular
- subvalvular- membranous or fibrous ring
- supravalvular- constriction of the ascending aorta obs flow
What type of murmur is associated with AS?
high pitched crescendo-decrescendo systolic ejection murmur that radiates into the neck
-systolic click at apex
What is pulmonic stenosis?
narrowing of entrance into pulm artery–increased R vent pressure
What type of murmur is present in mod to sev pulm stenosis?
widely split S2 w/ sys ejection click at LSB and radiates to back
What are the 6 cyanotic CHDs?
5 Ts and 1 E
What are the four problems associated with Tetra(4)logy of Fallot (ToF)?
- Pulm stenosis
- RV hypertrophy
- Large, overriding aorta
- VSD
What type of shunt is a ToF and what is the major concern with it?
R to L
- limitation of pulm blood flow
- oxygen-poor blood enters the aorta w/ varying degrees of hypoxemia
What is the most common cyanotic CHD?
ToF (wont be profoundly blue)
What are the sx of ToF?
- progressive cyanosis
- irritability, poor feeding, BUT growth and development are usually not delayed
- hypoxemic spells–“tet spells”
- loud, rough sys ejection murmur that radiates to the back
If a test question mentions a booth shaped heart you are thinking of??
ToF
What are the tx options for ToF?
Depends on the presenting sx–aggressive or palliative
- prostaglandin infusion (keep PAD open)
- Beta blockers (slow HR)
- emergency systemic to pulmonary shunt
- complete repair (open heart)
What is Tricuspid atresia?
Tricuspid valve is missing–no flow between RA and RV
Blood must flow from the RA to the LA through an ASD and a VSD is present to pump blood btw the ventricles
They will be very blue at birth!
What would a CXR show in a bebe with tricuspid atresia?
an enlarged RA
What is the tx for Tricuspid atresia?
Medical: prostaglandin infusion to keep PDA open and diuretics
Surgical: major cardiovascular surgery
prognosis is guarded
What is Transposition of great vessels?
aorta arises from the right ventricle, and the pulm artery arises from the left ventricle—completely incompatible with life unless there is a ASD, VSD, or PDA that allows mixing
What is the degree of hypoxia dependent upon in a TGA?
the degree of mixing
Infants whose PDA has closed and who have a small ASD will be intensely cyanotic
You are delivering a baby (like the badass you are) and it comes out blue…(oh shit) you remember Prof Jaynsteins lecture on CHD and you’re thinking it probably has Transposition of Great Vessels…will putting oxygen on the lil bebe help?
Nope! if it is TGA, hypoxia does not respond to O2 administration
PANCE loves this one (so I heard in lecture)
What is a Totally anomalous pulmonary venous return (TAPVR)?
Instead of the pulm veins returning oxygenated blood to the left atrium, they empty into the systemic venous system
What must be present for a TAPVR to be compatible with life?
ASD or PFO
What is truncus arteriosus?
A single arterial trunk arises from both ventricles that supplies the systemic, pulmonary and coronary circulation
-VSD is always present
What are the sx of truncus arteriosus?
Min cyanotic but in HF at birth
Systolic thrill at LSB
Loud, early sys click w/ a single S2
Need an ECHO and surgery
What is Ebstein’s anomaly?
The tricuspid valve is abnormal and inserts well down into the RV. There is often severe tricuspid regurgitation which can lead to death of fetus or infant
What is a dx finding of Ebsteins anomaly on a CXR? EKG?
“wall to Wall heart”
Right atrial enlargement, RBBB
