Peds - Exam 2 - Cardiac - What To Know Flashcards
Chest X-ray
- Most frequently ordered
- Shows information about shape and size of heart, pattern of blood flow especially through pulmonary vessels
Cardiac catheterization
- Invasive - thread cath through peripheral vessel (usually femoral)
- Complications: bleeding, hematomas, infection, blood clots
- Mark pedal pulses before site so they are palpated again in same position
Post procedure:
- It is NORMAL for pulse site to be weaker for a few hours after procedure
- Vital signs - count HR for full minute
- Check for drainage of blood - if dressing saturated, apply pressure just above the site (1 in above), call physician or have someone call for you.
- Pt should lay with extremity straight for 4-6 hours
- Dressing needs to stay clean dry intact for 24 hours after (no bathing etc)
- No tub baths 3 days (older children can shower day after cath)
- Avoid strenuous activity for several days but may attend school
- Can resume regular diet without restrictions
- Acetaminophen or ibuprofen for pain
Echocardiography
- Non-invasive, nonpainful
- Can be stressful b/c child has to lay still - may need mild sedative
CHF
- Inability of heart to pump adequate amount of blood to meet body’s demands
- Earliest signs in infant - tachycardia (sleeping HR of > 160)
o Impaired myocardial function
- Tachycardia; fatigue; weakness; restlessness; S3/S4; diaphoresis; irritability
- Decreased perfusion – pale, cool extremities; decreased BP, decreased urine output; slow cap refill
o Pulmonary congestion
- Tachypnea, dyspnea, respiratory distress, cyanosis, exercise intolerance
o Systemic venous congestion
- Peripheral and periorbital edema, weight gain, ascites, hepatomegaly (may be able to palpate liver), neck vein distention
Congenital vs acquired heart defect
Congenital:
- Anatomic –> abnormal function
- Seen most commonly
- Causes: maternal or environmental (fetal alcohol syndrome, maternal illness - rubella, infants of diabetic mothers, cytomaglovirus, toxoplasmosis, etc); genetic; mostly multifactorial
Acquired
- Disease process - infection, autoimmune response, environmental factors, familial tendencies
Increased pulmonary blood flow - caused by which defects?
- Atrial septal defect
- Ventricular septal defect
- Patent ductus arteriosus
- Atrioventricular canal
Obstruction to blood flow from ventricles - caused by which defects?
- Coarctation of aorta
- Aortic stenosis
- Pulmonic stenosis
Decreased pulmonary blood flow - caused by which defects?
- Tetralogy of Fallot
- Tricuspid astresia
Mixed blood flow - caused by which defects?
- Transposition of great arteries
- Total anomalous pulmonary venous return
- Truncus arteriosus
- Hypoplastic left heart syndrome
ASD (Atrial Septal Defect)
- It is an opening between the atria
- Blood is going to flow from L to R – then causes increased blood flow to lungs
- Child often presents well, not always caught early on because they are asymptomatic
- Tx: know in general, usually do cardiac cath procedure (if small enough) or surgical repair procedure with patch
VSD (Ventricular Septal Defect)
- Most common congenital heart defect we see
- Defect in the ventricular septum
- Manifestations, severity, prognosis – all depends on size –> Will affect treatment, how badly they present
- Will hear murmur
- Tx is surgical
- Prognosis depends on size
PDA (Patent Ductus Arteriosus)
- Ductus SHOULD close by ~15 hours after birth
- Can treat that by administering indomethacin in preemies and newborns to close that – otherwise will do surgical intervention or cath lab to close it
- Prognosis overall good – in preemies, can be worse prognosis because there can be other medical issues
COA (Coarctation of Aorta)
- Coarctation – narrowing of aorta – typically near insertion of ductus arteriosus
- Causes increased pressure proximal to defect
- Causes bounding pulses in arms
- Decreased perfusion to lower extremities (cool cyanotic)
- Infants – signs of CHF in infants
- Condition can deteriorate rapidly – how large of an area is narrowed?
- Older children – dizziness, headache, fainting
- Going to treat typically with balloon angioplasty (older than 6 mos old) if not too large
AS (Aortic Stenosis)
- Kids should NOT be in strenuous exercise
- Serious defect because it tends to be progressive
- Sudden periods of ischemia and decreased CO – can lead to death (which is why it can be so dangerous)
- Narrowing of aortic valve
- Clinical – infants with severe defects – decreased CO – faint pulses, low BP, poor feeding
- Older kids – exercise intolerance, dizziness, chest pain
PS (Pulmonic Stenosis)
- Pulmonic stenosis – pulmonic valve narrowed – in extreme form, can be completely closed off (resulting in no blood to lungs) which would be very serious
- Decreased blood flow to lungs and R ventricular hypertrophy
- Foramen ovale can reopen which allows some shunting – some pts have PDA to help compensate
- Chest xray shows cardiomegaly
- Balloon angioplasty – very successful, what is typically done
Tetralogy of Fallot
4 defects involved in complete defect
- VSD (ventricular septal defect)
- Pulmonic stenosis
- Overriding aorta
- Right ventricular hypretrophy
S/S characteristic “tet spells” (blue spells) – acute episodes of cyanosis and hypoxia typically occurring after feeding or crying (baby turns blue when cries, or blue around lips after feeding, etc)
Surgery – multi-stage procedure
Risk of emboli, LOC, sudden death, seizures
One way we can prevent seizures is to keep child hydrated (prevent dehydration)
Tricuspid Atresia
- Failure of tricuspid valve to develop
- Tx is going to be giving the prostaglandin E to keep open the foramen ovale so blood can continue to shunt – otherwise no blood flow to lungs
- High surgical mortality rate
- Surgery is multistep procedure
Transposition of Great Vessels
- No communication between systemic and pulmonary circulation
- Symptoms depend on type and size of associated defects – the bigger the septal defects, the less cyanotic the newborn will appear (but will still see signs of CHF)
Total Anomalous Pulmonary Venous Connection
- Very very rare defect
- Instead of pulm veins going to L atrium, Pulm veins go to systemic circulation via right atrium, shunted via ASD (atrial septal defect)
- Clinical manifestations - usually cyanotic early
Hypoplastic left heart
- Primary defect - hypoplastic L ventricle – L vent so small, not functioning
- R side compensates with PDA and foramen ovale
- Most of the blood can flow across foramen ovale, so that some of that oxygenated blood can go back into the r atrium then into r ventricle – pumped out to lungs
- Because of PDA patent ductus arteriosus – some goes into systemic circulation
- Tx for this – need to keep shunts open using prostaglandin E infusion
- Tx is ultimately going to be surgery – multiple surgeries into correcting this, and the mortality is pretty HIGH
Postop cardiac surgery
It is normal to have temp up to 100 F post-op, but any higher need to notify MD. Worry about post op infection
If on bypass during sx, will come back intubated on vent
VERY CAREFUL suctioning! No more than 5 secs, GIVE O2 before and after sxn. 2 person job
Chest Tubes After Cardiac Surgery
Monitor chest tube drainage q hour for COLOR
- Immediate postop may be bright red, but changing to serous
Monitor chest tube drainage for quantity
*** Notify surgeon if chest tube drainage >3 ml/kg/hr ×3 consecutive hours OR 5-10 ml/kg in any 1 hour (possible hemorrhage)
Be alert for cardiac tamponade (rapid onset; life-threatening)
Bacterial Endocarditis
Bacterial endocarditis or BE, or IE (infective endocarditis), or SBE (subacute bacterial endocarditis)
Infection in valves and endocardium
Usually sequelae of sepsis in child w/ cardiac disease or congenital anomaly
Staph, Strep, Candida, gram-negative bacteria
High-dose ANTBX: Penicillin, amipicillin, methicillin, cloxacillin, streptomycin, or gentamicin
Amphotericin or flucytosine for fungal infections
Treat 2-8 weeks. If antbx unsuccessful»CHF develops, valvular damage
Prophylax before dental procedures, bronchoscopy, T&A, SURGERIES
Prevention of IE (infective endocarditis)
Prophylactic antibiotics ONLY for highest-risk CHD patients
Recent changes in prophylaxis guidelines
Prophylaxis before dental work, invasive respiratory treatment, or procedures on soft tissue infections
No prophylaxis for GI/GU procedures
Administer prophylaxis 1 hour before procedure
Meticulous dental hygiene
NEED GOOD TEACHING FOR PARENTS OF HIGH-RISK PTS. These parent should not wait to bring their kids in…even if suspect just a cold, need to be evaluated
Rheumatic Fever clinical manifestations
Carditis involves endocardium, pericardium, and myocardium; most commonly the mitral valve
Arthritis is reversible and migrates, especially in large joints (knees, elbows, hips, shoulders, wrists)
Erythema marginatum—rash; usually on trunk and proximal portion of extremities. Red macule w/ clear center and wavy, well-demarcated border
Subcutaneous nodules: small, nontender nodules appear over bony prominences (hands, feet, elbows, scalp, scapulae, vertebrae) persist indefinitely after onset of the disease and resolve w/ no resulting damage.
Aschoff bodies: Inflamed hemorrhagic bullous lesions that cause swelling, fragmentation, and alterations in connective tissue. Found in the heart, blood vessels, brain, and on serous surfaces of joints and pleura.
Prevention of RHD
**THIS IS WHY WE CHECK ALL KIDS WITH SORE THROAT FOR STREP AND SEND BACK UP CULTURE PRN
Kawasaki Disease
Acute systemic vasculitis, unknown cause
Duration 6-8 weeks, self-limiting
Without treatment of KD, 20%-25% have cardiac complications
Dilation of coronary arteries (ectasia)
Coronary artery aneurysms (giant aneurysms > 8 mm)
Acute, subacute, convalescent phases
Etiology
Uncomfirmed but likely infectious cause. Have seen geographic and seasonal outbreaks
Peak incidence in toddler ages
Seasonal variations (late winter/early spring)
Widespread inflammation of small and medium-size arteries
Clinical Manifestations
High fever—unresponsive to antipyretics/ antibiotics
“Strawberry” tongue
Edema hands and feet
Extreme irritability (inconsolability)
It can be really tough to take care of these kids bc of the extreme irritability
Periungual desquamation
Arthritis
Coronary complications
Tx
high dose IVIG and salicylate (ASPIRIN) therapy
