Test 2 ...need to focus Flashcards
1
Q
In tricuspid or mitral regurgitation, what murmur would you expect to hear?
A
Holosystolic
2
Q
With a VSD, what murmur would you expect to hear?
A
Holosystolic
3
Q
With a Mitral valve prolapse, what murmur would you expect to hear
A
Late systolic
4
Q
With pulmonary and aortic stenosis, what murmur would you expect to hear?
A
Ejection (early systolic) with click
5
Q
what type of murmurs are always pathologic
A
diastolic
6
Q
In aortic regurgitation, what murmur would you expect to hear?
A
Early diastolic that radiates to the apex
7
Q
In pulmonary regurgitation what murmur would you expect to hear?
A
Early diastolic that radiates along the left sternal border
8
Q
In mitral stenosis what murmur would you expect to hear?
A
Mid-diastolic heard at the apex
9
Q
In tricuspid stenosis, what murmur would you expect to hear?
A
Mid-diastolic heard at the left lower sternal border
10
Q
• Infants: tachypnea, feeding difficulties (e.g., decreased volume or increased time spent feeding), poor weight gain, excessive perspiration (especially when feeding), and excessive irritability. Wheezing and tachypnea from pulmonary congestion often mistaken for bronchiolitis.
Children: fatigue, exercise intolerance, anorexia, abdominal pain, dyspnea, and cough.
Infants and children:
• Tachycardia, decreased peripheral pulses, delayed capillary refill, and cool extremities. • Abdominal pain is a common presenting complaint and may be overlooked or dismissed. Hepatomegaly, ascites can be present with abdominal distension. • Edema may be present in dependent portions of the body (e.g., lower extremities in an ambulatory child; body wall and sacrum if nonambulatory).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 410). Wolters Kluwer Health. Kindle Edition.
A
Congestive heart failure
11
Q
what pH inbalance would you see in Congestive heart failure
A
Metabolic acidosis
12
Q
Acute HF is used to describe a functional change in the heart that can occur quickly leading to what 4 functional problems
A
congestion
mal-perfusion
tachycardia
hypotension
13
Q
4 main characteristic signs and symptoms of Heart failure mentioned in Bolick
A
edema
resp distress
growth failure
exercise intolerance
14
Q
what 2 vitamin deficiencies can cause Heart failure in infants
A
Vit D
Hypocalcemia
15
Q
where is PMI felt
A
It comes from the RV
felt along L mid clavicular line
at the 4th intercostal space in infants and 5th intercostal space in older patients
16
Q
Treatment for heart failure
A
Diuretics
ACE Inhibitors - reduce activation of RAA system (perpetuator of HF cycle) and helps prevent remodeling
or
ARBS reduce activation of RAA system (perpetuator of HF cycle) second choice when has dry cough on ACE
B blockers- slow heart rate, prevent arrhythmias, reduce myocardial apoptosis and fibrosis and reduce afterload
aldosterone agonists - similar to ARB but predisposes patients to hyperkalemia
digoxin - increases contractility
inotropes
mechanical support
17
Q
Diuretics used in HF
A
1st line:
Furosemide (Lasix)
Chlorothiazide (Diuril)
2nd line:
Bumetanide (Bumex)
18
Q
What diuretic used in HF increases sodium excretion
A
Furosemide (Lasix)
19
Q
Which can cause ototoxicity
Chlorothiazide (Diuril)
Bumetanide (Bumex)
Furosemide (Lasix)
A
Furosemide (Lasix)
20
Q
what medication used in HF in used for its antifibrotic effects and promotes remodeling
A
Spironolactone (Aldactone)
21
Q
Your patient is on Spironolactone (Aldactone) which is an aldosterone antagonist and an ACE (Captopril, Enalapril or Lisinopril). What do you need to monitor more closely
A
This combination may produce hyperkalemia
22
Q
What side effect can be seen in males for Spironolactone
A
Male Gynecomastia
23
Q
what ACE inhibitor for HF is preferred in infants and neonates
A
Captopril
24
Q
What ACE inhibitor for HF can cause angioedema
A
Enalapril
25
What ACE inhibitor for HF is preferred in adolescents due to daily dosing
Lisinopril
26
What do you need to monitor closely when a pt is on Enalapril
Renal function
potassium levels
27
What is preferred in heart failure and why
ACE or ARBS
ACEs because ARBS do not increase bradykinin levels.
ACEs can cause a dry cough
28
What ARB is used in Heart failure
Losartan
29
What B blocker has been shown to significantly reduce mortality in heart failure
Carvedilol
30
Which B Blocker selectively blocks B-1 receptors with little or no effect on B2 receptors and reduces inappropriate tachycardia
Metoprolol succinate
31
How is Digoxin excreted
Kidneys
32
What inotrope used in HF has a 1-4 hr half life, decreases afterload and increases cardiac output without increasing myocardia oxygen consumption
Milrinone
33
What inotrope is used for short term rescue therapy in HF however can increase arrhythmias and myocardial oxygen consumption
Epinephrine
34
• Inotropic support with β-agonists such as ______ or ______ can improve cardiac output.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 412). Wolters Kluwer Health. Kindle Edition.
dopamine
dobutamine
35
Phosphodiesterase inhibitors (e.g., milrinone) are both an _______ and a \_\_\_\_\_\_\_.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 412). Wolters Kluwer Health. Kindle Edition.
inotropic agent
vasodilator
36
If inotropic support is needed in HF treatment, discontinue chronic _______ therapy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 412). Wolters Kluwer Health. Kindle Edition.
beta-blocker
37
• \_\_\_\_\_\_\_increases myocardial contractility; maintain normal _______ levels in the setting of heart failure.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 412). Wolters Kluwer Health. Kindle Edition.
Calcium
ionized calcium levels
38
\_\_\_\_\_ is a potassium-sparing diuretic that has the added benefit of preventing cardiac remodeling in Hf treatment
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 412). Wolters Kluwer Health. Kindle Edition.
Aldactone
39
Timeline to develop post pericardiotomy syndrome
within a few weeks to months after surgery
40
symptoms for post pericardiotomy syndrome
2 out of 5 present
fever without other cause
pleuritic chest pain
pericardial effusion
friction rub
new or worsening pleural effusion
as fluid accumulates around the heart, they become short of breath and tachypneic
may hear a pericardial friction rub
Pericardial tamponade occurs when the pericardial effusion is of a size where venous return is impeded and contractility impaired - SS are muffled heart sounds, JVD, hypotension (AKA Becks triad) along with decreased venous return, poor cardiac output -\> resp failure, tachycardia, narrowed pulse pressure and poor peripheral perfusion
41
Treatment for post pericardiotomy syndrome
5-7 days of NSAID agents such as Ibuprofen or Ketorolac (this may need to continue for several weeks)
Systemic steroids
Methotrexate for chronic PPS symptoms
Colchicine for joint inflammation
Diuretics when there is edema due to CO
echo guided pericardiocentesis for tamponade - after drained, use isotonic IV fluid for volume replacement
42
cold shock vs warm shock presentation
Cold - features of low cardiac output
- Tachycardia
- AMS
- Poor peripheral perfusion
- mottled skin
- prolonged cap refill
Warm- features of high cardiac output
- vasodilation
- Tachycardia
- bounding pulses
- brisk cap refill
- flushed
43
```
Medication class that alters the force of energy of muscle contractions
-Increases CO by increasing contractility
```
Inotropes
44
Med class that raises blood pressure by increasing vascular constriction
Vasopressors
45
Med class that alters heart rate
Chronotropes
46
med class that affects rate of myocardial relaxation (allows more filling time)
Lusitropes
47
space.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 348). Wolters Kluwer Health. Kindle Edition.
Cardiac Tamponade
48
Cardiac arrest ensues with uncorrected cardiac tamponade with what ECG finding
Pulseless electrical activity (PEA)
49
Presentation of Cardiac Tamponade
Beck Triad (classic)
- Hypotension
- JVD
- Muffled heart sounds
- pulsus paradoxus
- Narrow pulse pressure
- pericardial rub
- shock with tachycardia, tachypnea, and depressed mental status
50
tests for cardiac tamponade
echo
chest x ray - globular heart shadow
ECG -
Low -voltage QRS in all leads
Abnormal ST segment
51
Treatment for cardiac tamponade
Medical emergency
needle pericardiocentesis with pigtail to prevent reaccumulating
Fluid resuscitation
Treat underlying disease process (infection)
52
In trauma patients, hypotension refractory to fluid resuscitation should prompt suspicion of
cardiac tamponade
53
Hypotension with distended neck vein should always include _____ in the differential diagnosis
cardiac tamponade
54
A dilation of the left or both ventricles with impaired contraction/systolic dysfunction in the absence of an abnormal loading condition (e.g., hypertension, valvular disease, or coronary artery disease).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 351). Wolters Kluwer Health. Kindle Edition.
dilated cardiomyopathy
55
• Hypertrophied, nondilated ventricle in the absence of a hemodynamic disturbance that is capable of producing the existent magnitude of wall thickening (e.g., hypertension, aortic valve stenosis, catecholamine secreting tumors, hyperthyroidism).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 351). Wolters Kluwer Health. Kindle Edition.
Hypertrophic cardiomyopathy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 351). Wolters Kluwer Health. Kindle Edition.
56
Restrictive filling and reduced diastolic volume of either or both ventricles with normal to near normal systolic function and wall thickness.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 352). Wolters Kluwer Health. Kindle Edition.
• Restrictive cardiomyopathy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 351). Wolters Kluwer Health. Kindle Edition.
57
• Ability of the ventricle to pump blood is impaired and cannot maintain adequate cardiac output to meet the body’s demand. • Over time, the ventricles become progressively stiff and do not fill appropriately. • Results in a backup of blood into pulmonary circulation, which causes pulmonary edema, pulmonary hypertension, and atrial enlargement.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 352). Wolters Kluwer Health. Kindle Edition.
Dilated cardiomyopathy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 352). Wolters Kluwer Health. Kindle Edition.
58
The ventricles become thick and stiff, leading to impaired filling and the inability to meet the cardiac output demands of the body. • Over time, the ventricles become stiffer and can cause obstruction of blood flow out through the aorta.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 352). Wolters Kluwer Health. Kindle Edition.
Hypertrophic cardiomyopathy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 352). Wolters Kluwer Health. Kindle Edition.
59
Leads to decreased filling compliance of the ventricles, causing severely elevated right atrial (RA) pressures and size. • The severely enlarged atrium can cause atrial arrhythmias (often difficult to control) as well as significant pulmonary hypertension.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 352-353). Wolters Kluwer Health. Kindle Edition.
Restrictive Cardiomyopathy
60
Management of Dilated Cardiomyopathy
Oxygen
Inotropic support
continuous tele
Fluid management- Be cautious with fluids
Diuretics - afterload reducers
- VAD
- ECMO
- Transplant
61
management of Hypertrophic cardiomyopathy
No inotropes - can worsen systolic function
B-Blockers - help with chest pain and palpitations
Calcium channel blockers for angina and to improve diastolic function
Avoid dehydration - make sure heart has adequate preload
62
Management of Restrictive cardiomyopathy
No proven therapies currently exist
Anticoagulation is recommended
High risk for sudden embolic events
B Blockers
ACE inhibitors
Diuretics
Pacemakers
VAD
ECMO
Heart transplant - consider early bc pulmonary HTN is contraindication to transplant
63
Vascular communication between the left pulmonary artery (PA) and the descending aorta
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 358). Wolters Kluwer Health. Kindle Edition.
PDA
64
When does the PDA normally close
within the first 12-24 hours of life or by the first week
65
PDA
what murmur
where do you hear it in neonates vs older children
large PDA
Systolic murmur Left sternal border (neonates)
Continuous murmur Left upper sternal border (older children)
loud continuous “Machinery-type” murmur throughout the precordium, bounding pulses
66
With a large PDA, what do you see with Blood Pressure and pulse
Widened pulse pressure with low diastolic pressure
Bounding peripheral pulses
all from over circulation
will have resp distress
67
large PDA, what will you see on x ray
increased pulmonary vascular markings and cardiomegaly from LA and LV enlargement.
68
In PDA
what will you see on ECG
left atrial enlargement and LV hypertrophy with possible biventricular hypertrophy in the presence of PH and obstructive vascular disease.
69
diagnostic for PDA
ECHO
70
Meds for PDA
• Nonsteroidal anti-inflammatory drugs (NSAIDS): Indomethacin or a special intravenous (IV) form of ibuprofen has been used to help close a PDA; especially viable alternative for premature infants. Contraindicated in infants with intraventricular hemorrhage (IVH).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 359-360). Wolters Kluwer Health. Kindle Edition.
71
When is surgical intervention required on PDA
if open past 3 months of age....Typically closure done in the first 6 months of life
closure via cath is now standard
72
what is this?
PDA
73
communication in the atrial septum
ASD
74
ASD occurs more frequently in \_\_\_\_
females
75
ASD that is located in the center of the atrial wall near the fossa ovalis and is the most common.
Ostium secundum
76
What type of ASD
## Footnote
located low in the septum at the junction with the AV valves, often associated with abnormal valves
Ostium primum
77
what type of ASD: located at the junction of the SVC and the right atrium, often associated with partial anomalous pulmonary venous drainage of the right pulmonary veins (PAPVR)
Sinus Venosus
78
What shunting occurs in ASDs
Left to right
79
Over time what do you see in an ASD
R atrial dilation, R ventricular volume overload and increased PBF
Atrial arrhythmias, CHF, Pulmonary hypertension
80
clinical presentation in ASD
Depends on the size of the defect and the relative compliance of both the ventricles. Even with large ASDs and significant shunts, infants and children are rarely symptomatic
Most patients are asymptomatic but may experience fatigue and dyspnea with large shunts
Auscultation reveals a systolic ejection murmur at the L sternal border (pulmonary blood flow murmur), a wide fixed, split S2, and in large shunts a diastolic murmur from flow across the TV.
81
ASD diagnostics
* Chest radiograph: cardiomegaly with increased PVM.
* Electrocardiography: R-axis deviation with right ventricular hypertrophy (RVH) and right bundle branch block (RBBB) pattern.
* Echocardiogram: sufficient for diagnosis; can miss associated PAPVR.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 362). Wolters Kluwer Health. Kindle Edition.
82
when do they recommend closure of an ASD
3-5 yrs old
83
most common form of CHD
VSD
84
Communication between the right and left ventricles
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 363). Wolters Kluwer Health. Kindle Edition.
VSD
85
most common type of VSD
Perimembranous - doesnt usually close on own
86
Opening in the upper portion of the ventricular septum
Perimembranous VSD
87
Opening in the septum is just below the pulmonary valve in the ventricular septum
Outlet type (subarterial) VSD
88
opening is just below the AV valves (tricuspid and mitral) in the ventricular septum
Inlet type (canal) VSD
Can be associated with Atrioventricular (AVC) defect
89
an opening in the muscular portion of the lower ventricular septum.
Muscular VSD
many of these close spontaneously and do not require surgery
90
What type of shunting in VSD
Left to Right
91
In Non-restrictive VSD, shunting is determined by the \_\_\_
Pulmonary vascular resistance (PVR)
92
Murmur heard in VSD
Harsh holosystolic murmur at LSB
may have thrill and/or middiastolic rumble at apex
A systolic regurgitant murmur along the L sternal border is present in all VSDs and may be louder in smaller defects. (loud/harsh)
S1 is normal and the S2 is loud and split. There may be a an S3, thrill at the L sternal border, an active precordium, and a diastolic rumble at the left sternal border in large defects.
93
Chest XRAy in VSD
Enlarged L atrium with prominent main PA
94
why may you have an infant come in symptomatic at 4-6 weeks of life with VSD
As the PVR drops in the in the infant, generally 4-6 weeks of age, VSDs allow shunting from the high-pressure LV to the low-pressure RV across the ventricular septum and into the PA, leading to increased PBF, LA dilation, and LV volume overload.
Qp (quantity of blood to lungs) \> Qs (quantity of blood to body)
95
ECG finding with VSD
Large VSDs on ECG will show LA enlargement, L axis deviation, BBB, LV hypertrophy and possible RVH.
96
what axis deviation is normal in newborns
Rightward Axis due to the thickness of the R ventricles
QRS is going down in II and up in aVF for Rightward axis
97
what Axis deviation
Northwest axis deviation (extreme)
QRS is down in both I and aVF
98
what axis deviation
Normal
up in I and aVF
99
what axis deviation?
Left superior axis
up in I
down in aVF
100
what axis deviation
Rightward axis
down in I
up in aVF
normal in infancy
101
VSD treatment
Initial therapy is directed at controlling CHF symptoms through medical management with diuretics, afterload-reducing medications (digoxin), and nutritional support.
If the pt is asymptomatic without evidence of PH, waiting until 4 to 5 years of age is warranted to maximize the potential for spontaneous defect closure.
Spontaneous closure is possible with perimembranous and muscular defects; therefore, surgical repair may be avoided and is only recommended for defects that cannot be medically managed. -half close by age of 2, and 90% by age 6
Surgery is indicated for patients with symptoms of CHF despite maximal medical therapy, growth failure despite supplementation, PH, or LV volume overload.
Typically surgery is done within the 1st year of life.
Most are repaired via an opening in the RA and visualized through the Tricuspid valve; and closed with a synthetic or pericardium patch. Care is taken to avoid the AV conduction tissue in the septum. Transesophageal echo can be utilized to rule out residual VSDs.
Small VSDs can be closed during cardiac catheterization using “clam shell” method.
102
• Defect resulting from nonfusion of the endocardial cushion.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 367). Wolters Kluwer Health. Kindle Edition.
Atrioventricular Canal (AVC)
103
What type of AV canal?
## Footnote
ostium primum defect associated with a cleft in the anterior mitral valve (two separate AV valves); no VSD.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 367). Wolters Kluwer Health. Kindle Edition.
Partial
104
what type of AV canal?
## Footnote
ostium primum defect with AV valves only partially separated into two valves; has VSD but may be small.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 367). Wolters Kluwer Health. Kindle Edition.
Transitional
105
what type oof AV canal?
## Footnote
ostium primum defect with large nonrestrictive VSD and a single AV valve; Three subtypes are recognized (Rastelli types A, B, and C).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 367). Wolters Kluwer Health. Kindle Edition.
Complete
106
Findings for a AV canal defect
Systolic regurgitant murmur at the Left lower sternal border
FTT
Resp distress
CHF
107
ECG for AV canal
Electrocardiography: left axis deviation, biatrial and biventricular hypertrophy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 370). Wolters Kluwer Health. Kindle Edition.
108
Main problems in TOF
Pulmonary stenosis
Right Ventricular hypertrophy
Overide of Aorta
VSD
109
Boot shaped heart on Xray
TOF
110
what shunting is in TOF
Pink TET - L to R with CHF and pulmonary overcirculation
or
Too little pulmonary flow
R to L shunt with hypoxia (SaO2 70-80%)
111
TOF ECG findings
R axis deviation with RVH
112
TOF murmur
Harsh systolic ejection murmur at Upper Sternal border
113
Treatment for TOF
Asymptomatic patients: B blocker
Symptomatic/TET spells - infundibular muscle spasms -\> R to L shunting through VSD
-Supplemental oxygen, sedation, volume expansion, Knee-chest position
Severe cases - phenyl epinephrine, emergency surgery, ECMO
114
Causes of Pericarditis
most often viral origin; bacterial etiology is rare, but S. aureus and Streptococcus pneumoniae are most common
Collagen vascular diseases: rheumatic fever, Kawasaki,
Autoimmune: lupus, scleroderma, Rheumatoid Arthritis
Postpericardiotomy syndrome- common form that follows heart surgery
Dressler syndrome (post ischemia)
Uremic Pericarditis
115
what is happening in Constrictive Pericarditis?
Over time it becomes hard for the heart to relax or expand due to perisistent inflammation fibrosis which is caused by the immune cells making the pericardium more stiff
Stroke volume down
HR up
Similar to Tamponade physiology but happens more gradually
116
symptoms of pericarditis
Fever
Chest pain that is worse with heavy breathing
improves with sitting up and leaning forward
117
symptoms of Large Pericardial effusions (\>100mL of fluid)
Decreased Heart sounds
Decreased Cardiac output -\> leads to
- Shortness of breath
- Low BP
- Lightheadedness
118
ECG changes in Acute Pericarditis stage 1 (first couple of days to weeks)
then what is the progression for Stage II - IV
ST segment elevations
PR segment depressions
then
T waves Flatten
then
T waves invert
eventually return to normal
119
Pericardial Effusion ECG changes
Low voltage on QRS or Alternans (QRS complexes have diff heights)
120
Water Bottle Sign on X ray
Pericardial Effusion
121
122
Bacterial or fungal infection of the endocardial lining of the heart valves
Endocarditis
123
Risk Factors for Endocarditis
1. Previous Endocarditis
2. Prosthetic Valve or Pacemaker
3. Valvular or Congenital Heart Disease
4. IV drug use
5. IV catheter
6. Immunosuppression
7. Recent Dental or Surgical Procedure
124
What Bacteria causes Endocarditis
Leading: (high fever and hemodynamic instability - Suspect these 2)
1. Staphylococcus Aureus and MRSA
2. strep pneumonia
3. B homlytic Strep
Also:
Less Virulent:
1. 2. Enterococci
3. Coagulase-neg Staphylococci
More Virulent:
1. Staphylococcus aureus
2. Streptococcus Pneumoniae
3. B-Hemolytic Streptococci
4. Aspergillus
Neonates:
1. S. aureus
2. Coagulase-neg staphylococci
3. candida
4. less frequent - GBS, gram neg rods and S.pneumoniae
Gram negative organisms and fungus - sneaky and can culture neg (HACEK)
1. Haemophilus
2. Aggregatibacter
3. Cardiobacterium
4. Eikenella
5. Kingella
6.
125
Endocarditis symtoms
* Acute vs Subacute/chronic
* Acute - 2 weeks
* Subacute- happens over a few months
* Heart murmur (from blood passing vegetation) - Turbulance
* Septic Emboli - vegetation breaking off
* Splinter Hemorrhage (under fingernails)
* Janeway lesions (hands and feet) - painless
* Stroke
* Pulmonary infarts
* Conjunctival hemorrhage
* Bacterial Antigen-Antibody Complexes
* Osler's Nodes (painful) - Finigers and Toes/feet
* Roth Spots (eyes)
* Glomerulonephritis (kidneys)
Neonates
* fever or hypothermia
* seizures
* hemiparesis
Subacute
* Arthralgias
* myalgias
* headache
* malaise
* relapsing fever
* poor appetite
126
Diagnosis for Endocarditis
Dukes Major
* two positive blood cultures for a typical pathogen
* two or more positive cultures for less common organisms,
* significant Echo findings.
Dukes Minor
* predisposing conditions such as CHD,
* fever,
* embolic vascular phenomena
* immunologic phenomena,
* Single blood culture
Definite IE includes satisfaction of two major criteria, one major and three minor criteria, or five minor criteria
Transthoracic echo vs Transesophageal echo
* Transthoracic is cheaper and less expensive but lower sensitivity
* Transesophageal is higher sensitivity
127
ECG finding for infective endocarditis
Heart Block
Conduction delay with an isolated prolonged PR interval
128
Treatment Endocarditis
1. 6 weeks of IV antibiotics
2. Follow up with blood cultures every 48-72 hours
3. NSAIDS and PPI
4. If autoimmune etiolgoy - corticosteroids
5. If they have a prostetic valve - typically requires surgical replacement
Empiric
* 2 broad spectrum antibiotics that covers
* MRSA (staph)
* MSSA (staph)
* Streptococci
* Enterococci
* Tailored to type of valve
* Native Valve or older prosthetic valve
* Ampicillin-Sulbactam
* Gentamicin
* Cant tolerate Beta Lactams?
* Vancomycin
* Gentamicin
* Ciprofloxacin
* Newer Prostetic Valve (less than 12 months)
* Vancomycin
* Gentamicin
* Rifampin
Blood Cutures show MSSA Native Valve Endocarditis
* Nafcillin or Oxacillin
* Allergic to PCN?
* Cephalosporin
Blood Cultures show MRSA Native Valve Endocarditis
* Vancomycin
Blood Cultures show Staph aureus prostethic valve endocarditis
* Vancomycin
* Gentamicin
* Rifampin
Streptococcal Endocarditis
* PCN G or Ceftriaxone for 4 weeks
* Add Gentamicin to either to shorten treatment to 2 weeks
* If allergic to B lactams or have a resistant...Vancomycin monotherapy
Enterococcal Endocarditis
* Gentamicin plus either PCN, Ampicillin or Vancomycin for 6 weeks
* If vancomycin resistant enterococcus -\> Teicoplanin or Daptomycin
HACEK Endocarditis
* Native Valve: Ceftriaxone for 4 weeks
* Prostetic valve: Ceftriaxone for 6 weeks
129
For individuals at high risk for endocarditis what is the recommendations prior to dental procedures
Oral Amoxicillin 1 hr before the procedure
or
IV/IM Ampicillin 1 hr before the procedure
if Allergic to PCN
Azithromycin, Clarithromycin, Cephalexin or Clindamycin orally 1 hr prior
130
Postinfectious complecation of Group A Beta-Hemolytic Streptococcus (GAS) Pharyngitis
Rheumatic Fever
| (from Strep Pyogenes "Strep Throat")
131
Symptoms of Rheumatic fever
* Sudden-onset sore throat
* fever
* difficulty swallowing
* scarlatina rash (Erythema Marginatum)
* nausea
* vomiting
* abdominal pain
* enlarged anterior lymph nodes
* tonsillopharyngeal erythema.
* Migratory arthritis
* pancarditis
* PANDAS
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 438-439). Wolters Kluwer Health. Kindle Edition.
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133
Major diagnostic criteria of Acute Rheumatic fever
**Jones Criteria**
Polyarthritis
Carditis
Subcutanious nodules
Erythema Marginatum
Syndenham Chorea
+ previous Strep infection - Streptococcal antibody test (antistreptolysin O titer) is the most reliable lab evidence of prior infection.
Minor criteria
* Fever
* Raised ESR//CRP
* Arthralgia
* Prolonged PR interval
* Previous RF
*
ECHO may be obtained to assess for valvular abnormalities (mitral valve thickening, chordae tendineae lengthening, aortic valve insufficiency, or mitral valve insufficiency)
134
treatment for Rheumatic fever
Rest
anti-inflammatory meds NSAIDs (naproxen/ Ibuproprofen) ASA or corticosteroid if no improvement
antibiotics to wipe out any strep hanging around
either Single dose of: Benzathine PCN (benzylpenicillin) - 1st choice or
course of oral PCN VK or amoxicillin
if they have a PCN allergy use a first generation cephalosporin (cephalexin)
clindamycin or a macrolide (Azithromycin or Clarithromycin)
to eradicate beta-hemolytic streptococcus, ASA for inflammation, and bed rest. Long-term PCN prophylaxis (preferably IM) is required
135
Heart complications associated with Rhumatic Fever - Chronic Rheumatic heart disease
* Regurgitation and Stenosis
* Mitral
* Aortic
136
Systolic ejection murmur
LLSB or between LLSB and Apex
Grades I-II/VI
Vibratory , musical quality
Intensity decreases in upright position
Usually heard ages 3-6 yrs old
Stills murmur
137
describe a Still's Murmur
Systolic ejection murmur
LLSB or between LLSB and Apex
Grades I-II/VI
Vibratory , musical quality
Intensity decreases in upright position
Usually heard ages 3-6 yrs old
138
nutritional requirements in HF patients
120-160 Kcal/kg/day to thrive
increase of 50-100% protein may be needed
omega 3 fatty acid supplements
may be at risk for Vit D deficiency → due to prolonged use of diuretics, limited mobility
Magnesium deficiency → patients on diuretic therapy
Zinc and selenium protect cell membrane from free radial injury and are cardioprotective against CAD and cardiac dysfunction
139
What will labs show on Post pericardiotomy syndrome
CBC (leukocytosis, eosinophila), procalcitonin (marker to evaluate presence of bacterial infection), blood cultures, and wound culutres if drainage is present, elevated inflammatory markers (CRP/ESR)
Troponin 1, CKMB, BNP, and lactate levels provide insight into myocardial injury and systemic perfusion
140
HR for SVT
other requirements?
Rates in infants can be 300, adolescents even 220
Rate above 220 infant
children over 180
abnormal P waves
no beat to beat variability
narrow QRS complex tachycardia
141
electrical pathway of the heart
SA node
AV node
Bundle of HIS
Purkinje Fibers
142
Treatment for SVT
w/ poor perfusion synchronized cardioversion starting with 0.5-1 J/Kg and can be increased to 2J/kg
NEVER delay cardioversion while awaiting IV placement in unstable pt
IV access- 0.1mg/kg/dose adenosine (blocks AV conduction thereby terminating most SVT in which the AV node forms part of the reentry circuit)
Caution to use adenosine in astmatic pt as it can induce bronchospasm
Stable pt- vagal maneuvers
Bag of ice on forehead up to 10 seconds
Valsalva maneuver in older pt
Chronic mgmt- digoxin, propranolol, or nadolol
Other tx- antiarrhythmics flecainide, propafenone, sotalol, amiodarone
If other tx fails radiofrequency catheter ablation
143
144
what does Atrial Flutter look like
Regular rhthym
Atrial 250-350 bpm
AV conduction ratio usually 2:1, can be 3:1 or 4:1
P waves that give off a saw tooth appearance
145
Treatment for Atrial Flutter
Medication
cardioversion
Definitive treatment -\> Catheter ablation
rate control-slow ventricular rate digoxin, propranolol, CCB
pts receiving digoxin should avoid cardioversion unless arrhythmia is life threatening (associated with malignant ventricular arrhythmias) rapid atrial esophageal pacing may be effective
rhythm control- antiarrhythmic meds to suppress dysrhythmias
electrophysiology study and catheter ablation are a class 1 indication for recurrent or persistent AF pts over 15kg
146
Atrial Fibrillation - what does this look like
Atrial Heart rate \> 500 BPM
No P waves
No AV conduction ratio
Irregularly irregular rhythm
QRS complexes have no pattern
Ventricular rate of 120-80 bpm
147
Holiday Heart Syndrome
Atrial Fibrillation occurs after Binge Drinking
148
Treatment in Atrial Fibrillation
Treatment- B blockers and CCB
Digoxin, propranolol, verapamil can be used to slow the ventricular rate and reduce patient symptoms
Antiarrhythmic meds reduce risk of recurrence – sotalol and amiodarone
anticoagulant therapy -at risk for clots due to pooling blood
Cardioversion
149
Bundle of Kent
Accessory pathway that acts as a shortcut from Atria to ventricles
WPW syndrome
150
what inherited mutation associated with WPW
Autosomal dominant mutation of the PRKAG2 gene
151
drugs that promote QT that can lead to toursade
antiarrhythmics - blocks sodium and k channels - quinidine, disopyramide, procainamide, lidocaine, mexiletine, flecainide, and propafenone
phenothiazines
tricyclics
ampicillin
organophosphate insecticides
152
Bazett's Formula
To get QTc
Qt (ms)
divided by
The square root of RR(s) divided by 1s
Long QT is \>440 ms males
\>460 ms in females
153
Treatment Toursades
Mag Sulfate (25-50mg/kg max 2g)
Electrical pacing
Mgmt- BB (propranolol 2-4mg/kg/day), atenolol (0.5mg/kg/day), surgical therapy (cardiac pacemaker, ICD, left cardiac sympathetic denervation surgery)
154
causes of V fib
hypoxia, hyperkalemia, digoxin, or quinidine toxicity, MI, myocarditis, or complications from cardiothoracic surgery CHD
155
wide complex tachycardia defined as a series of 3 or more PVCs with a HR between 120 and 200 bpm
Ventricular Tachycardia
156
treatment in unstable Ventricular tachycardia
Synchronized cardioversion
0.5-1J/kg
Pulseless VT -\> defibrilation of 2-4 J/kg
Stable -
antiarrhythmics such as amiodarone, sotalol or lidocaine
157
what congenital defects have R - L shunting
Tetralogy
Transposition
Tricuspid atresia
158
what congenital defects have L to R shunting
Patent ductus arteriosus
VSD
ASD
159
what CHD have mixing of blood (mixed shunting)
Truncus
TAPVR
HLH
160
supravalvar stenosis is associated with what 2 syndromes
Williams syndrome and Alagille syndrome
161
Pulmonary valve doesnt close all the way so in diastole blood leaks back
Pulmonary Regurgitation
162
Pulmonary valve doesnt open all the way in systole making it harder to pump to the lungs
Pulmonary stenosis
163
What two other conditions/syndromes are associated with pulmonary stenosis
Tetrology of Fallot
Noonan's Syndrome
164
when pulmonary stenosis develops over time due to mechanical stress....there is Fibrosis and Calcification of the valve which causes what sound
Ejection click
with Turbulence - Crescendo-Decrescendo murmur Between S1 and S2
165
What happens as a result of Pulmonary stenosis?
**Concentric R ventricular Hypertrophy**
(R ventricle is working harder to push blood past the stenosis...Sarcomeres in the cardic muscle are added in parallel)
Blood backs up -\> **R sided heart failure**
**Microangliopathic Hemolytic anemia** (RBC are damaged having to fit through the valve...get broken into schistocytes and expelled in urine)
**Hemoglobinuria**
**Symptoms**
* Blood Backs up
* **Distended Neck Veins**
* **Swelling in ankles and feet**
* **hepatosplenomegaly**
* **Cyanosis**
* **Shortness of Breath**
* **Fatigue**
166
Treatment for Pulmonary stenosis
Balloon Valvuloplasty
possible PGE
167
Aortic valve doesnt open all of the way during systole making it harder for blood to be pumped to the body
Aortic stenosis
168
What causes Aortic stenosis
Stress over time in adulthood
Bicuspid Aortic Valve - wears down faster
Chronic Rheumatic fever (commisural fusion)
169
what do you hear in aortic stenosis
Ejection Click
crescendo-decrescendo murmur between S1 and S2
170
What does aortic stenosis cause
**Concentric Left Ventricular Hypertrophy**
(Sarcomeres added in parallel)
**Heart Failure - exercise induced symptoms (angina, ect)**
**Microangiopathic Hemolytic Anemia**
**Hemoglobinuria**
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treatment in Aortic stenosis
Initial medical management for a neonate who presents in a low CO state consists od CV resuscitation, inotropic and ventilatory support and initiation of PGE to restore systemic perfusion.
Possible biventricular repair if large enough
For infants catheter balloon valvuloplasty or surgical valvotomy is often initial treatment of choice.
172
What syndrome are individuals predisposed to Bicuspid Aortic Valve
Turner Syndrome (mosaicism)
173
What bp gradient is significant in coarctation
\>20mmHG
174
3 sign on x ray
coarctaion
sonmetimes seen in older children
175
whos more at risk for coarctation
what should they be worked up for?
Females
80% are associated with bicuspid aortic valve
work up for Turner's syndrome
176
4 extremetity blood pressures...what warrants further eval?
SBP \> 15 mmHg than lower extremety
177
treatment coarctation
Initial stabilization includes an infusion of PGE, to restore ductal patency and distal perfusion
Continuous infusion of nipride or B-Blockers like esmolol are often required in the immediate post-op period. Then transition to oral therapy with ACE-I such as captopril or enalapril or B-Blocker like propranolol or atenolol prior to discharge.
Done by left thoracotomy
178
all four pulmonary veins drain aberrantly into the systemic venous system or the RA.
TAPVR
179
4 categories of TAPVR
Supracardiac- most common form, in which the pulmonary veins drain into the SVC via the left vertical vein to the innominate vein.
Infracardiac- 2nd, th pulmonary veins drain into the portal vein, ductus venosus, hepatic vein, or inferior vena cava below the diaphragm. (Most likely to become obstructed).
Intracardiac- pulmonary venous hypertension with resultant pulmonary edema, PH, LCOS and severe hypoxemia.
Or mixed
180
Most common form of TAPVR
the pulmonary veins drain into the SVC via the left vertical vein to the innominate vein.
Supracardiac
181
which type of TAPVR
## Footnote
2nd, th pulmonary veins drain into the portal vein, ductus venosus, hepatic vein, or inferior vena cava below the diaphragm. (Most likely to become obstructed).
Infracardiac
182
which type of TAPVR
## Footnote
pulmonary venous hypertension with resultant pulmonary edema, PH, LCOS and severe hypoxemia.
Intracardiac
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What does the pt look like with obstructed TAPVR
creates pulmonary venous hypertension with resultant pulmonary edema, PH, LCOS, and severe hypoxemia.
There is an increased RV impulse, a widely split and fixed S2 which can be increased, a systolic ejection murmur, and a diastolic rumble if there is excessive flow across the TV.
If there is PV obstruction present with marked cyanosis, LCOS, and respiratory distress in the neonatal period.
A heart murmur is often absent, but there may be a GALLOP!!!
184
What does the pt look like with unobstructed TAPVR
185
snowman sign on x ray
TAPVR
186
187
ECG on TAPVR
R axis deviation and RVH
188
Treatment for TAPVR
Absolutely no nitric oxide!! Giving NO will. Increase PBF to the lungs and is contraindicated in preoperative obstructed pulmonary veins.
These babies need emergent care and surgical repair.
189
Characterized by the aorta arising from the anatomic RV and the PA arising from the anatomical left ventricle. There might be a VSD
Transposition of Great Arteries
190
diabetic mothers are at higher risk for developing the defect
Transposition of Great Arteries
191
2 parallel circuits
Right ventricle attaches to aorta
Left ventricle to pulmonary artery
Transposition of Great Arteries
192
The urgency of repair TGA depends on what
The amound of mixing between the 2 sides (mostly at the ASD)
193
“egg on a string” with a large. Globular heart or be normal, on X ray
Transposition of Great Arteries
194
Treatment for TGA
PGE may be needed to maintain ductal flow but can be trialed off once open atrial communication is confirmed. If desats occur, the infusion should be resumed, and ductal flow is necessary to increase pulmonary venous return to the LA, increasing the pressure gradient between the LA and RA, thereby aiding in atrial mixing.
Trickiest part is moving the coronary arteries to go with the aorta
195
An inflammation of the blood vessels that can lead to necrosis and arterial aneurysms, more specifically coronary artery aneurysms.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1350). Wolters Kluwer Health. Kindle Edition.
Kawasaki disease
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age and gender most affected by Kawasaki
• Affects 9.1 to 32.5 per 100,000 children annually, with a small male predominance. • Most commonly affects patients under the age of 4 years, with a peak incidence between 18
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1350). Wolters Kluwer Health. Kindle Edition.
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diagnostic criteria for Kawasaki disease
* Specific criteria, in addition to fever for 5 days, must be met for the diagnosis of classic (4–5 criteria) or atypical or incomplete Kawasaki (2 criteria).
* Bilateral painless bulbar conjunctival injection: without exudate.
* Changes in lips and oral cavity: injected oral mucosa, dry/cracked lips, strawberry tongue.
* Polymorphous exanthema.
* Cervical lymphadenopathy (≥1.5 cm): typically unilateral.
* Changes in extremities (e.g., palms of hands and/or soles of feet).
Acute: erythema and edema; convalescent: peeling/desquamation.
• Other findings. • Cardiovascular: heart murmur, congestive heart failure, pericardial effusion, **ECG changes** (e.g., arrhythmias, abnormal Q waves, prolonged PR or QT intervals, ST segment changes), and enlarged cardiac silhouette on chest radiograph, myocardial infarction, and arterial aneurysms throughout the body, including the coronaries. •
Gastrointestinal: abdominal pain, diarrhea, nausea and/or vomiting, hepatitis. •
Musculoskeletal: arthritis. • Pulmonary: upper respiratory tract symptoms, pulmonary infiltrate. • Genitourinary: sterile pyuria. •
Joint: arthralgias, arthritis. •
Skin: perineal rash; transverse furrows of fingernails (Beau lines). •
Laboratory abnormalities. • Leukocytosis; increased neutrophils, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelets, serum transaminases, and γ-glutamyl transferase; hypoalbuminemia, anemia. • Sudden-onset high fever: typically the first presenting sign.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1350-1351). Wolters Kluwer Health. Kindle Edition.
Mnemonic CRASH and BURN
C= conjuntivitis
R= Rash
A= Adenopathy (Cervical)
S= Strawberry tongue (Oral Changes)
H= Hands and Feet (extremity changes)
BURN= fever \>5 days
Mnemonic
A, Rash: Maculopapular, diffuse erythroderma, or erythema multiforme-like.
B, Conjunctivitis: Bulbar conjunctival injection without exudate; bilateral.
C, Oral changes: Erythema and cracking of lips (cheilitis); strawberry tongue; erythema of oral and pharyngeal mucosa.
D and E, Palmar and plantar erythema: Usually accompanied by swelling; resolves with subsequent periungual desquamation in the subacute phase.
F, Cervical adenopathy: Usually unilateral, node ≥1.5 cm in diameter.
G, Coronary artery aneurysms:
H, Peripheral artery aneurysms:
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3 phases of Kawasaki
Acute - weeks 1-2
Subacute: week 2-4
Convalescent - week 3 - 8
199
pertinent labs in Kawasaki
• Inflammatory markers: elevated CRP and ESR. • CBC: leukocytosis, neutrophilia, eosinophilia, anemia, and thrombocytosis. • Metabolic panel: hypoalbuminemia, hypokalemia, elevated transaminases and GGT, elevated pancreatic enzymes. • Coagulation factors: elevated fibrinogen.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1351-1352). Wolters Kluwer Health. Kindle Edition.
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Treatment for Kawasaki
Prompt diagnosis is key. •
IV immunoglobulin (IVIG) 2 g/kg. •
Aspirin (ASA) 80 to 100 mg/kg/day divided every 6 hours and weaned with defervescence. •
Long-term therapy: Treatment is tailored to the risk level identified and includes: •
Risk level I: no coronary involvement. ASA for 6 to 8 weeks with counseling follow-up every 5 years. •
Risk level II: coronary artery dilation with resolution by 8 weeks. ASA for 6 to 8 weeks with counseling follow-up every 3 years. •
Risk level III: coronary aneurysm measuring 3 to 6 mm. ASA until resolution of aneurysm and limited activity for 8 weeks if \<10 years of age. Stress test every 2 years and prior to admission into sports for those \>10 years of age. Annual echocardiography and angiography if abnormal stress test is observed. •
Risk level IV: nonobstructive coronary aneurysm measuring \>6 mm and/or multiple complex aneurysms. Long-term ASA in addition to anticoagulation therapy. Annual stress test, biannual echocardiography and ECG in addition to a cardiac catheterization on a biannual or annual basis. No high-impact sports. Counseling. •
Risk level V: obstructed coronary aneurysms. All recommendations included in risk level IV in addition to β-adrenergic blocking agents.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1352-1353). Wolters Kluwer Health. Kindle Edition.
DO NOT DELAY TREATMENT OF KD TO OBTAIN ECHOCARDIOGRAM CONFIRMING KAWASAKI DISEASE!
The mainstay initial treatment for both complete and incomplete KD is a single high dose of IVIG together with acetyl- salicylic acid (ASA), which is supported by clinical trial evidence. The efficacy of IVIG administered in the acute phase of KD is well established to reduce the prevalence of coronary artery abnormalities
ASA has been used in treatment of KD for many years. Although ASA has important anti-inflammatory activity (at high doses) and antiplatelet activity (at low doses), it does not appear to lower the frequency of development of cor- onary abnormalities.177 During the acute phase of illness,
Give High-dose IVIG (2 g/kg given as a single intravenous infusion) within 10 days of illness onset but as soon as possible after diagnosis,
Only give past the 10th day in presence of fever, and significant elevation of inflammatory markers, or coronary artery abnormalities
ASA is administered every 6 hours, with a total daily dose of 80 to 100 mg·kg. ASA is reasonable until the patient is afebrile
Corticosteroids have only been shown to benefit in very high risk cases
IVIG RESISTANCE
IVIG second course 2g/kg
Methylpred 20-30 mg/kg IV x 3 days
Infliximab may be given instead of second course IVIG
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Treatment in syncopy
Neurocardiogenic:
90% of patients will have improved symptoms with increased fluid and salt intake. Goal for teen girls is 3L daily and goal for teen boys is 3.5L daily, along with 8 gm extra sodium
Abortive techniques: lying down with presyncope, compression stockings to prevent venous pooling, counter-pressure maneuvers like squatting and leg crossing, and avoiding stimuli that cause syncope
2nd line treatment includes midodrine, fludrocortisone, SSRIs, and beta blockers
Admit if central cyanosis, abnormal ECG, pathologic cardiac murmur, history of CHD repair, loss of consciousness \>5min, neurological deficit, severe dehydration, severe anemia, adrenal crisis, severe hypoglycemia
202
what lesions need PGE
Used for cyanotic lesions such as Pulmonary stenosis, Aortic Stensosis, Coarc, TOF, TGA, TAPVR
203
meaning of spleen and liver enlargement
Liver -\> systemic venous congestion
Spleen -\> consider infective endocarditis
204
Wide pulse pressure may be seen in
PDA, truncus arteriosus, AC malformations, aortic insufficiency
205
Narrow pulse pressure seen in
pericardial tamponade, aortic stenosis, HF
206
excellent data as to systemic and pulmonary venous anatomy, proximal pulmonary pulmonary artery anatomy, relationships of great arteries and arch abnormalities
Chest CT angiogram
207
what can cause vocal cord paralysis
Important cause of laryngeal dysfunction
May be unilateral or bilateral
Mostly caused by damage to recurrent laryngeal nerve then by central lesion → Left recurrent laryngeal nerve passes around the aortic arch and is more susceptible to damage then right laryngeal nerve
Causes
Peripheral nerve damage (neck traction during delivery of infant or thoracic surgery), mediastinal lesions
Central causes → arnold-chiari malformation, hydrocephalus, intracranial hemorrhages
208
manifestations of vocal cord paralysis
bipasic stridor
alterations in voice and cry, including weak cry in infants
Hoarseness
Aphonia
At risk for aspiration → manifested by cough/choking with drinking, coarse airway sounds audibly and by auscultation
209
treatment in vocal cord paralysis
patients with traumatic injury to recurrent larygneal nerve often have spontaneous improvement over time, usually within 3-6 months
if paralyzed vocal cord not recovered in 1 year of injury → likely permanently damanged
Gelform injection of a paralyzed vocal cord can responsition the cord and improved phonation and airway protection
patient who have severe airway obstruction and aspiration may need tracheostomy tube placement
210
Neonatal infections
- Common organisms
- empiric treatment
## Footnote
Common organisms: GBS, E. coli, Listeria monocytogenes, S. aureus, Enterococcus species, HSV, CMV, Varicella-zoster virus, RSV, Candida species
ampicillin, gentamicin or cefotaxime, when HSV is suspected acyclovir
211
Treatment for
## Footnote
Acute Bacterial Sinusitis
Amoxicillin or
Augmentin
212
Treatment for
Acute pharyngitis
strep +
Amoxicillin or penicillin
213
Treatment for Adenovirus
supportive care
immunocompromise receive
Cidofovir
214
Treatment for Acute otitis media
215
Pneumonia
Common causes by ages
**Neonates \< 30 days**
* Bacteria
* E.coli
* Group B Streptococcus
* Listeria Monocytogenes
* Other Causes
* Bacteria
* Group D strep
* H. Influenzae
* Strep pneumoniae
* Ureaplasma urealyticum
* Bordetella pertussis
* Viruses
* Herpes simplex virus
* Cytomegalovirus
**1-3 months**
* Bacteria
* S. pneumoniae
* Chlamydia Trachomatis
* B.pertussis
* Viruses
* RSV
* Influenza
* Parainfluenza
* Adenovirus
* Other causes
* Bacteria
* H.Influenzae
* Moraxella catarrhalis
* Staph aureus
* U. urealyticum
* Virus
* Cytomegalovirus
* Metapneumovirus
3 mos - 5 years
* Bacteria
* Mycoplasma pneumoniae
* C.Trachomatis
* S.pneumoniae
* Virus
* RSV
* Influenza
* Parainfluenza
* Adenovirus
* Rhinovirus
* Other
* Bacteria
* H.Influenzae
* M.catarrhalis
* S. aureaus
* Neisseria meningitis
* mycobacterium tuburculosis
* Varicella-zoster
5 years to adolescents
* Bacteria
* M.pneumoniae
* C.Trachomatis
* S.pneumoniae
* Other
* Bacteria
* H.influenzae
* Legionella Species
* M. tuberculosis
* S.aureus
* Virus
* Adenovirus
* Ebstein-Barr virus
* Influenza virus
* Parainfluenza
* Rhinovirus
* RSV
* Varicella-zoster
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Treatment for Pneumonia by age
**Birth - 1 month:** Parenteral Ampicillin and gentamicin. Can consider cefotaxime in addition to or in lieu of gentamicin
**1 month to 3 months well appearing:** Amoxicillin (high dose)
Alternative agents: Sulfamethoxazole/trimethoprim, amoxicillin-clavaulanic acid, or macrolide. Can also use parenteral ceftriaxone for first dose then change to oral amox
**1 month to 3 months ill appearing:** Parenteral cefotaxime or cefuroxime
consider addition of macrolide if concerns for pertussis or chlamydia
**4 months to 5 years:** Amox (high dose)
Alt: Sulfamethoxazole/trimethoprim, Augmentin or macrolide
**\>5 years to adolescence:** Macrolide alone if low suspicion of Strep pneumoniae
Add: If persist or conern for S. pneumonia - Add B-lactam antibiotic such as amox or cephalosporin
217
synagis qualifications
Synagis is indicated for the prevention of serious lower respiratory tract disease caused by RSV in children at high risk of RSV disease
* Infants born before 29 weeks, 0 days gestation who are younger than 12 months at the start of RSV season
* For infants born during the RSV season, fewer than 5 monthly doses will be needed
* If born greater than 29 weeks, 0 days may qualify for if
* Congenital heart disease
* Acyanotic heart disease who are receiving medication to conrol congestive heart failure and will require cardiac surgical procedures and infants with moderate to severe pulmonary hypertension
* Cyantoic heart disease- cardiac specialist decides
* Recommendations apply to infants in the first year of life who are born within 12 months of onset of the RSV season
* After surgical procedures that involve cardiopulmonary bypass, for children who are receiving prophylaxis and who continue to require prophylaxis after a surgical procedure, a post operative dose of palivizumab (15mg/kg) should be considered after cardiac bypass or at the conclusion of extra corporeal membrane oxygenation for kids \<24 months
* Children \<2yo undergo cardiac transplantation during the RSV season may be considered for palivizumab
* DO NOT give it to
* Hemodynamically insignificant heart disease
* Secundum atrial septal defect,
* Small ventricular septal defect
* Pulmonic stenosis
* uncomplicated aortic stenosis
* Mild coarctation of the aorta
* Patent ductus arteriosus
* Infants with lesions adequately corrected by surgery, unless they continue to require medication for CHF
* Infants with mild cardiomyopathy who are not receiving medical therapy for condition
* Children in the second year of life
* Chronic lung disease
* Gestation age \<32 weeks, 0 days and requirement of \>21% Oxygen for at least the first 28 days of birth- during first year of life, during RSV season
* Only recommended in second year of life if meat CLD requirement and continue to require medical support (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) during the 6th months prior to the second RSV season
* Or another condition
* Infants with neuromsk disease or congenital anomaly that ipparis the ability to clear secretions from the upper airway because of ineffective cough are known to be at risk for a prolonged hospitalization and should be considered during the first year of life
* If \<24mo and severely immunocompromised (chemo/ transplant/ etc) during the RSV season
* Down syndrome only if they meet other qualifications (HD, CLD, premature)
* Cystic fibrosis only if
* CLD and/ or nutritional compromise in first year of life
* Second year of life if severe lung disease or weight for length less than the 10th percentile
* Typically NOT recommended in the second year of life
* Unless CLD who continues to require medical interventions 6 months prior to the RSV season
* If any infant/ child is hospitalized with RSV while receiving vaccine, the vaccine monthly should be discontinued bc the likelihood of a second infection is very low
* Those in neonate area who qualify should receive the first dose 48-72 hours before discharge to home or promptly after discharge
* Hospital prevention is based off of adherence to infection-control practices
RSV Seasonality
* 5 monthly doses at 15mg/kg will provide more than 6 months of serum palivizumab concentrations above the desired level
* Not recommended to give more than 5 doses
* Typically November- march (coverage till april)
* If october -february (coverage till march)
* If initiated in december- april (covers may)
* If born in january receive last dose in march
*
218
219
Croup
What causes it
How do you treat it
Parainfluenza 1,2,3,4
RSV
Dex 0.6mg/kg x 1 dose
Racemic epi (peak effect 10-30 min fades 60-90 min)
Rebound effect may occur- monitor for 3 hours after rac epi
may repeat racemic epi every 20 min for 1-2 hrs max
220
Meningitis common organisms by age
**Neonates \<3 mth**
* GBS
* E.Coli
* Listeria monocytogenes
* Other gram neg bacilli
* HSV can cause severe encephalitis
* Less common
* Listeria monocytogenes
* Enterococcus faecalis
* Neisseria Meningitis
* Strep pneumoniae
* other streptococci
* Citrobacter species
* Salmonella
* Pseudomonas aeruginosa
* Haemophilus influenzae
* Staphylococcus aureus
**1-3 months**
* S.pneumoniae
* Gram-neg bacilli
* GBS
* Less common
* N. miningitidis
\> 3 months
* S. pneumoniae
* Neisseria meningitidis
* less common
* Gram neg bacilli
* Group B strep
3 months- 9 years
* Streptococcus pneumoniae & Neisseria meningitidis are the most common causes of acute bacterial meningitis.
* Group B streptococcus is responsible for a small percentage.
10 years – 18 years
* N. meningitis is responsible for the majority of bacterial meningitis.
* H. influenzae should be considered for those unvaccinated from Hib vaccine and those from underdeveloped countries.
Enteroviruses are the most common cause of viral meningoencephalitis.
Arboviruses, transmitted commonly via vectors such as mosquitoes and ticks are responsible for some cases of meningoencephalitis in summer months.
* West Nile, La Crosse, Powassan and St. Louis are the most common.
221
Kernig and Brudzinski sign
meningitis
222
meds for Meningitis
Newborns (0-28 days)
* Cefotaxime plus ampicillin with/without gentamicin
* Alternative - ampicillin plus gentamicin
Infants and toddler (1 month to 4 yrs)
* Ceftriaxone or cefotaxime plus vancomycin
Children and adolescents 5-13 plus adults
* ceftriaxone or cefotaxime plus vancomycin
* Alt Cefepime plus vancomycin
Children \> 1 month
Empirical board spectrum antimicrobial coverage with vancomycin and either cefotaxime or ceftriaxone should be started.
Acyclovir should be initiated for all infants and children with suspected HSV encephalitis.
Duration of treatment (N. 388)
N. meningitidis is 5-7 days
H. Influenzae is 7-10 days
S. pneumoniae is 10-14 days
Gram-negative bacilli should be treated for a minimum of 21 days or 14 days beyond the first negative CSF culture, whichever is longer.
Lipincot:
Recent neurosurgery or ventricular shunt: coagulase-negative staphylococci (Staphylococcus epidermidis), methicillin-susceptible and methicillin-resistant Staph. aureus (i.e., MSSA, MRSA), aerobic gram-negative bacilli (Pseudomonas aeruginosa), Propionibacterium acnes.
* vancomycin + cefepime; vancomycin + ceftazidime; or vancomycin + meropenem.
Basilar skull fracture: Streptococcus pneumoniae, Neisseria meningitidis, Strep. pyogenes. •
* Management: vancomycin + 3rd-generation cephalosporin.
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otitis media common organisms
* strep pneumoniae
* nontypable Haemophilus influenzae
* moraxella catarrhalis
* Group A strep - less frequent
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treatment for Otitis media
* The recommended first-line therapy for most children meeting criteria for antibiotic therapy is amoxicillin (80-90 mg/kg/day in two divided doses)
* Some children with mild illness or uncertain diagnosis may be observed if appropriate follow-up within 48-72 hours can be arranged with initiation of antibiotic therapy if symptoms do not self-resolve.
* The failure of initial therapy with amoxicillin at 3 days suggests infection with β-lactamase-producing H. influenza, M. catarrhalis, or resistant Strep. pneumoniae.
* Recommended next-step treatments include high-dose amoxicillin-clavulanate (amoxicillin 80-90 mg/kg/day), cefdinir, or ceftriaxone (50 mg/kg IM in daily doses for 3 days).
* IM ceftriaxone is especially appropriate for children with vomiting that precludes oral treatment.
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MSSA treatment
Treatment options: \*
**Cefazolin,** oxacillin, or **nafcillin** IV or cephalexin PO
Alternative options: Clindamycin or vancomycin IV; clindamycin PO
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MRSA treatment
Treatment options:\*
Vancomycin
Clindamycin - Some may become resistant; should be considered in refractory hypotension with concern for toxic shock.
Bactrim
Linezolid
Daptomycin - Not for treatment of pneumonia or children \<1 yrs.
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ABX for appendicitis
Piperacillin/Tazobactam (Zosyn)
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Clostridium difficile treatment
Discontinue inciting abx
Metronidazole is currently the drug of choice for the initial treatment of children and adolescents with mild to moderate disease
Oral vancomycin or vancomycin administered by enema with or without intravenous metronidazole is indicated as initial therapy for patients with severe disease and for patients who do not respond to oral metronidazole.
Severe or fatal disease is more likely to occur in neutropenic children with leukemia, in children with intestinal stasis (eg, Hirschsprung disease), and in patients with inflammatory bowel disease.
Antiperistaltic medications should be avoided because they may obscure symptoms and precipitate complications, such as toxic megacolon.
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organisms for Fever of unknown orgin (temp \>100.9 most days for at least 3 weeks or after a week of intense eval without diagnosis)
Most common infecious causes: EBV, Bartonella henselae, UTI and osteomyelitis
Salmonellosis
Tuberculosis
Rickettsia diseases
Syphilis
Lyme disease
Cat-Scratch disease
Atypical prolonged common viral disease
EBV
CMV
Viral hepatitis
Coccidioidomycosis
Histoplasmosis
Malaria
Toxoplasmosis
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TB organisms
Caused by an acid-fast bacilli of the mycobacterium tuberculosis complex
Most common cause is M. Tuberculosis
Also caused by M. bovis, africanum, bovis BCG, caprae, mungi, orygis, canetti, microti
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TB treatment
Steroids as adjunctive therapy for TB meningitis reduce death and tuberculomas
* Dexamethasone 0.3-0.4 mg/kg/day for first 2 weeks then tapered for 2 weeks
* Prednisolone 2mg/kg/day for 2 weeks then tapered for 2 weeks
Used liquid and fixed dose formulation for best adherence
Child may always have “abnormal” CXR
Drug related hepatitis is concern with isoniazid and rifampin therapy
* Peripheral neuritis is rare but can occur with INH therapy, can be prevented with concomitant administration of pyridoxine
* Rifampin will change color or urine to deep organ red during initial part of therapy
Severe cases of TBM or military TB- do monthly liver function test
* Contact clinician with signs of hepatoxicity- vomiting, abdominal pain, jaundice
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malaria organism
P. falciparum
* P. falciparum accounts for the majority of severe malaria and death
* The vast majority of of persons returning to the US infected with P. falciparum acquired the infection in sub-saharian Africa during the previous 1-2 months.
* P. vivax, P. ovale, P. malariae, P. knowlesi
\*A traveler returning from an endemic area with fever has malaria until proven otherwise\*
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treatment of malaria
Atovaquone-proguanil and artemether-lumefantrine are first-line treatments for chloroquine resistant malaria, which is present throughout the world with the exception of Central and South America and some countries in the Middle East.
For severe malaria, IV quinidine or artesunate are recommended.
* Special attention should be given to blood glucose and cardiac rhythm with IV quinidine, given possible hypoglycemia and long QT syndrome.
Exchange transfusion may be considered when parasitemia reaches greater than 5-10%.
Consultation with subspeciality services is based on severity of presentation and patient’s response to therapy
* Specialists from ID, neurology, GI, nutrition, critical care and rehabilitation medicine may be valuable.
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Pertussis (Whooping cough) organism
Caused by Bordetella pertussis, a gram negative pleomorphic bacillus
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Treatment of pertussis
Macrolide antibiotics (azithromycin, clarithromycin, or erythromycin)
erythromycin not recommended for neonates due to development of pyloric stenosis
Treatment during the catarrhal phase eradicates nasopharyngeal carriage of organisms within 3-4 days and may lessen symptoms
Treatment during the paroxysmal stage does not alter the course of the illness but decreases potential for spreading the disease to others.
Hospitalize young infants or any age group with moderate to severe resp distress, dehydration, or evidence of encephalopathy
Prevention: DTaP
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Rocky Mountain spotted fever organism
Infection with Riskettsia rickettsii, an obligate intracellular gram (-) coccobacillus, results in vasculitis
from ticks or blood transfusion (Rare)
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organism for Lyme disease
After inoculation of Borrelia burgdorferi spirochetes into the skin by the black-legged tisk, the organism disseminates to numerous organs → immune respone
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treatment for lyme
Treatment
Doxcycline for 10 days (10 days or less are safe and have not been proven to cause dental staining in children less than 8 years old), Amoxicillin for 14 days, or Cefuroxime for 14 days
Alternative therapy includes azithromycin for 14 days
Arthiritis is treated using the same oral regimen as for early localized disease but for 28 days. For persistent or recurrent arthritis, the doxy course should be repeated or IV ceftriaxone for 14-28 days
Mycoarditis is treated with IV cetriaxone for 14-21 days
CNS disease is treated with IV ceftriaxone for 14 days
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Treatment for Rocky Mountain spotted fever
Treatment: may take several weeks to resolve
\*\*Treatment should not await serologic confirmation in the appropriate epidemiologic and clinical setting\*\*
Doxcycline is favored for all ages of children for 7-10 days and continue until fever has ceased for 72 hours and clinical disease has resolved.
Fluoroquinolones may be effective
Chloramphenicol was the previous standard but it no longer recommended
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Viral Meningitis Treatment
Usually self limiting
However if HSV suspected to be the cause -Acyclovir IV
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Bronchilitis Pathogens
RSV
Adenovirus
influenza
parainfluenza
Human metapneumovirus (hMPV)
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How do you close a PDA
Endomethacin
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Common heart defects in Down syndrome
AV septal defect
VSD
PDA
TOF
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Which meningitis has
increased protein and low glucose in CSF
Bacterial
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which type of meningitis
has WBC \<100 on CSF
Viral
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acidosis and hypercarbia _____ pulmonary vascular resistance which can cause worsening hypoxia.
increase
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Suspicious for meningitis
CSF contains RBC in a non-bloody tap
what does this mean
Suspicious for HSV meningitis. Start Acyclovir
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what syndrome commonly has TOF
DiGeorge
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what syndrome goes with cardiomyopathy
Noonans
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Viral causes of myocarditis
specifically
Coxsackie Viruses A and B
Parvovirus B19 and Human Herpesvirus type 6
not as common, Adenovirus
EBV
Hepatitis C
influenza
parainfluenza
HIV
CMV
unusual for herpes to be isolated and most commonly parvovirus or coxsackie viruses are isolated.
