Unit 2: Ped Cards Flashcards
______% of pts with trisomy 21 have what type of cardiac lesions?
40%
structural cardiac lesions
all patients with Trisomy 21 should have what diagnostic test?
echo
what two valve regurgitations are common in pts with Marfans?
Mitral and Aortic (MArfans)
What cardiac defect is associated with Turners?
Coarctation
What three cardiac defects are associated with Noonan syndrome?
- pulmonary stenosis
- ASD
- cardiomyopathy
what cardiac defect is common in pts with fetal alcohol syndrome?
- VSD
* vodka septal defect
what difference in blood pressures would you expect to see in Coarctation of Aorta?
- discrepancy btwn upper and lower extremities
- arms are higher bp than legs
- if 20mm hg difference suspect COA
what difference in blood pressures would you expect to see in Supravalvular Aortic Stenosis?
- Higher in right arm than left arm
- supravalvular… R comes before L
- R > L
what difference in blood pressure would you expect to see with Aortic Valve Stenosis?
Narrow pulse pressure
what BP difference would you expect to see in Aortic Regurg or Insufficiency?
Wide pulse pressure
things to look for in general PE (8 things)
- distress
- cyanosis
- clubbing
- edema
- squatting (compensatory reaction)
- diaphoresis
- syncope
- tachypnea
4 things to inspect or palpate for on cardiac assessment
- lifts
- heaves
- thrills
- PMI
3 things to inspect or palpate for on abd assessment
- hepatomegaly
- spleenomegaly
- ascites
what three dx tests help define cardiac disease?
- xrays “radiographs”
- ECG
- ECHO
most common pediatric cardiology referral is what?
“innocent heart murmurs”
name the 5 innocent heart murmurs from the ppt
- newborn
- still murmur
- pulmonary ejection
- venous hum
- carotid and cranial bruits
newborn murmur is heard when in the lifespan?
first few days of life
where is the newborn murmur heard?
LL sternal border
newborn murmur description?
short systolic grade I-II
newborn murmur is heard at the ______ sternal border and is described as _______ systolic, grade_____
- LL sternal border
- short systolic
- grade I-II/VI
still murmur is heard when in the lifespan?
*2-7y
still murmur is described as?
*musical or vibratory
still murmur is described as long or short?
short
still murmur is low or high pitched?
high
still murmur is systolic or diastolic?
sys
still murmur is loudest where? and in what position?
- midway btwn apex and L sternal border
* loudest when supine
which murmur is the most common in older kids and adults?
(a common tourist site, Pulmonary cannon…)
pulmonary ejection murmur
when is pulm ejection murmur heard in the lifespan?
3y and up
is pulm murmur soft or loud?
soft
is pulm ejection murmur systolic or diastolic/
sys
where is pulm ejection murmur heard?
Left upper sternal border (Light Up Sky Bombs)
what grade is pulm ejection murmur?
grade I-II/VI
can launch 1-2 hundred yards
when in the lifespan is a venous hum heard?
2y and up (venus has 2 musical note tattoos)
where is the venous hum located? and best heard in what position?
- Right infraclavicular area
* sitting position
how is venous hum described?
continuous musical
what grade is venous hum?
Grade I-III/VI (tattoo took 1-3 hours)
carotid bruit is heard when in the lifespan?
“older child & adolescent”
where is the carotid bruit heard?
supraclavicular area
how is carotid bruit described? (length and timing)
long systolic (long HYStory of being ejected from school…)
what grade is carotid bruit?
grade II-III/VI
innocent murmurs must be distinguished from what?
murmurs due to underlying pathology
what 3 acquired heart diseases do we need to know?
- kawasaki
- rheumatic fever
- endocarditis
kawasaki causes (4)
- bacterial
- viral
- environmental
- genetic
what is kawasaki’s effect on the heart/vessels?
inflammation in medium arteries including coronaries
clinical s/s of kawasaki
- fever
- conjunctivitis
- erythema of lips and oral mucosa
- peripheral erythema/edema
- rash and peeling skin
- cervical adenopathy
how is kawasaki dx’d?
- ECHO
* must have 5d of fever and at least 4/5 symptoms
who is most at risk for rheumatic heart disease?
- AAs
- females
- children
- adolescents
RHD is usually proceeded by an ______ infection with what pathogen?
- URI
* Group A beta-hemolytic
what is the most serious consequence of rheumatic fever?
carditis
treatment of RHD
long acting benzathine PCN
- ASA (naproxen)
- corticosteroids for carditis
endocarditis usually occurs in children with a history of ??
*congenital heart disease
endocarditis can occur due to?
invasive instrumentation like central venous catheters
“A&P of endocarditis”
*infection of endocardium from fungus or bacteria
clinical s/s of endocarditis
- prolonged fever
- vasculitis (petechiae, splinter hemorrhages of nails, conjunctival hemorrhages, janeway lesions)
- osler nodes
- clubbing of fingers
- positive blood cultures
treatment for endocardidis
*treat underlying pathogen with abx or antifungals
pts w high risk of recurrent endocarditis may require what?
future prophylaxis for 5-10y or until age 21. see module 2 Q&A for good questions and answers
what arrythmias from ppt?
- sinus
- prolonged QT
- PACs
- wandering atrial pacemaker
- SVT
how are arrythmias diagnsed?
EKG
sinus arrythmia: rate _____ during inspiration and _______ during expiration
- increases
* decreases
prolonged QT can be a cause of ______ in ______
- sudden death
* athletes
PACs are _____ in the absence of underlying heart disease
*benign
wandering atrial pacemaker means?
*impulse has wandered from sinus node to another atrial site
SVT is also known as
WPW - wolff parkinsons white
structural cardiac defects from ppt
- PDA
- foramen ovale
- ASD
- VSD
- AVSD
- coarctation
- tetrology
in normal infants the ductus arteriosis spontaneously closes at what age?
1-5 days
A&P of PDA?
persistence of nomral fetal vessel joining the pulmonary to the aorta
blood shunting pathway of PDA?
- Left to right
* normal pulmonary vascular resistance
s/s PDA
- FTT
- tachypnea and diaphoresis with feeding
- bounding peripheral pulses if defect is large
PDA murmur sounds like what?
continuous rough machinery
where is PDA loudest?
2nd LEFT intercostal space
PDA is dx’d how?
echo directily visualizes
treatment of PDA
surgical closure
*premies > 1200gms at birth have success with indomethiacin (NSAID)
A&P of PFO
is NORMAL and necessary for fetal circulation.
*a hole in the septum btwn left and right atrium
clinical s/s/ PFO
- stroke
* nothing else??
PFO murmur systolic or diastolic?
systolic ejection
dx of PFO
- “imaging”
* ECHO
treatment of PFO
surgery to close
anticoagulants to protect against stroke.
A&P of ASD
*opening btwn sep
A&P of ASD
- hole in septum betwen atria
* blood shunts left to rigth
heart sounds w ASD
- fixed widely split S2
* RV heave
murmur of ASD. where?
systolic ejection murmur
*pulmonary area
grade of ASD murmur?
grade I-II/VI
larger ASDs will have a different murmur. what/where
- diastolic flow
* LL sternal border
s/s ASD?
frequently asymptomatic and often goes unnoticed into adulthood
ASD dx?
- radiographs
- EKG
- ECHO
treatment for ASD?
surgical or catheterization to close for symptomatic children with large defect and associated right heart dilation
VSD A&P
septal defect between ventricles
VSD blood shunting
left to right with normal pulmonary resistance
VSD s/s
- usually appear in infancy
* FTT, tachypnea and diaphoresis with feeding is a significant sign of HF
VSD dx
- radiogrpahs
- EKC
- ECHO
treatment of VSD
manage HF
surgery
AVSD commonly dx’d in which genetic disorder
Down’s
does ASVD spontaneously close?
no
A&P of ASVD
*“incomplete fusion of embryonic endocardial cushions, varying degrees of AV valves abnormality”
murmur of ASVD?
- often inaudible in neonates
* loud pulmonary component S2
heart sounds with ASVD?
loud pulmonary component of S2
dx of ASVD?
ECHO will show cardiac enlargement
*EKG shows extreme left axis deviation
treatment of ASVD
- SURGERY
* urgency depends on significance of defect and symptoms (arrythmias, HF, pulm HTN)
carctation of the aorta is the leading cause of _____ in the 1st month of life
HF
COTA affects males ______x more than females
3
most females who have COTA also have what genetic disorder
turners
A&P of COTA
narrowing of the aortic arch
cardinal s/s of COTA
absence of femoral pulses
BP difference of COTA
upper to lower extremity systolic pressure gradient greater than 20mm hg. does this mean the upper extremities are 20 points high SBP than the lower extremities? must due to absence of femoral pulses being a cardinal sign of COTA
COTA murmur sound and location
blowing systolic
back or left axilla
dx of COTA
radiographs
EKG
ECHO
treatment of COTA
PGE2 (prostaglandin used to maintain ductal patency and preserve systemic perfusion until surgery )infusion until stabilized then surgery to correct
Tetralogy of Fallot A&P… seems vague. check chart
*anterior deviation of infundibular septum causes narrowing of the RV outflor tract, right side arch of aorta in 1/2 of pts
murmur timing and location of TOF
systolic ejection
left sternal border
clinical s/s TOF
- hypoxemia in infancy
- fatigue
- dyspnea on exertion
- clubbing of fingers and toes
- chronic arterial desaturation causes elevated RBCs and H&H
diagnosis of TOF
2 dimensional imaging
treatment of TOF
early surgical repair
HF: important to determine the _____
*cause
right and left HF can result from ______ or _______ overload
*volume or pressure
HF occurs when the heart fails to meet _____ and _____ demands of the body
- circulatory
* metabolic
HF c/c
- irritability
- diaphoresis with feedings
- fatigue
- exercise intolerance of evidence of pulm congestion
dx of HF
symptoms
radiographs
EKG
ECHO
treatment of HF
focus on improving cardiac function with
- ACEI (FIRST LINE)
- diuretics
_______ are the first line therapy for children requiring long term treatment of HF
ACE INHIBS
see zitelli and davis ebook for pics of
*clubbing
cyanosis
*appearance of children w genetic syndromes with associated cardiac abnormalities
tbl 20-13 in hay for Jones criteria for dx of rheumatic fever
MAJOR manifestations
- carditis
- polyarthritis
- sydenham chorea
- erythema marginatum
- subcu nodules
MINOR manifestions
clinical s/s = previous rheumatic fever or rheumatic heart disease, polyarthralgia
labs = elevated sed rate, CRP, leukocytosis in acute phase
EKC = prolonged QT interval
PLUS supporting evidence of prior strep infection (increased antistreptolysin O or other strep antibodies, positive throat culture for GAS
a still murmur is usually present btwn ______ years of age. Its timing is _____ and _______. Its sound is ______ pitched and ______/______. location is between _____ and _______. best heard in what position?
- 2-7y
- timing = short and systolic
- high pitched and muscial/vibratory
- apex and LSB
- supine
after 2-7 white russians the dude just wants to lay STILL for a short siesta and vibe to some music by apex and LSB. don’t bother him for at least 1-3 hours.
- age = 2-7 years
- STILL MURMUR
- timing = short, systolic (siesta)
- vibratory/musical
- btwn apex and LSB
- grade 1-3
PULMONARY cannon has been open for 3+ years now and is known for its soft ejection SYStem that can launch LIGHT UP SKY BOMBs at least 1-2 hundred yards
- Pulmonary ejection murmur
- age = 3+ years
- timing = soft, systolic ejection murmur
- location = LUSB (left upper sternal border)
- grade 1-2
VENUS hums to herself continuously so she got a tattoo of 2 music notes under her right collar bone. She sat in the tattoo chair for 1-3 hours.
- venous hum
- timing and sound = continuous musical
- age = 2+ years
- location = right infraclavicular
- best heard = sitting
- grade 1-3
CARson is a brute of an older child, almost adolescent. He has a long HYStory of being ejected from 2-3 schools. You can tell he’s angry when his veins right above his clavicle start popping out.
- carotid bruit
- age = older child and adolescent
- timing = long systolic ejection
- grade 2-3
- location = supraclavicular
Lora Lee StarBucks is a new barista. She has only been working for a few days but has already found 1-2 SHORTcuts to learning the SYSTEM.
- NEWborn murmur
- location = LLSB
- age = first few days of life
- grade 1-2
- timing: short, systolic
P to the A from the left to the right. PVR is normal, you can breathe pretty well til you feed at night. 2nd LIS with a rough machine sound, bounding peripheral pulses if a large defect is found. Indometh for premies like Seth.
- PDA
- sound: continuous rough machinery
- blood flow: L –> R, with normal PVR
- location: 2nd LIS
- bounding peripheral pulses if defect is large
- FTT, tachypnea, diaphoresis with feed
- indomethacin for premies
V. S. D. heard at the double LSB. Holosystolic with a RV heave. left to right flow, hard to feed though. normal PVR but you get HF and a surgery scar.
- VSD
- location LLSB
- holosystolic
- RB heave
- FTT, tachypnea, diaphoresis with feed
- treat HF
- surgery
PFO, but ya might now know til ya have a stroke. Migraines are no joke. Systolic Ejection Murmur might be your only hope.
- PFO
- thrombosis, migraine
- systolic ejection murmur
ASD with a RV heave. S2 with a fixed wide split. grade 1-3 because of it. Listen to the LLSB if you wanna take charge. You’ll find a diastolic murmur if the defect is large.
- ASD
- fixed wide split S2
- RV heave
- grade 1-3
- diastolic murmur if defect is larger, heard at LLSB
AVSD cant hear in neonates but when older an S2 pulmonary sound resonates. EKG may show left axis deviation. Surgery urgency depends on acuity of situation.
- ASVD
- incomplete fusion of embryonic endocardial cushions, varying degrees of AV valves abnormality
- murmur often inaudible in neonates
- loud pulmonary component of S2
- surgery
COA. you’re gonna have a bad day when your femoral pulses go away. 20mm mercury upper over lower. systolic murmur sounds like a leaf blower. Listen at the back or left armpit. Girls with Turner’s are a known culprit. Boys are 3x more affected. PGE2 helps keep blood flow connected but surgery is the ultimate intervention. Heart failure in the first month might be your first hunch.
- COA
- absence of femoral pulses
- UE BP 20mm hg higher than LE
- boys 3x more than girls
- girls with Turners
- PGE2 infusion to keep patent until surgery
- leading cause of HF in first month
Tet is a bet you’re going to the Operating room. hypoxemia and cyanosis seem like certain doom. systolic ejection at left sternal border. dyspnea on exertion is certainly in order. chronic desat causes clubbing of digits, elevation of RBCs, hgb, hematocrit.
- four defects: VSD, PS, misplaced aorta, RV hypertrophy.
- hypoxemia, cyanosis, DOE, clubbing of fingers/toes, elevated RBCs, H&H
- 2 dimensional imaging needed
