Week 4 - Cardiovascular Flashcards
Kawasaki disease
Acute generalized systemic small and medium vessel vasculitis occurring throughout the body. Macrophages invade the vasculature
Symptoms of Kawasaki Disease
Persistent fever for at least 5 days plus four of the following:
- bilateral conjunctival redness
- changes of the lips and oral cavity
- cervical lymphadenopathy
- polymorphous exanthema (swelling of the hands or feet) or perineal area
Six components when suspected Kawasaki’s disease but no complete diagnosis
- albumin ≤3.0 g/dL;
- urine ≥10 WBC/HPF;
- platelet count ≥450,000 after 7 days of fever;
- anemia consistent with age values;
- total white blood cell count ≥15,000/mm3; and
- elevation of alanine aminotransferase.
Kawasaki’s disease - acute phase
- Conjunctival hyperemia
- erythematous rash of hands and feet
- unilateral lymph node swelling
Kawasaki’s disease -subacute phase
- Fever, rash and cervical lymphadenopathy abate
- Arthralgias
- Desquamation of the skin over the fingertips
- Thrombocytosis (elevated platelets)
- Cardiac disease
Kawasaki’s disease -convalescent phase
- Starts around day 25
- Elevated ESR
- Abnormalities of the coronary vessels
- Myocarditis
Diagnosis of Kawasaki’s Disease
Diagnosis of exclusion. May run CBC with differential, ESR, CRP
Management of Kawasaki’s disease
- IVIG therapy
- High dose ASA for anti inflammatory properties
- Second dose IVIG
- Anticoagulation if coronary aneurysm is present
a. Warfarin
b. clopidogrel
Atrial Septal defect s/s
asymptomatic; older children may have fatigue, exertional dypnea, be thin, history of frequent URI or pneumonia
Atrial septal defect PE
- Murmur not noticed until 2-3
- Mild left anterior chest bulge
- S1 normal or split
- S2 widely split
- Grade 1-4 rating, medium pitched, not harsh systolic crescent-decrescendo
Diagnostics for atrial septal defect
X-ray shows cardiac enlargement
Management of atrial septal defect
- small defects may close on own
- large defects require closure through cardiac catheterization
- Aspirin or clopidogrel
Ventricular septal defect
Opening in septum between ventricles; most common congenital defect; most close spontaneously
Ventricular septal defect PE
- Low pitch grade 2-6 holosystolic murmur
- Thrill on left sternal border
- Signs of progressing CHF
- S3 or s4 gallop
Ventricular septal defect S/S
asymptomatic with small to moderate openings
infants with large openings exhibit symptoms (dyspnea, respiratory infections, diaphoresis, fatigue)
Ventricular septal defect diagnosis
Chest x-ray shows normal or enlarged heart depending on the size of the defect
Management for heart defects
Small defect – monitor Q6 months
Large defects – diuretics, ACE, Beta blockers, monitor intake and weight gain, teach s/s of HF, surgery to repair
Left sided systolic heart failure
Heart cannot pump enough blood to supply the body – walls of the ventricle are thin and weak, unable to pump out meaning blood remains in the ventricle reducing output
Causes of left sided systolic heart failure
a. structural defects of heart valves
b. disease of heart muscle (cardiomyopathy)
c. arrhythmias
d. heart attack
Right sided systolic heart failure
- Walls of right ventricle are think and weak, unable to pump blood out, reduced cardiac output
- Commonly caused by left sided heart failure
Risk factors for right sided systolic heart failure
a. HTN
b. CAD
c. Metabolic syndrome
d. DM
e. Structural heart abnormalities
Symptoms of right sided systolic heart failure
a. Fatigue
b. Weakness
c. SOB
d. Swelling of lower limbs
e. Decreased alertness
f. Reduced ability to exercise
Characteristics of heart murmur
- intensity - easily heard upon auscultation, soft, no thrill
- timing - systolic
- location - pulmonic area
- radiation - also heard in the left axilla
- quality - harsh crescendo-decrescendo
- duration - heard in mid systole
- pitch - medium sound
Grades of heart Murmur
A grade 1 murmur is barely audible.
A grade 2 murmur is soft but easily audible.
A grade 3 murmur is louder but is not accompanied by a thrill.
A grade 4 murmur is loud with a palpable thrill.
A grade 5 murmur can be heard with the stethoscope partially off the chest and a thrill is palpable.
Finally, the grade 6 murmur is audible without a stethoscope.
All murmurs louder than grade 3 are pathological.
Peripheral pulmonary stenosis murmur
usually heard at 1 to 2 months if the blood vessels to the lungs are small. This type of murmur resolves around 6 months of age. Soft blowing sound.
Flow murmur
more common in 8- to 14-year-olds with thinner chest walls and is the sound of normal blood flow. Early to mid systolic, decreases with standing increases with CO. Soft blowing sound.
Still’s murmur
most common between the ages of 2 and 6. This murmur has a musical characteristic and usually resolves by age 12. Short, vibratory, musical “twangy string” sound
Venous hum
common between the ages of 2 and 8 and is the normal blood flow through the veins of the upper chest. It disappears with the turning of the head or jugular vein compression. All these murmur types are innocent.
Qualities that may indicate pathological murmur
- Murmur in child with CHD
- Diastolic murmur
- Systolic murmur with thrill
- Pansystolic murmur
- Continuous murmur (not suppressed with pressing carotid)
- Systolic clicks
- Opening snaps
- Fixed splitting
- Accentuated s2
- Not positional
- Grade 4 or higher
- Harsh quality
Hypertension in a child
Systolic, diastolic or both in the 95%+ percentile for age, sex and height on at least three separate occasions
Over age 13, 130/80 is considered hypertensive
Things to assess when looking at HTN in a child
- Neonatal history
- Prior hospitalizations or trauma
- Diet and exercise
- Sleep history (OSA)
- Medications
- Chronic illnesses
- Headache, chest pain, dyspnea
- History for family – HTN, MI, stroke, DM, HLD
Hypertension PE
- BMI, growth
- Edema, pallor, flushing
- Pulses upper and lower
- Elevated BP on 3+ occasions
Diagnostics HTN in a child
- Search for secondary causes of HTN (renal function, plasma renin levels)
- CBC, ESR, CRP, UA & culture, electrolytes, BUN, creatinine, plasma renin
Treating HTN in children
- BP check annually
- Two follow-up measurements within 1-2 months
- If overweight
a. Caloric restriction
b. Exercise 30-60 min per day w/relaxation techniques
c. Avoid smoking, caffeine, drug and alcohol intake - If HTN persistent refer to cardiology for treatment (ACE, ARB, beta blocker, CCB, diuretic)
Sickle Cell Disease
Vaso-occlusion of blood vessels and periods of inadequate supply to the body’s tissues. Can impact all parts of the body
Caused by mutated gene that causes abnormal hemoglobin which are sickled and stick more easily to vessel walls causing interrupted blood and oxygen flow.
S/S of sick cell disease
- Chronic pain
- Anemia
- Frequent infections
- Delay of growth and puberty
- Underweight
- Fatigue
- Swollen hands and feet
- Eye problems (blocked vessels in the retina)
Education for patients with sickle cell disease
- Fluid intake – dehydration an trigger a crisis
- Avoid infection – good hand hygiene and avoiding sick people
- Activity – moderate activity with rest – hypoxia can trigger crisis
- Rest and adequate nutrition
- Maintain immunizations
- Wear medical identification
- Avoid the cold and elevation – they can be triggers
- Pain control with crisis – tyelnol, advil, narcotics
- Daily folic acid
- Penicillin V prophylaxis daily until age 5
How is sickle cell anemia diagnosed
Diagnosis via isoelectric focusing (IEF), hemoglobin electrophoresis, or sickle solubility testing
