Week 8: PEDS Cardiac Flashcards
What parts of fetal circulation are unique to it specifically
Foramen Ovale
Ductus Arteriosus
Umbilical Vein
2 Umbilical Arteries
How does blood move in the fetus
Enters the baby from the umbilial vein –> umbilical vein joins the inferior vena cava –> goes to right atrium –> blood diverted from lungs through the foramen ovale –> left atrium then left ventricle –> aorta –> body gets O2
blood return to right atrium –> right ventricle –> pumped to pulmonary artery –> ductus arteriosus diverts blood to the aorta past where the carotids are, so oxygen poor blood goes back to the mom
Foramen Ovale
Hole between the L and R atria that will close after birth
it allows blood to move to the left atrium which allows blood to get around the body rather than go to the lungs (blood is already oxygenated)
So it connects the atria so that oygenated blood can get to the aorta and out to the body and brain
Ductus Arteriosus
connects the aorta and pulmonary artery so that deoxygenated blood gets to the right ventricle and then leaves via umbilical arteries or the lower half of the fetus
Umbilical Vein
1
sends oxygenated blood from the placenta to the fetus
Umbilical Artery
2
deoxygenated blood moves from fetus to placenta
We want to see how many vessels in the umbilical cord
3 - 2 UA and 1 UV
Fetal Circulation Path for oxygenated blood
oxygenated blood –> placenta –> umbilical vein –> shunted past fetal liver byductus venosa –> inferior vena cava to right atrium –> proceed through foramen ovale –> left atrium to left ventricle –> aorta –> brain and body
Fetal Circulation Path for poorly oxygenated blood
superior vena cava –> right atrium mixing with oxygenated blood –> right ventricle and then pulmonary tree (small amount to lungs which are nonfxnal and collapsed) –> ductus arteriosus –> aorta –> placenta via umbilical arteries
___ means blood away from the fetus
arteries
___ means blood to the fetus
vein
What forces the alveoli of the fetal lungs to open
when the infant takes the first breath, the dramatic increase in O2 and expansion of lungs leads to DECREASED PULMONARY VASCULAR RESISTANCE (PVR) which allows for increased pulmonary blood flow
When does the Foramen Ovale close
ideally closes at birth - can take a few days though
the blood is entering the right atrium from the top
When does the ductus arteriosus close
4 days after birth
What leads to increased systemic vascular resistance (SVR)
clamping the umbilical cord
this stops fetal circulation
Children are not just …
small adults
The child heart lies more where compared to adults
heart lies more horizontal and higher in the chest
The apex of a child’s heart is where
found at the 3rd or 4th intercostal space
How does child HR and BP differ
HR faster and BP lower
What is more common in child hearts
murmurs
regularly irregular HRs
What is never normal in neonates and what can it indicate?
Diaphoresis and/or nosebleeds (epistaxis) - never normal in neonates
can indicate heart defects or GI defects
2 types of Cardiac Dysfunction
- Congenital
2. Acquire
Congenital Cardiac Dysfunction
“Born with it”
Ex: Atrial septal defect, ventricular septal defect, patent ductus arteriosus, tetrology of fallot, hyperplastic left heart, etc.
Acquire Cardiac Dysfunction
“Develops after birth”
ex: CHF, HTN, Rheumatic Heart Dx
* CHF is sometimes congenital but not always
When in gestation does the heart form
4-6 weeks
__ to ___ occurence of congenital heart anomalies occur per 1000 births
4-10
If someone has a congenital heart anomaly what is more likely to occur
other body system effects too like downs syndrome, TE fistula, hernias (inguinal, umbilical)
Causes of Congenital Heart Defects
- Genetic (Downs, Trisomy, 18, 21, Family Hx)
- Drugs (mom took)
- Infections
- Maternal Conditions (IDDM, Lupus, Seizure Disorder, Cocaine and Alcohol, Abuse, >40).
The first three weeks are important to heart development, but…
women usually learn they are pregnany much later and their actions could have made an impact
If mom says there is something wrong…
then something is probably wrong
Ways to Diagnose and Detect Heart Defects
Fetal Ultrasound
Fetal Echo
X Ray
Echo and Electro Cardiograms
MRI
Cardiac Cath
H&P!!! - If mom says there is something wrong like they are sweating, not feeding or falling asleep during, then something is probably wrong
Important Assessments to make for babies before and after birth
Health promotion and health management of baby and mother
Hx of maternal illness
Family Hx
Presence of other anomalies
Poor growth and development
FTT
Issues related to chronicity
S/S of a Congenital Heart Defect
Poor Feeding
Murmur
Poor Weight Gain (FTT)
Cyanosis - not always right away - often after 2nd day of life or more
Tachycardia
Tachypnea
Clubbing
Polycythemia
Squatting
Frequent URIs
Crackles (CHF Major Complication)
Central Edema
Activity Intolerance
Low O2 Saturation
JVD (may be hard to see)
Activity Intolerance
Periorbital Edema in babies
Why is there a push to advocate for non-quick discharge after births?
To try and see if cyanosis occurs after a few days and prevent an infant from having cardiogenic shock
Clubbing occurs as a result of
chronic hypoxia
Polycythemia
increased Hct as a defensive mechanism - increased RBC production - can be an issue with dehydration
What is squatting with heart defects
It is squatting occurring to increase and maintain oxygenation and icnrease blood flow to tissues
seen a lot with Tetralogy of Fallot
Why are URIs more common with heart defects
because there is increased breathing and effort of breathing
___ is a major complication of CHF
crackles
3 Categories of Heart Defect Etiology
Acyanotic
Cyanotic
Obstructive Systemic Blood Flow
Acyanotic Heart Diseases
Increased Pulmonary Blood Flow (Red Coloring) - too much
ex: CHF, PDA, ASD, VSD, Atrioventricular Canal (AV Canal or AVC)
Cyanotic Heart Diseases
Decreased pulmonary blood flow (Blue coloring) too little
Cyanosis occuring from increased concentration of reduced Hgb (no O2 on it)
ex: Tricuspid atresia (TA), Pulmonary atresia (PA), Transposition of the great arteries (TGA), Teralogy of Fallot
Is blue coloration always a sign of cyanotic heart disease
no its not always a sign but usually is
Obstructive Systemic Blood Flow Heart Diseases
Blood cannot get to where it needs to go - lungs or body
ex: Coarctation of the aorta, aortic stenosis, hypoplastic left heart
also can see blue coloration
Acyanotic means…
increased pulmonary blood flow
S/S of Acyanotic Defects
Murmurs - get louder with CHF from turbulent blood flow
Pulmonary Edema
Rales(crackles from fluid) and Rhonchi
Widening pulse pressure
Tachycardia (too much fluid in CHF)
thrill possible
FTT
recurrent resp infections
poor weight gain - feed poorly
Nursing Interventions for Acyanotic Heart Defects
Keep O2 Sats up - NC, HFC, Vent
Digitalize - IV, precautions done (Digoxin)
Diuretics and Fluid Restrictions - Lasix, high calorie formula to dec amt fed
Accurate I&O
Frequent breaks w feeding, lavage feeds or IV feeds - less work
All of this done before surgeyr is done
Patent Ductus Arteriosus (PDA)
Failure of the Ductus Arteriosus to close soon after birth (which joins the pulmonary artery and aorta)
Symptoms dependent on the amount of shunting and degree of pulmonary HTN
Flow higher pressure of aorta to the lower presusre of the pulm artery so more blood flow here increases issues of CHF due to shunting
You often see what as low in PDA
low diastolic BP
PDA is more common in…
premature infants
Treament for PDA
- Pharmacological - Indocin - for premies or those too ill for surgery
- Surgery - for term infants or those who indocin doesnt work - cath lab
What surgery is done to close a PDA
lateral incision
Why is it important to monitor UO, BUN, and Cr when taking Indocin to close PDA
because it can cause kidney damage
What category is PDA
acyanotic
Atrial Septal Defect (ASD)
Defect in the septum between the right and left atrium
similar s/s but not the same as patent foramen ovale
oxy blood moves L atrium to R atrium which causes PVR to decrease and LVP increases leading to the shunting from L to R from high to low pressure
Why may you hear murmurs from ASD
from the shunting of blood
WHy does CHF occur with ASD
increased blood flow to lungs from more blood in R atrium going to lungs
What category is ASD
Acyanotic
Treatments for ASD
If asymptomatic - watch and wait for spon closure
If ASD w/ CHF (RHF) treat CHF and delay surgical repair
If ASD w/ intractible CHF - early surgical repair
Cath lab pulls flap closed
Ventricular Septal Defect (VSD)
Abnormal opening between ventricles
Blood will flow L ventricle to R ventricle
What is the most common congenital heart defect
ventricular septal defect (VSD)
What is the size of the opening between ventricles for VSD
size of a pinhole all the way to lack of a septum
S/S of VSD
CHF - FTT, fatigue, tachypnea
Murmur
pulmonary HTN
Category of VSD
Acyanotic
Treatment for VSD
IT WILL CLOSE ITSELF 30-50% OF THE BED!!!!!!
If not closing, but asymptomatic - no treatment
Intractable CHF (RHF) from VSD - needs to be closed early –> diruetics, high calorie feedings to tune up for surgery and then get them into surgery
Symptoms of VSD increase…
with the size of defect and amount of shunting
Remember Cyanotic heart disease means…
decreased pulmonary blood flow
S/S of Cyanotic Heart Diseases
Cyanosis (which does not respond as expected to O2 tx)
Tachycardia
Dyspnea
Hepatomegaly
FTT
Polycythemia
Clubbing
Diaphoresis w/ feeding
Tet Spell / Hypercyanotic Spell
What is a Hypercyanotic Spell (Tet Spell)
Increased rate and depth of breath, increased HR, cyanosis, pallor, poor tissue perfusion, diaphoresis, irritability, crying, seizures, LOC - BLUE HANDS AND MOUTH
Happens when waking from sleeping, with feedings, crying, and defecating, constipation and agitation
Tet Spells are treated…
aggressively:
calm child, delay procedure, morphine to knock them out, give O2, propanolol, kne chest (prone), IV fluids, dopamine or phenylephrine
Why can hepatomegaly occur from cyanotic heart defects
because heart failure can lead to an enlarged liver
NIs for Cyanotic Heart Defects
Prostaglandin E1
O2 management
Bicarbonate
Keep calm and keep procedures to minimum - cyanosis increases with crying and feeding
Gavage feeding or IV feeding - less work
Knees to chest - squat
Antibiotic prophylaxis for dental work or invasive procedures is needed
Prostaglandin E1 is used in cyanotic heart defects why
to keep a patent ductus arteriosus open
Why is bicarb given for cyanotic heart defects
to manage metabolic acidosis
Why do knees to chest (squat) for cyanotic heart defects
to decrease systemic blood flow return to the heart
Why is antibiotic prophylaxis given for cyanotic heart defects
to prevent myocarditis from occurring
If someone has a TET spell what should be done immediately
pull knees to chest (squat) to decrease systemic blood flow to the heart and improve oxygenation
Transposition of the Great Vessels
Cyanotic Heart Defect
Noncommunicating systemic and pulmonary system
Caucses circulation to be reversed and is non conductive to life
How is circulation reversed in Transpotition of the Great Vessels
pulmonary vessel comes out of left ventricle instead of R
aorta comes out of right ventricle instead of L
Often has ASD or VSD (cannot survive without these)
Transposition of the Great Vessels is …
non conductive to life w/o intervention
If the ductus closes in Transpotition of the Great Vessels what can occur
cardiogenic shock
Treatment for Transposition of the Great Vessels
Survival depends on early aggressive management!!!:
PGE_1 infusion to keep PDA open to prevent cardiogenic shock
Create a septal defect to allow access
Correct vessels surgically later
Surgical correction w/ in a week age
___-___% of survival with repair for transposition of the great vessels
90-95%
What surgery is done for Transposition of the Great Vessels
Arterial Switch
They used to do conduits to correct circulation but there is risk for clotting in these
Tetrology of Fallot
Cyanotic Heart Defect
Combo of 4 defects that causes Tet Spells
Leads to chronic problems even after fixing it
What is the most common cyanotic heart lesion
Tetrology of Fallot
What are the 4 defects in Tetrology of Fallot
Pulmonic Stenosis - Obstruction of Outflow to the lungs d/t narrow vessel
- VSD
- Overriding aorta - aorta sits between R and L venticle so blood comes from both and goes out systemically causing cyanotic effect
- Right ventricular hypertrophy (rarer)
What defect can lead to Pentology of Fallot
VSD
Treatment for Tetrology of Fallot
Knee to Chest (Squat) - decreases systemic vascular resistance
Surgery in stages
What is the morality rate of terology of fallot
10% - very high
Someone who had their tetrology of fallot treated still…
may never be symptom free - chronic issues occur
Obstructive systemic blood flow heart defects means…
decreased blood flow to body
S/S of Obstructive Systemic Blood Flow
diminished pulses - radial and pedal
poor color - blue
delayed capilary refill
decreased UO - because of poor blood flow to kidneys
CHF w/ pulmonary edema
pressure increase in lower extremities
Poor feeding/weight gain = FTT
BP is generally what way in obstructive systemic blood flow
BP generally decreased in lower extremity - but normal is higher in LE than UE
take a 4 limb blood pressure
NIs for Obstructive Systemic Blood Flow
depending on defect and symptoms: follow interventions for increased pulmonary blood flow or decreased pulmonary blood flow
If incr: treat systemic heart failure
If decr: look at tx for tetrology of fallot or knee to chest to increase blood flow
Coarctation of the Aorta
Obstructive Heart Defect
Presents in 2nd week of life
May or may not be symptomatic
it is narrowing of the aorta (aortic arch) either before or after the ductus arteriosus (after is most common)
Coarctation of the Aorta leads to increased risk for what
CVA - decreased systemic blood flow leading to strokes
AAA - abdominal aortic aneurysm
The most common location for coarctation of the aorta occurs before or after the ductus arteriosus?
After
S/S of Coarctation of the Aorta
HA
Epistaxis
Dizziness
BP increase in UE, Decreased in LE
CHF (LHF) w/ Hepatomegaly from CHF
Decreased pulses and pressures in LE
Gallops, thrills, murmurs - depend on VSD for mumurs and gallop heard in CHF
The discrepancy of BP between UE and LE in Coarctation of the Aorta is
almost 10 points which is huge
What category of heart defect is coarctation of the aorta
Obstructive Systemic Blood Flow
Tx for Coarctation of the Aorta
Medically manage CHF
Prostaglandin E1 - keep PDA open if symptomatic early on
Delay surgical correction via balloon dilation to buy time, then resect subclavian artery to the aorta past the constriction
What keeps the PDA open when needed to prevent cardiogenic shock
Prostaglandin E1 - PE1
What does survival from coarctation of the aorta depend on
depends on the complexity of coarct (VSD present? pre or post ductal) and recurrence - depends on complexity
The 3 categories of heart defects are what kinds of heart disease
Congenital
What are the 4 important Acquired Heart Disease to know
CHF
Rheumatic Fever
Kawasaki’s
HTN
Why do we see more HTN nowadays
increased incidence of obesity in children
Rheumatic Fever
Acquired Heart Disease - Autoimmune disease caused by Group A Infection (strep in rare cases)
S/S of Rheumatic Fever
Fever
Painful/tender Joints
Red Hot or Swollen Joints
Chest Pain
Palpitations
Fatigue
SOB
Chorea
Erythema Marginatum
Chorea
poor muscle coordination
Erythema marginatum
Papular rash on the body
We diagnose rheumatic fever with…
the Jones Criteria
Jones Criteria
criteria of required, major, and minor s/s that determine if someone has Rheumatic fever
What are the requirements needed in the Jones Criteria
1 required, 2 major s/s and no minor s/s
OR
1 required, 1 major, 1 minor
What is teh required symptom for rheumatic fever/jones criteria
Recent Strep Infection
What are the major s/s used in the jones criteria
polyarthritis
carditis
chorea
erythema marginatum
subq nodules
What are the minor s/s used in the jones criteria
fever
arthralgia
previous RHD or RF
Increased CRP
Increased ESR
prolonged PR interval
What increases CRP
inflammation
What increases ESR
inflammation because of fibrinogen
Complications occurring in the heart from Rheumatic Fever
Valve Stenosis
Valve Regurgitation
Damage to heart muscle
A Fib
Heart Failure
Labs and Tests to look for with Rheumatic Fever
Elevated ESR
Elevated CRP
leukocytosis (increased WBC)
Prolonged PR interval
Tx for Rheumatic Fever
anti infectives
anti inflammatories
tx of CHF if occurring - digoxin and diuretics
prophylactic antibiotics everyday until 18 yo and with dental care/surgery as adults
Kawasaki Disease
A type of acquired heart dsiease
a multisystem inflammatory disese leading to aneurysms, ischemic heart disease, and infarcts
What is the etiology of Kawasaki Disease
etiology unknown but likely infection triggers to certain susceptible people
How serious is Kawasaki Disease
self limiting and gets better but without treatment 25% of people develop cardiac sequelae
S/S of Kawasaki Disease Stage 1
High fever unresponsive to treatment > 5 days
Reddened Conjunctiva
Pharyngitis - strawberry tongue
Rash varies with child - red palms and peeling on hands and feet
Cervical lymphadenopathy
Labs - elevated ESR
S/S of Kawasaki Disease Stage 2
cracking lips and fissures
peeling fingers and toes
joint pain
cardiac disease - coronary blood vessel inflammation aneurysms, MI d/t coronary blood vessel inflammation
s/s similar to multi system inflmmatory disease
Tx for Kawasaki Disease
Hospitalized >3 days usually yo treat fever and potential cardiac issues: high dose IV gamma globulin, coumadic, salicylate therapy, and steroid use (controversial)
follow up for several weeks to months
How long is the hospital stay usually for kawasaki disease
greater than or equal to 3 days
How long is follow up for kawasaki disease usually
several weeks to months
If there is no cardiac involvement with Kawasaki’s Disease in the first month…
they are usually going to be ok
