Cardiology Flashcards
1
Q
First Heart Sound
- Reflects closure of the ___ valve, then the ___ valve.
A
First Heart Sound
- Reflects closure of the mitral valve, then the tricuspid valve.
2
Q
Clicks are heard near the 1st heart sound.
- Ejection clicks with pulmonary valve stenosis - occur early in systole at the L base of the heart and can vary with respiration.
- Aortic ejection clicks - are generally heard at the apex and do not vary with respiration
A
Clicks are heard near the 1st heart sound.
- Ejection clicks with pulmonary valve stenosis - occur early in systole at the L base of the heart and can vary with respiration.
- Aortic ejection clicks - are generally heard at the apex and do not vary with respiration
3
Q
Second Heart Sound
- Reflects closure of the ____ valve then the _____ valve
- Normally, the 2nd heart sound has “physiologic” splitting, which results from increased venous return with ____.
- Fixed splitting of S2
- Due to delayed RV emptying and can indicate possible ASD, R bundle-branch block (RBBB), or severe pulmonary stenosis.
- Paradoxical splitting of S2 (splitting during expiration rather than inspiration)
- Due to delay in LV emptying, with the aortic closure sound coming after the pulmonic.
- Will hear this in severe AS or with L bundle branch block (LBBB)
A
Second Heart Sound
- Reflects closure of the aortic valve then the pulmonic valve
- Normally, the 2nd heart sound has “physiologic” splitting, which results from increased venous return with inspiration.
- S2 is normally split because aortic valve (A2) closes before the pulmonary valve (P2)
- Fixed splitting of S2
- Due to delayed RV emptying and can indicate possible ASD, R bundle-branch block (RBBB), or severe pulmonary stenosis.
- Paradoxical splitting of S2 (splitting during expiration rather than inspiration)
- Due to delay in LV emptying, with the aortic closure sound coming after the pulmonic.
- Will hear this in severe AS or with L bundle branch block (LBBB)
4
Q
Third Heart Sound
- Can hear the 3rd heart sound in diastole, when there is rapid, passive filling of a “relatively stiff” ventricle.
- An S3 sound can be quite normal in children and pregnant women.
A
Third Heart Sound
- Can hear the 3rd heart sound in diastole, when there is rapid, passive filling of a “relatively stiff” ventricle.
- An S3 sound can be quite normal in children and pregnant women.
5
Q
Fourth Heart Sound
- S4 is almost always abnormal in children.
- It can be heard with aortic stenosis, mitral regurgitation, hypertrophic cardiomyopathy, and HTN with LV hypertrophy.
A
Fourth Heart Sound
- S4 is almost always abnormal in children.
- It can be heard with aortic stenosis, mitral regurgitation, hypertrophic cardiomyopathy, and HTN with LV hypertrophy.
6
Q
In the first 6 hours of life, murmurs are usually pathologic and caused by a valve defect (ie aortic or pulmonary stenosis, mitral or tricuspid regurgitation).
After 6 hours, as the pulmonary vascular resistance falls, the majority of murmurs are benign and due to normal transition sounds.
A
In the first 6 hours of life, murmurs are usually pathologic and caused by a valve defect (ie aortic or pulmonary stenosis, mitral or tricuspid regurgitation).
After 6 hours, as the pulmonary vascular resistance falls, the majority of murmurs are benign and due to normal transition sounds.
7
Q
Investigate any murmur that is:
- Present immediately after birth (often a sign of an abnormal cardiac valve)
- Accompanied by cyanosis
- Accompanied by evidence of poor perfusion (delayed capillary refill)
- Louder than Grade 2
- Accompanied by tachypnea
- Persistent after the 2nd day of life
The following findings should always lead to referral: Loud pansystolic murmurs, an abnormally loud or single S2, an S4, or an ejection or midsystolic click.
Diastolic murmur is always pathologic.
A
Investigate any murmur that is:
- Present immediately after birth (often a sign of an abnormal cardiac valve)
- Accompanied by cyanosis
- Accompanied by evidence of poor perfusion (delayed capillary refill)
- Louder than Grade 2
- Accompanied by tachypnea
- Persistent after the 2nd day of life
The following findings should always lead to referral: Loud pansystolic murmurs, an abnormally loud or single S2, an S4, or an ejection or midsystolic click.
Diastolic murmur is always pathologic.
8
Q
PDA
- Initially systolic and as pulmonary vascular resistance drops, become continuous, rumbling (machine-like), and crescendo-decrescendo - the classic sound of a PDA murmur
- Ductus arteriosus closes in 50% of cases within 24 hours of birth, 90% in 48 hours, and virtually all in ____ hours. Closure is delayed in preterm births and in babies born at high altitude.
A
PDA
- Initially systolic and as pulmonary vascular resistance drops, become continuous, rumbling (machine-like), and crescendo-decrescendo - the classic sound of a PDA murmur
- Ductus arteriosus closes in 50% of cases within 24 hours of birth, 90% in 48 hours, and virtually all in 72 hours. Closure is delayed in preterm births and in babies born at high altitude.
9
Q
VSDs
- Small VSDs have a high-frequency sound and may only occur in early systole.
- Larger VSDs cause a holosystolic harsh murmur.
A
VSDs
- Small VSDs have a high-frequency sound and may only occur in early systole.
- Larger VSDs cause a holosystolic harsh murmur.
10
Q
Pulmonary stenosis
- Loudest at the LUSB
- Midsystolic harsh ejection murmur
A
Pulmonary stenosis
- Loudest at the LUSB
- Midsystolic harsh ejection murmur
11
Q
Aortic stenosis
- Loudest at the RUSB
- Pt: Loud systolic murmur at the R upper sternal border associated with a click
A
Aortic stenosis
- Loudest at the RUSB
- Pt: Loud systolic murmur at the R upper sternal border associated with a click
12
Q
Innocent murmur can be safely diagnosed if it meets 4 rules:
- 1) Physical exam is normal except for the murmur
- 2) Child is asymptomatic (negative review of symptoms)
- 3) Hx has no flags of causes of structural heart disease such as fever (as seen with streptococcal pharyngitis [pre-rheumatic fever] or endocarditis)
- 4) No additional abnormal heart sounds such as clicks
A
Innocent murmur can be safely diagnosed if it meets 4 rules:
- 1) Physical exam is normal except for the murmur
- 2) Child is asymptomatic (negative review of symptoms)
- 3) Hx has no flags of causes of structural heart disease such as fever (as seen with streptococcal pharyngitis [pre-rheumatic fever] or endocarditis)
- 4) No additional abnormal heart sounds such as clicks
13
Q
Systolic innocent murmurs
- They get louder when the child is placed ______, bc stroke volume increases with this maneuver. The murmurs get louder with exercise, anxiety, anemia, or fever.
- They can get softer or disappear with a Valsalva maneuver. (If Valsalva increases the murmur, think hypertrophic cardiomyopathy or obstructive L heart lesions!)
A
Systolic innocent murmurs
- They get louder when the child is placed supine, bc stroke volume increases with this maneuver. The murmurs get louder with exercise, anxiety, anemia, or fever.
- They can get softer or disappear with a Valsalva maneuver. (If Valsalva increases the murmur, think hypertrophic cardiomyopathy or obstructive L heart lesions!)
14
Q
Still’s murmur (aka vibratory murmur)
- Very common benign systolic ejection murmur with a low-pitched musical quality or vibratory character. Some describe the sound similar to a plucked-string instrument or the “honking” tone of a kazoo. Musical quality is what makes this easily recognizable
- Can hear it best at the ____, not in the back
- Decreases in intensity with expiration (not heard during the valsalva maneuver), positional changes that decrease venous return (standing) and with faster heart rates.
- Murmur goes away by 12-15yo
- Reassurance
A
Still’s murmur (aka vibratory murmur)
- Very common benign systolic ejection murmur with a low-pitched musical quality or vibratory character. Some describe the sound similar to a plucked-string instrument or the “honking” tone of a kazoo. Musical quality is what makes this easily recognizable
- Can hear it best at the LLSB, not in the back
- Decreases in intensity with expiration (not heard during the valsalva maneuver), positional changes that decrease venous return (standing) and with faster heart rates.
- Murmur goes away by 12-15yo
- Reassurance
15
Q
Peripheral pulmonary stenosis (PPS)
- Common functional murmur that occurs shortly after birth when there is a huge increase in blood flow to the lungs via the pulmonary artery. A murmur results when this increased flow in the pulmonary artery hits the relatively small branches and causes turbulence.
- This turbulence causes a soft, Grade 1-2 midsystolic ejection murmur heard in the _____ or with radiation to the back and axilla.
- Can also occur and be severe/pathologic in infants with congenital rubella syndrome, ____ syndrome, or ____ syndrome.
A
Peripheral pulmonary stenosis (PPS)
- Common functional murmur that occurs shortly after birth when there is a huge increase in blood flow to the lungs via the pulmonary artery. A murmur results when this increased flow in the pulmonary artery hits the relatively small branches and causes turbulence.
- This turbulence causes a soft, Grade 1-2 midsystolic ejection murmur heard in the RUSB or with radiation to the back and axilla.
- Can also occur and be severe/pathologic in infants with congenital rubella syndrome, Williams syndrome, or Alagille syndrome.
16
Q
Venous hum
- Caused by blood draining down collapsed jugular veins into dilated intrathoracic veins. The high velocity makes the vein walls “flutter,” resulting in a low-pitched murmur.
- Venous hum is generally absent when the pt is supine bc the neck veins are distended and there is no pressure gradient between the 2 areas.
- Valsalva maneuver, turning of the head, or compression of the jugular vein also makes the murmur go away.
- Murmur: _____ murmur through systole and diastole, heard best in 1st and 2nd intercostal spaces, changes with neck movement
A
Venous hum
- Caused by blood draining down collapsed jugular veins into dilated intrathoracic veins. The high velocity makes the vein walls “flutter,” resulting in a low-pitched murmur.
- Venous hum is generally absent when the pt is supine bc the neck veins are distended and there is no pressure gradient between the 2 areas.
- Valsalva maneuver, turning of the head, or compression of the jugular vein also makes the murmur go away.
- Murmur: Continuous murmur through systole and diastole, heard best in 1st and 2nd intercostal spaces, changes with neck movement
17
Q
Angina/MI
- Look for cocaine/crack use in the adolescent, familial hyperlipidemia, or a hx of Kawasaki disease.
A
Angina/MI
- Look for cocaine/crack use in the adolescent, familial hyperlipidemia, or a hx of Kawasaki disease.
18
Q
Arrhythmia
- ____ is the most likely cause of acute chest pain if an arrhythmia is the etiology.
A
Arrhythmia
- SVT is the most likely cause of acute chest pain if an arrhythmia is the etiology.
19
Q
Aortic Dissection
- Look for hx or findings of Marfan or Ehlers-Danlos syndrome. Also look for aortic dissection in any child with severe chest pain after trauma.
A
Aortic Dissection
- Look for hx or findings of Marfan or Ehlers-Danlos syndrome. Also look for aortic dissection in any child with severe chest pain after trauma.
20
Q
Costochondritis
- Pain and tenderness of the anterior chest at the costochondral or costosternal articulations.
- ALWAYS reproducible with ____
- Tx: Resolves in a week or less.
A
Costochondritis
- Pain and tenderness of the anterior chest at the costochondral or costosternal articulations.
- ALWAYS reproducible with palpation over the area
- Tx: Resolves in a week or less.
21
Q
Tietze syndrome
- Pain and swelling of the anterior chest pain, normally involving the _____ costochondral junction on one side.
- Pain and swelling come and go and can last months-years
- Look for _______ in particular!
A
Tietze syndrome
- Pain and swelling of the anterior chest pain, normally involving the 2nd or 3rd costochondral junction on one side.
- Pain and swelling come and go and can last months-years
- Look for varicella zoster in particular!
22
Q
Precordial Catch (aka “Texidor twinge”)
- Sudden onset of severe, sharp, or shooting chest pain that is recurrent and localized at the _____ area.
- Lasts 30 sec- few minutes and then resolves.
A
Precordial Cath (aka “Texidor twinge”)
- Sudden onset of severe, sharp, or shooting chest pain that is recurrent and localized at the cardiac apex area.
- Lasts 30 sec- few minutes and then resolves.
23
Q
Slipping rib syndrome
- Occurs in the __, __, or ___ ribs at the anterior tip of each.
- A lower rib can move up and override the upper rib, resulting in severe pain that can last for hours or days.
A
Slipping rib syndrome
- Occurs in the 8th, 9th, or 10th ribs at the anterior tip of each.
- A lower rib can move up and override the upper rib, resulting in severe pain that can last for hours or days.
24
Q
- Vasovagal (neurocardiogenic, vasodepressor) syncope is most common. Typically has a ______.
- Tx: Increasing fluid and salt intake. Discourage caffeine.
A
- Vasovagal (neurocardiogenic, vasodepressor) syncope is most common. Typically has a prodrome of dizziness and/or vision changes.
- Tx: Increasing fluid and salt intake. Discourage caffeine.
25
Q
- Situational syncope (eg due to micturition, defecation, or sight of blood)
- Can be elicited by noxious stimuli, pain, emotion, prolonged standing, or sudden position change from lying or sitting to standing.
- Hair grooming syncope may be related to vasovagal syncope, and increasing fluids and salt intake may help prevent episodes.
A
- Situational syncope (eg due to micturition, defecation, or sight of blood)
- Can be elicited by noxious stimuli, pain, emotion, prolonged standing, or sudden position change from lying or sitting to standing.
- Hair grooming syncope may be related to vasovagal syncope, and increasing fluids and salt intake may help prevent episodes.
26
Q
- Orthostatic Hypotension
- Typically occurring with prolonged standing in a warm environment or on quickly arising from a supine to standing position.
- POTS (Postural Orthostatic Tachycardia Syndrome) is a related disorder in which tachycardia is the dominant finding.
A
- Orthostatic Hypotension
- Typically occurring with prolonged standing in a warm environment or on quickly arising from a supine to standing position.
- POTS (Postural Orthostatic Tachycardia Syndrome) is a related disorder in which tachycardia is the dominant finding.
27
Q
- Cardiogenic syncope
- Important findings include systolic ejection murmur (AS, HCM), preceding chest pain or palpitations, and symptoms with exercise.
- Any patient who has syncope with exercise requires a cardiac evaluation bc vagal tone is reduced during exercise.
- If suspect arrhythmia, order a 24-hr Holter and EKG (Note; An EKG is probably the best test to order in a pt with recurrent, unexplained syncope!)
- EKG will assess for a prolonged QT interval or WQW, and may find signs of ischemia.
A
- Cardiogenic syncope
- Important findings include systolic ejection murmur (AS, HCM), preceding chest pain or palpitations, and symptoms with exercise.
- Any patient who has syncope with exercise requires a cardiac evaluation bc vagal tone is reduced during exercise.
- If suspect arrhythmia, order a 24-hr Holter and EKG (Note; An EKG is probably the best test to order in a pt with recurrent, unexplained syncope!)
- EKG will assess for a prolonged QT interval or WQW, and may find signs of ischemia.
28
Q
INFECTIVE ENDOCARDITIS
- Primary endocarditis - Infection of native heart tissue
- Secondary endocarditis - Infection of prosthetic material
- Occurs most often in children with underlying congenital heart disease (92% of endocarditis have underlying heart defect, congenital or rheumatic)
- Path:
- ____ (40%) and ____ (20-30%) are the most common organisms responsible for IE in pediatric patients with or without congenital heart disease.
- _____ is the more likely pathogen in an otherwise structurally normal heart
- Streptococcus mitis is more often associated with abnormal cardiac valves (congenital heart disease, rheumatic heart disease, postoperative changes)
- HAACEK organisms. These are often responsible for “culture-negative” endocarditis bc they can require >7 days to grow to detectable levels in culture media
- H__
- A__
- A__
- C__
- E__
- K___
- In prosthetic valve endocarditis (PVE), occurring up to 1 year after surgery, by far the most common organism is ____ (55-60%)
- If IV drug addicts: ___ (50%), enterococci (15%), streptococci (20%), pseudomonas and serratia (10%), Candida (5%)
- ____ (40%) and ____ (20-30%) are the most common organisms responsible for IE in pediatric patients with or without congenital heart disease.
- Pt:
- The clinical presentation of infective endocarditis can be subacute or acute and is often nonspecific.
- Subacute, over several weeks, with more indolent often prolonged course of fever and nonspecific symptoms such as malaise, arthralgias, weight loss, and diaphoresis
- OR Acute, rapidly progressive
- Presents differently in children than in adults/adolescents:
- ABE: Janeway lesions (small painless hemorrhagic lesions on the palms and soles resulting from embolization of heart vegetations)
- SBE: Children only rarely have Roth spots (small retinal hemorrhages), Osler nodes (small tender intradermal nodules on the fingers, palms, and soles/toes), conjunctival hemorrhages, heart murmurs, and splinter hemorrhages (linear streaks beneath the nail beds)
- Osler nodes and Roth spots are late developments of SBE and are seen less frequently today bc SBE is diagnosed tx earlier.
- Duke criteria
- 3 major criteria
- _______ for infective endocarditis (blood culture is positive in >95% of pediatric cases)
- 2 positive separate blood cultures with typical pathogens consistent with IE
- OR Persistently positive blood cultures with microorganisms consistent with IE- At least 2 positive cultures of blood drawn >12 hours apart
- Or all of 3 or a majority of >4 separate cultures of blood
- OR Single positive blood culture with Coxiella burnetii or antiphase I IgG antibody titer >1:800
- _______ for infective endocarditis (blood culture is positive in >95% of pediatric cases)
- New findings on ________ consistent with endocarditis
- Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material
- New valve regurgitation
- Abscess or vegetations
- New partial dehiscence of prosthetic valves
- New findings on ________ consistent with endocarditis
- _______ consistent with valve regurgitation
- Minor criteria
- Underlying heart disease or IV drug abuse
- Fever >38C
- Microbiologic evidence: Positive blood cultures but does not meet major criteria or serologic evidence of active infection with organisms consistent with IE
- Vascular phenomenon: Evidence of vasculitis, major arterial emboli, septic pulmonary infarcts, mycotic aneurysms, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions
- Immunologic phenomena: Glomerulonephritis, Osler’s nodes, Roth’s spots, and positive rheumatoid factor
- 3 major criteria
- Work-up
- 2 Blood cultures obtained separately
- Echocardiography is needed - to evaluate valves for lesions, such as vegetations or abscesses
- Dx:
- Definitive infective endocarditis when patient has any of the following:
- Pathologic criteria
- Microorganisms demonstrated by culture or histologic exam of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen
- OR Pathologic lesions; vegetation or intracardiac abscess confirmed by histologic exam showing active endocarditis
- Clinical criteria:
- ___ major criteria OR
- __ major and __ minor criteria OR
- __ minor criteria
- Pathologic criteria
- Possible infective endocarditis
- __ major criterion and __ minor criterion OR __ minor criteria
- Definitive infective endocarditis when patient has any of the following:
- Tx:
- Prolonged course of appropriate IV antibiotics for 4-8 weeks
- Tx of native valve endocarditis
- Streptococci (viridans streptococci and S bovis)
- PCN-sensitive streptococci: 4 weeks of ____ or ____
- PCN-insensitive streptococci: 4 weeks of PCN G (at higher dose than used in PCN-sensitive) or ceftriaxone
- MRSA: Vancomycin for 6 weeks.
- Enterococci: Ampicillin/PCN G + gentamicin for 4-6 weeks
- HACEK: Ceftriaxone, ampicillin (if susceptible), or ciprofloxacin for 4 weeks
- Streptococci (viridans streptococci and S bovis)
- Tx of prosthetic valve endocarditis
- Strep/enterococci: Same for >6 weeks
- Staph: Nafcillin (>6 weeks)+ rifampin (>6 weeks) + gentamicin (2 weeks)
- HACEK: Ceftriaxone, ampicillin (if susceptible), or ciprofloxacin x4 weeks
A
INFECTIVE ENDOCARDITIS
- Primary endocarditis - Infection of native heart tissue
- Secondary endocarditis - Infection of prosthetic material
- Occurs most often in children with underlying congenital heart disease (92% of endocarditis have underlying heart defect, congenital or rheumatic)
- Path:
- Viridans streptococci (Streptococcus mitis) (40%) and Staph aureus (20-30%) are the most common organisms responsible for IE in pediatric patients with or without congenital heart disease.
- Staph aureus is the more likely pathogen in an otherwise structurally normal heart
- Streptococcus mitis is more often associated with abnormal cardiac valves (congenital heart disease, rheumatic heart disease, postoperative changes)
- HAACEK organisms. These are often responsible for “culture-negative” endocarditis bc they can require >7 days to grow to detectable levels in culture media
- Haemophilus species
- Aggregatibacter parainfluenzae
- Aggregatibacter actinomycetemcomitans
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella species
- In prosthetic valve endocarditis (PVE), occurring up to 1 year after surgery, by far the most common organism is Staph epidermidis (55-60%)
- If IV drug addicts: S aureus (50%), enterococci (15%), streptococci (20%), pseudomonas and serratia (10%), Candida (5%)
- Viridans streptococci (Streptococcus mitis) (40%) and Staph aureus (20-30%) are the most common organisms responsible for IE in pediatric patients with or without congenital heart disease.
- Pt:
- The clinical presentation of infective endocarditis can be subacute or acute and is often nonspecific.
- Subacute, over several weeks, with more indolent often prolonged course of fever and nonspecific symptoms such as malaise, arthralgias, weight loss, and diaphoresis
- OR Acute, rapidly progressive
- Presents differently in children than in adults/adolescents:
- ABE: Janeway lesions (small painless hemorrhagic lesions on the palms and soles resulting from embolization of heart vegetations)
- SBE: Children only rarely have Roth spots (small retinal hemorrhages), Osler nodes (small tender intradermal nodules on the fingers, palms, and soles/toes), conjunctival hemorrhages, heart murmurs, and splinter hemorrhages (linear streaks beneath the nail beds)
- Osler nodes and Roth spots are late developments of SBE and are seen less frequently today bc SBE is diagnosed tx earlier.
- Duke criteria
- 3 major criteria
- Blood culture positive for infective endocarditis (blood culture is positive in >95% of pediatric cases)
- 2 positive separate blood cultures with typical pathogens consistent with IE
- OR Persistently positive blood cultures with microorganisms consistent with IE- At least 2 positive cultures of blood drawn >12 hours apart
- Or all of 3 or a majority of >4 separate cultures of blood
- OR Single positive blood culture with Coxiella burnetii or antiphase I IgG antibody titer >1:800
- Blood culture positive for infective endocarditis (blood culture is positive in >95% of pediatric cases)
- New findings on echocardiogram consistent with endocarditis
- Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material
- New valve regurgitation
- Abscess or vegetations
- New partial dehiscence of prosthetic valves
- New findings on echocardiogram consistent with endocarditis
- New murmur consistent with valve regurgitation
- Minor criteria
- Underlying heart disease or IV drug abuse
- Fever >38C
- Microbiologic evidence: Positive blood cultures but does not meet major criteria or serologic evidence of active infection with organisms consistent with IE
- Vascular phenomenon: Evidence of vasculitis, major arterial emboli, septic pulmonary infarcts, mycotic aneurysms, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions
- Immunologic phenomena: Glomerulonephritis, Osler’s nodes, Roth’s spots, and positive rheumatoid factor
- 3 major criteria
- Work-up
- 2 Blood cultures obtained separately
- Echocardiography is needed - to evaluate valves for lesions, such as vegetations or abscesses
- Dx:
- Definitive infective endocarditis when patient has any of the following:
- Pathologic criteria
- Microorganisms demonstrated by culture or histologic exam of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen
- OR Pathologic lesions; vegetation or intracardiac abscess confirmed by histologic exam showing active endocarditis
- Clinical criteria:
- 2 major criteria OR
- 1 major and 3 minor criteria OR
- 5 minor criteria
- Pathologic criteria
- Possible infective endocarditis
- 1 major criterion and 1 minor criterion OR 3 minor criteria
- Definitive infective endocarditis when patient has any of the following:
- Tx:
- Prolonged course of appropriate IV antibiotics for 4-8 weeks
- Tx of native valve endocarditis
- Streptococci (viridans streptococci and S bovis)
- PCN-sensitive streptococci: 4 weeks of PCN G or ceftriaxone
- PCN-insensitive streptococci: 4 weeks of PCN G (at higher dose than used in PCN-sensitive) or ceftriaxone
- MRSA: Vancomycin for 6 weeks.
- Enterococci: Ampicillin/PCN G + gentamicin for 4-6 weeks
- HACEK: Ceftriaxone, ampicillin (if susceptible), or ciprofloxacin for 4 weeks
- Streptococci (viridans streptococci and S bovis)
- Tx of prosthetic valve endocarditis
- Strep/enterococci: Same for >6 weeks
- Staph: Nafcillin (>6 weeks)+ rifampin (>6 weeks) + gentamicin (2 weeks)
- HACEK: Ceftriaxone, ampicillin (if susceptible), or ciprofloxacin x4 weeks
29
Q
Infective Endocarditis Prophylaxis prior to dental procedures
- Prophylaxis is recommended in patients who have
- Prosthetic cardiac valves or prosthetic material used for cardiac valve repair
- Hx of infective endocarditis
- Undergone cardiac transplant who develop cardiac valvuloplasty
- Unrepaired cyanotic congenital heart disease (including patients with palliative shunts and conduits)
- Repaired cyanotic congenital heart disease with prosthetic material/device during the 1st 6 months after the procedure (as endothelialization of the prosthetic material occurs within 6mo after procedure and will not be reliably completed) or residual defects (such as residual shunt, persistent leak, abnormal flow)
- Antibiotic prophylaxis is not recommended for any other form of congenital heart disease, for GU or GI procedures (or acquired valve disease, HCM, or bicuspid aortic valve).
A
Infective Endocarditis Prophylaxis prior to dental procedures
- Prophylaxis is recommended in patients who have
- Prosthetic cardiac valves or prosthetic material used for cardiac valve repair
- Hx of infective endocarditis
- Undergone cardiac transplant who develop cardiac valvuloplasty
- Unrepaired cyanotic congenital heart disease (including patients with palliative shunts and conduits)
- Repaired cyanotic congenital heart disease with prosthetic material/device during the 1st 6 months after the procedure (as endothelialization of the prosthetic material occurs within 6mo after procedure and will not be reliably completed) or residual defects (such as residual shunt, persistent leak, abnormal flow)
- Antibiotic prophylaxis is not recommended for any other form of congenital heart disease, for GU or GI procedures (or acquired valve disease, HCM, or bicuspid aortic valve).
30
Q
Prophylactic regimens
- Standard general prophylaxis
- _____ 50 mg/kg (max 2g) PO 1 hour before procedure
- Unable to take oral medications
- _____ 50 mg/kg (max 2g) IM/IV within 30 min before procedure
- Allergic to penicillin
- ____ 20mg/kg (max 600mg) PO 1 hour before procedure
- Or Cephalexin or cefadroxil 50mg/kg (max 2g) 1 hour before procedure
- Cephalosporins are not used if PCN allergy is an immediate-type hypersensitivity reaction
- Or Azithromycin or clarithromycin 15mg/kg (max 500mg) PO 1 hour before procedure
- Both allergic to penicillin and unable to take oral meds
- ____ 20mg/kg (max 600mg) IV within 30 min before procedure
- Or Cefazolin 25mg/kg IM/IV (max 1g) within 30 min before procedure.
- PO doses are given 1 hour before surgery whereas IM/IV doses are given within 30 min
If the pt is already on chronic amoxicillin/penicillin, prescribe the ppx abx from a different class
A
Prophylactic regimens
- Standard general prophylaxis
- Amoxicillin 50 mg/kg (max 2g) PO 1 hour before procedure
- Unable to take oral medications
- Ampicillin 50 mg/kg (max 2g) IM/IV within 30 min before procedure
- Allergic to penicillin
- Clindamycin 20mg/kg (max 600mg) PO 1 hour before procedure
- Or Cephalexin or cefadroxil 50mg/kg (max 2g) 1 hour before procedure
- Cephalosporins are not used if PCN allergy is an immediate-type hypersensitivity reaction
- Or Azithromycin or clarithromycin 15mg/kg (max 500mg) PO 1 hour before procedure
- Both allergic to penicillin and unable to take oral meds
- Clindamycin 20mg/kg (max 600mg) IV within 30 min before procedure
- Or Cefazolin 25mg/kg IM/IV (max 1g) within 30 min before procedure.
- PO doses are given 1 hour before surgery whereas IM/IV doses are given within 30 min
If the pt is already on chronic amoxicillin/penicillin, prescribe the ppx abx from a different class
31
Q
CARDIOMYOPATHY
- 3 main types: Dilates, hypertrophic, and restrictive.
- If diagnosed in a young child (<4yo), it is important to screen for metabolic disorders.
- If there is a 1st degree family hx of cardiomyopathy or sudden death at an early age, screen family members for cardiomyopathy with genetic testing, EKG, and/or echo.
A
CARDIOMYOPATHY
- 3 main types: Dilates, hypertrophic, and restrictive.
- If diagnosed in a young child (<4yo), it is important to screen for metabolic disorders.
- If there is a 1st degree family hx of cardiomyopathy or sudden death at an early age, screen family members for cardiomyopathy with genetic testing, EKG, and/or echo.
32
Q
Hypertrophic Cardiomyopathy
- Is the most common cause of sudden death on the athletic field in the US
- ____inheritance? disorder with variable expression.
- 50% of the mutations occur on chromosome 14.
- Are at risk of death from arrhythmias. HCM (with or without obstruction) is the most common cardiac cause of sudden death in young athletes at sporting events in the US
- Murmur is delayed in onset - a Grade 3-4/6 crescendo-decrescendo systolic murmur at the middle L to upper R sternal border.
- Murmur gets ____ with Valsalva or rising to an erect position. Either of these reduces venous return, resulting in a decrease in LV volume and an increase in the effect of the obstruction.
- If you have the child squat, venous return increases and decreases the murmur due to LV dilatation.
- Look for a child in whom the murmur gets ______ with squatting. It is HCM, not AS!
- Note: These same maneuvers produce the opposite effects in AS.
- Screening EKG shows common findings of LVH, prominent septal Q waves, and abnormal repolarization or strain (look for negative T waves in V6). L axis deviation, ST-T wave abnormalities, conduction abnormalities and/or pathological Q waves.
- Dx: Echo showing abnormal LVH without other cause
- Management
- ______ are the mainstay of therapy.
- Children who have symptoms of syncope, aborted sudden death, arrhythmias, or severe thickening of their interventricular septum requires placement of an implantable cardioverter-defibrillator and/or surgical therapy (myectomy) to remove part of the thickened myocardial tissue (typically from the interventricular septum).
A
Hypertrophic Cardiomyopathy
- Is the most common cause of sudden death on the athletic field in the US
- AD disorder with variable expression.
- 50% of the mutations occur on chromosome 14.
- Are at risk of death from arrhythmias. HCM (with or without obstruction) is the most common cardiac cause of sudden death in young athletes at sporting events in the US
- Murmur is delayed in onset - a Grade 3-4/6 crescendo-decrescendo systolic murmur at the middle L to upper R sternal border.
- Murmur gets louder with Valsalva or rising to an erect position. Either of these reduces venous return, resulting in a decrease in LV volume and an increase in the effect of the obstruction.
- If you have the child squat, venous return increases and decreases the murmur due to LV dilatation.
- Look for a child in whom the murmur gets softer with squatting. It is HCM, not AS!
- Note: These same maneuvers produce the opposite effects in AS.
- Screening EKG shows common findings of LVH, prominent septal Q waves, and abnormal repolarization or strain (look for negative T waves in V6). L axis deviation, ST-T wave abnormalities, conduction abnormalities and/or pathological Q waves.
- Dx: Echo showing abnormal LVH without other cause
- Management
- Beta-blockers are the mainstay of therapy.
- Children who have symptoms of syncope, aborted sudden death, arrhythmias, or severe thickening of their interventricular septum requires placement of an implantable cardioverter-defibrillator and/or surgical therapy (myectomy) to remove part of the thickened myocardial tissue (typically from the interventricular septum).
33
Q
Athlete’s Heart
- Path: Physiologic condition characterized by increased LV wall thickness in response to intense cardiovascular training.
- EKG for LV hypertrophy: high-voltage QRS complexes and lateral repolarization abnormalities (inverted T waves)
- However, hypertrophic cardiomyopathy is the most common cause of sudden cardiac death and causes similar findings on EKG. A young athletes with EKG findings of LVH and unexplained symptoms (chest pain, palpitations, presyncope, syncope) should be evaluated for HCM or other structure heart disease with TRANSTHORACIC ECHOCARDIOGRAPHY.
A
Athlete’s Heart
- Path: Physiologic condition characterized by increased LV wall thickness in response to intense cardiovascular training.
- EKG for LV hypertrophy: high-voltage QRS complexes and lateral repolarization abnormalities (inverted T waves)
- However, hypertrophic cardiomyopathy is the most common cause of sudden cardiac death and causes similar findings on EKG. A young athletes with EKG findings of LVH and unexplained symptoms (chest pain, palpitations, presyncope, syncope) should be evaluated for HCM or other structure heart disease with TRANSTHORACIC ECHOCARDIOGRAPHY.
34
Q
Hypertrophic cardiomyopathy vs Athlete’s heart
- HCM
- Left ventricular wall thickness >___mm
- Positive family hx of HCM
- EKG: Prominent Q waves; LVH criteria
- Left atrial size enlarged
- Small or normal LV cavity
- Abnormal LV diastolic function
- Athlete’s heart
- Left ventricular wall thickness less than ___mm
- No family hx
- EKG: No Q waves; LVH criteria
- Dilated LV cavity
- Normal LV diastolic function
A
Hypertrophic cardiomyopathy vs Athlete’s heart
- HCM
- Left ventricular wall thickness >15mm
- Positive family hx of HCM
- EKG: Prominent Q waves; LVH criteria
- Left atrial size enlarged
- Small or normal LV cavity
- Abnormal LV diastolic function
- Athlete’s heart
- Left ventricular wall thickness <15mm
- No family hx
- EKG: No Q waves; LVH criteria
- Dilated LV cavity
- Normal LV diastolic function
35
Q
Takotsubo Cardiomyopathy
- Pt: Chest pain, dyspnea, positive ___ in 95% cases
- Absence of coronary artery disease or angiographic evidence of plaque rupture
A
Takotsubo Cardiomyopathy
- Pt: Chest pain, dyspnea, positive troponin in 95% cases
- Absence of coronary artery disease or angiographic evidence of plaque rupture
36
Q
Acute pericarditis
- Path:
- Most common cause is idiopathic or viral (eg coxsackie A and B, echovirus, adenovirus)
- Pt:
- Pain is often relieved by leaning forward and sitting upright. Exacerbated by lying supine and inspiration or cough.
- ______ is pathognomonic but not found in every patient. It is a scratchy, high-pitched, to-and-fro sound caused by pericardial surfaces rubbing together.
- EKG: _____ with associated _____ (esp V6 and V6)
- Echo is performed to help distinguish pericarditis from myocarditis. Echo can have normal findings or demonstrate pericardial effusion.
- Tx:
- Often a benign condition and chest pain and inflammation be treated with anti-inflammatory medications ____.
A
Acute pericarditis
- Path:
- Most common cause is idiopathic or viral (eg coxsackie A and B, echovirus, adenovirus)
- Pt:
- Pain is often relieved by leaning forward and sitting upright. Exacerbated by lying supine and inspiration or cough.
- Pericardial friction rub is pathognomonic but not found in every patient. It is a scratchy, high-pitched, to-and-fro sound caused by pericardial surfaces rubbing together.
- EKG: Diffuse ST segment elevations with associated PR segment depression (esp V6 and V6)
- Echo is performed to help distinguish pericarditis from myocarditis. Echo can have normal findings or demonstrate pericardial effusion.
- Tx:
- Often a benign condition and chest pain and inflammation be treated with anti-inflammatory medications NSAIDs.
37
Q
Pericardial Effusion
- Can be caused by pericarditis.
- Characterized as serous, purulent, or bloody.
- Pt: Positional chest pain and may produce a friction rub caused by pericardial inflammation
- If the effusion is large, the heart sounds become muffled.
- EKG may demonstrate ___ QRS complexes, sinus tachycardia, and ___
- Diffusely low voltages on EKG is a non-specific sign that generally suggests that there is distance between the heart and the EKG leads.
- CXR may show cardiomegaly / enlarged cardiac silhouette (water-bottle heart) in case of large pericardial effusion
- Tx: Same as mentioned for acute pericarditis
A
Pericardial Effusion
- Can be caused by pericarditis.
- Characterized as serous, purulent, or bloody.
- Pt: Positional chest pain and may produce a friction rub caused by pericardial inflammation
- If the effusion is large, the heart sounds become muffled.
- EKG may demonstrate low-voltage QRS complexes, sinus tachycardia, and electrical alternans.
- Diffusely low voltages on EKG is a non-specific sign that generally suggests that there is distance between the heart and the EKG leads.
- CXR may show cardiomegaly / enlarged cardiac silhouette (water-bottle heart) in case of large pericardial effusion
- Tx: Same as mentioned for acute pericarditis
38
Q
Cardiac Tamponade
- Pt:
- ____ sign (more commonly seen in constrictive pericarditis).
- Remember: Normally with inspiration the pressure in the intrathoracic cavity drops and abdominal pressure increases, so that systemic venous return increases. With tamponade, the increase in venous return cannot be accomodated. This cause the jugular venous pressure to rise with inspiration, known as Kussmaul sign
- Pulsus paradoxus (variation of BP with breathing)
- Remember: Normally with inspiration, aortic BP can fall 4-10mmHg. With tamponade, the aortic pressure falls >____mmHg, resulting in pulsus paradoxus.
- Beck triad: 3 findings: ____, ____, ____
- ____ sign (more commonly seen in constrictive pericarditis).
- Classic question gives diastolic pressure readings in the 4 chambers of the heart that are all the same. This occurs in either tamponade or constrictive pericarditis
- Tx:
- ____ should always be bolused aggressively in suspected tamponade prior to pericardiocentesis to improve preload.
- Immediately remove fluid via _____
A
Cardiac Tamponade
- Pt:
- Kussmaul sign (more commonly seen in constrictive pericarditis).
- Remember: Normally with inspiration the pressure in the intrathoracic cavity drops and abdominal pressure increases, so that systemic venous return increases. With tamponade, the increase in venous return cannot be accomodated. This cause the jugular venous pressure to rise with inspiration, known as Kussmaul sign
- Pulsus paradoxus (variation of BP with breathing)
- Remember: Normally with inspiration, aortic BP can fall 4-10mmHg. With tamponade, the aortic pressure falls >10-15mmHg, resulting in pulsus paradoxus.
- Beck triad: 3 findings: Rising JVP, dropping systolic BPs, muffled heart sounds
- Kussmaul sign (more commonly seen in constrictive pericarditis).
- Classic question gives diastolic pressure readings in the 4 chambers of the heart that are all the same. This occurs in either tamponade or constrictive pericarditis
- Tx:
- IVFs should always be bolused aggressively in suspected tamponade prior to pericardiocentesis to improve preload.
- Immediately remove fluid via pericardiocentesis
39
Q
Constrictive Pericarditis
- Kussmaul sign occurs frequently, and pulsus paradoxus can also be present. End-diastolic pressures in all 4 chambers are equal.
- Tx by removing the restrictive fibrous tissue.
A
Constrictive Pericarditis
- Kussmaul sign occurs frequently, and pulsus paradoxus can also be present. End-diastolic pressures in all 4 chambers are equal.
- Tx by removing the restrictive fibrous tissue.
40
Q
Postpericardiotomy syndrome
- Can follow any surgery in which the pericardium is disturbed or opened but is most commonly seen following surgical ASD repair.
- Most attacks happen 1-4 weeks postsurgery, but they can occur as far out as 6 months.
- Pt: Acute pericarditis, pericardial effusion, and fever.
- Tx: _____ 80-100 mg/kg/day.
A
Postpericardiotomy syndrome
- Can follow any surgery in which the pericardium is disturbed or opened but is most commonly seen following surgical ASD repair.
- Most attacks happen 1-4 weeks postsurgery, but they can occur as far out as 6 months.
- Pt: Acute pericarditis, pericardial effusion, and fever.
- Tx: Aspirin 80-100 mg/kg/day.
41
Q
HEART FAILURE
- Cardiogenic shock from ductal dependent lesion should be at the top of the differential for any infant presenting in shock in the first 2-3 weeks of life.
- While orthopnea is commonly seen in adults, it is rarely seen in children.
- Management:
- Most important aspect of tx is patency of the PDA, which is achieved with empiric _____ infusion to keep the ductus open.
- Side effect of prostaglandin is _____
- Most important aspect of tx is patency of the PDA, which is achieved with empiric _____ infusion to keep the ductus open.
A
HEART FAILURE
- Cardiogenic shock from ductal dependent lesion should be at the top of the differential for any infant presenting in shock in the first 2-3 weeks of life.
- While orthopnea is commonly seen in adults, it is rarely seen in children.
- Management:
- Most important aspect of tx is patency of the PDA, which is achieved with empiric prostaglandin E-1 (PGE1) infusion to keep the ductus open.
- Side effect of prostaglandin is apnea
- Most important aspect of tx is patency of the PDA, which is achieved with empiric prostaglandin E-1 (PGE1) infusion to keep the ductus open.
42
Q
CHF
- Path:
- ADH release is increased, which decreases the excretion of water in the distal nephron, resulting in hyponatremia
- Infants
- Heart failure presents as feeding difficulties, distress with eating, or refusal to eat.
- Infants and young children often present with FTT and can also have respiratory symptoms such as tachypnea, retractions, and grunting.
- Pt:
- Infant - poor growth, tachypnea, poor feeding, sweating with feeding, fatigue, and irritability
- Young children - fatigue, abdominal pain due to ascites, nausea/vomiting, failure to thrive, and cough with wheezing
- Older children - exercise intolerance, SOB, decreased appetite, cough with wheezing, edema, palpitations, syncope, and chest pain
- Physical exam:
- Typically present with poor growth, tachypnea, tachycardia, and difficulty with activity.
- Timing of presentation of heart failure is also helpful in determining the cause:
- 1st week of life - Left heart obstruction (eg critical coarctation, hypoplastic L heart syndrome)
- 4-8 weeks of life - Left-to-right shunt (VSD, AVSD)
- 6-8 years of life - Acquired heart disease (eg rheumatic fever, myocarditis)
- Evaluation
- EKG
- An infant with CHF and EKG with deep Q waves in the inferior leads (II, III, AVF) should be evaluated for an anomalous left coronary artery from the pulmonary artery (ALCAPA).
- Echocardiography to assess myocardial function and to evaluate for structural cardiac defects.
- BNP (hormone secreted by heart to help regulate BP) and pro-BNP are elevated in pts with HF. These levels can be a helpful screening tool.
- Elevated serum BNP levels indicate that dyspnea is due to pulmonary congestion caused by cardiac failure.
- BNP levels are not elevated when dyspnea is caused by lung disease.
- EKG
A
CHF
- Path:
- ADH release is increased, which decreases the excretion of water in the distal nephron, resulting in hyponatremia
- Infants
- Heart failure presents as feeding difficulties, distress with eating, or refusal to eat.
- Infants and young children often present with FTT and can also have respiratory symptoms such as tachypnea, retractions, and grunting.
- Pt:
- Infant - poor growth, tachypnea, poor feeding, sweating with feeding, fatigue, and irritability
- Young children - fatigue, abdominal pain due to ascites, nausea/vomiting, failure to thrive, and cough with wheezing
- Older children - exercise intolerance, SOB, decreased appetite, cough with wheezing, edema, palpitations, syncope, and chest pain
- Physical exam:
- Typically present with poor growth, tachypnea, tachycardia, and difficulty with activity.
- Timing of presentation of heart failure is also helpful in determining the cause:
- 1st week of life - Left heart obstruction (eg critical coarctation, hypoplastic L heart syndrome)
- 4-8 weeks of life - Left-to-right shunt (VSD, AVSD)
- 6-8 years of life - Acquired heart disease (eg rheumatic fever, myocarditis)
- Evaluation
- EKG
- An infant with CHF and EKG with deep Q waves in the inferior leads (II, III, AVF) should be evaluated for an anomalous left coronary artery from the pulmonary artery (ALCAPA).
- Echocardiography to assess myocardial function and to evaluate for structural cardiac defects.
- BNP (hormone secreted by heart to help regulate BP) and pro-BNP are elevated in pts with HF. These levels can be a helpful screening tool.
- Elevated serum BNP levels indicate that dyspnea is due to pulmonary congestion caused by cardiac failure.
- BNP levels are not elevated when dyspnea is caused by lung disease.
- EKG
43
Q
CHF Management
- Management
- Tx: Depends on the cause and must be tailored specifically for each case.
- Diuretics and afterload reducers (ace inhibitors)
- Increasing the caloric density of feeds is often the 1st step in managing infants with growth failure related to heart failure.
- The recommended intake goal for infants with CHF is 140 kcal/kg/day.
- Goals of pharmacologic therapy include preload reduction, contractility enhancement, and afterload reduction.
- *Preload reduction (Diuretics): Principal agents for control of pulmonary as well as systemic venous congestion.
- Loop diuretics: Furosemide and bumetanide
- _______ are often the 1st medication added to management of pediatric heart failure.
- Side effects: Hypokalemia, hypochloremia, hyponatremia, metabolic alkalosis
- Agents that affect cortical diluting segment: Thiazide, metolazone
- Thiazides increase K loss and decrease Ca excretion
- Potassium-sparing diuretics: Spironolactone
- Monitor pts for hyperkalemia, esp if supplementing potassium or using an ACE-i.
- A much less common side effects (but one that shows up on exams!) is gynecomastia developing from the neurohormonal interactions.
- Loop diuretics: Furosemide and bumetanide
- *Contractility enhancement (Inotropic agents):Improve contractility of the heart. Goal is to increase cardiac output and improve perfusion to vital organs and tissues.
- Dopamine
- Dobutamine
- Epinephrine
- Milrinone
- Digoxin (Digitalis glycosides)
- Toxicity:
- Acute digoxin toxicity typically presents with nausea, vomiting, and diarrhea.
- Be esp aware of color-vision changes, confusion, or vertigo.
- Palpitations and arrhythmias (AV block, SVT, VT) are common also.
- If toxicity is severe, given digoxin-specific antibodies (Fab fragments).
- *Afterload reduction (Vasodilators): Important in remodeling or manipulating ventricular load
- ACE Inhibitors
- Sodium nitroprusside
- Cyanide toxicity is a concern if given for >48 hours
- If pt is in the ICU with an unexplained metabolic acidosis, consider prolonged use of sodium nitroprusside as a cause.
- Tx options for suspected cyanide toxicity, after discontinuing the drug, are sodium thiosulfate or hydroxocobalamin (vitamin B12).
- Beta blockers
- *Preload reduction (Diuretics): Principal agents for control of pulmonary as well as systemic venous congestion.
A
CHF Management
- Management
- Tx: Depends on the cause and must be tailored specifically for each case.
- Diuretics and afterload reducers (ace inhibitors)
- Increasing the caloric density of feeds is often the 1st step in managing infants with growth failure related to heart failure.
- The recommended intake goal for infants with CHF is 140 kcal/kg/day.
- Goals of pharmacologic therapy include preload reduction, contractility enhancement, and afterload reduction.
- *Preload reduction (Diuretics): Principal agents for control of pulmonary as well as systemic venous congestion.
- Loop diuretics: Furosemide and bumetanide
- Loop diuretics are often the 1st medication added to management of pediatric heart failure.
- Side effects: Hypokalemia, hypochloremia, hyponatremia, metabolic alkalosis
- Agents that affect cortical diluting segment: Thiazide, metolazone
- Thiazides increase K loss and decrease Ca excretion
- Potassium-sparing diuretics: Spironolactone
- Monitor pts for hyperkalemia, esp if supplementing potassium or using an ACE-i.
- A much less common side effects (but one that shows up on exams!) is gynecomastia developing from the neurohormonal interactions.
- Loop diuretics: Furosemide and bumetanide
- *Contractility enhancement (Inotropic agents):Improve contractility of the heart. Goal is to increase cardiac output and improve perfusion to vital organs and tissues.
- Dopamine
- Dobutamine
- Epinephrine
- Milrinone
- Digoxin (Digitalis glycosides)
- Toxicity:
- Acute digoxin toxicity typically presents with nausea, vomiting, and diarrhea.
- Be esp aware of color-vision changes, confusion, or vertigo.
- Palpitations and arrhythmias (AV block, SVT, VT) are common also.
- If toxicity is severe, given digoxin-specific antibodies (Fab fragments).
- *Afterload reduction (Vasodilators): Important in remodeling or manipulating ventricular load
- ACE Inhibitors
- Sodium nitroprusside
- Cyanide toxicity is a concern if given for >48 hours
- If pt is in the ICU with an unexplained metabolic acidosis, consider prolonged use of sodium nitroprusside as a cause.
- Tx options for suspected cyanide toxicity, after discontinuing the drug, are sodium thiosulfate or hydroxocobalamin (vitamin B12).
- Beta blockers
- *Preload reduction (Diuretics): Principal agents for control of pulmonary as well as systemic venous congestion.
44
Q
VSD
- Most common congenital heart lesion recognized in term newborns (25-30% of cases) in the first few years of life. (Bicuspid aortic valves are the most common congenital heart lesion but often are not recognized until teen or young adult ages.)
- At birth, a majority of VSDs occur in the muscular septum, but these usually close spontaneously at <1 yo.
- After 1yo, the majority of detected VSDs occur in the perimembranous septum (bw aortic and tricuspid valve)
- Pt:
- Most symptoms begin in term infants 4-8 weeks of age and consist of tachypnea, tachycardia, and feeding difficulties (classic heart failure symptoms in infants).
- Murmur: _______ murmur
- A small VSD, which does not allow any equalization of pressure between the LV and RV, has a high intensity murmur whereas a large VSD, which allows complete equalization of pressure between the LV and RV, can cause a soft murmur across the VSD
- Tx: Close persistent shunts that have >2x the normal pulmonary blood flow.
- Asymptomatic infants: Reevaluate periodically
- Symptomatic infants: Has signs of HF
- Go straight to cardiology consultation (if not available, order an echo)
- Surgery for larger defects or defects in the inlet or outlet septum, particularly with elevated R heart pressures by 6-12mo
- For muscular or perimembranous defects, medical therapy is given a chance bc these are more likely to decrease in size or even close spontaneously over time.
- Go straight to cardiology consultation (if not available, order an echo)
A
VSD
- Most common congenital heart lesion recognized in term newborns (25-30% of cases) in the first few years of life. (Bicuspid aortic valves are the most common congenital heart lesion but often are not recognized until teen or young adult ages.)
- At birth, a majority of VSDs occur in the muscular septum, but these usually close spontaneously at <1 yo.
- After 1yo, the majority of detected VSDs occur in the perimembranous septum (bw aortic and tricuspid valve)
- Pt:
- Most symptoms begin in term infants 4-8 weeks of age and consist of tachypnea, tachycardia, and feeding difficulties (classic heart failure symptoms in infants).
- Murmur: Holosystolic murmur
- A small VSD, which does not allow any equalization of pressure between the LV and RV, has a high intensity murmur whereas a large VSD, which allows complete equalization of pressure between the LV and RV, can cause a soft murmur across the VSD
- Tx: Close persistent shunts that have >2x the normal pulmonary blood flow.
- Asymptomatic infants: Reevaluate periodically
- Symptomatic infants: Has signs of HF
- Go straight to cardiology consultation (if not available, order an echo)
- Surgery for larger defects or defects in the inlet or outlet septum, particularly with elevated R heart pressures by 6-12mo
- For muscular or perimembranous defects, medical therapy is given a chance bc these are more likely to decrease in size or even close spontaneously over time.
- Go straight to cardiology consultation (if not available, order an echo)
45
Q
Patent Ductus Arteriosus (PDA)
- Incidence is inversely related to gestational age. Premature infants (weighing <1750g) have clinically apparent PDA 40-70% of the time.
- Normal:
- The PDA functionally closes within 10-15 hours after birth, but complete anatomic closure may not occur for 3 weeks.
- Murmur: Continuous “machinery-like” systolic murmur
- Pt:
- If PDA is small, child is otherwise asymptomatic
- If it is large, it causes a L-to-R shunt like a VSD, causing pulmonary overcirculation
- Bounding pulses and a wide pulse pressure on exam
- Tx:
- Bounding pulses and a wide pulse pressure on exam
- Supportive care, including correcting anemia along with modest fluid restriction. PEEP is useful in managing PDA
- Pharmacological closure using ________. Treat premature infants with indomethacin (prostaglandin inhibitor).
- Side effects: ____, dilutional ___, _____
- Should not be used if infant has any of the following
- Necrotizing enterocolitis
- Serum Cr >1.6
- Hourly UOP <1
- Bleeding diathesis
- Platelet count <50,000/uL
A
Patent Ductus Arteriosus (PDA)
- Incidence is inversely related to gestational age. Premature infants (weighing <1750g) have clinically apparent PDA 40-70% of the time.
- Normal:
- The PDA functionally closes within 10-15 hours after birth, but complete anatomic closure may not occur for 3 weeks.
- Murmur: Continuous “machinery-like” systolic murmur
- Pt:
- If PDA is small, child is otherwise asymptomatic
- If it is large, it causes a L-to-R shunt like a VSD, causing pulmonary overcirculation
- Bounding pulses and a wide pulse pressure on exam
- Tx:
- Bounding pulses and a wide pulse pressure on exam
- Supportive care, including correcting anemia along with modest fluid restriction. PEEP is useful in managing PDA
- Pharmacological closure using cyclooxygenase inhibitors (indomethacin, ibuprofen, tylenol). Treat premature infants with indomethacin (prostaglandin inhibitor).
- Side effects: Oliguria, dilutional hyponatremia, intestinal perforation
- Should not be used if infant has any of the following
- Necrotizing enterocolitis
- Serum Cr >1.6
- Hourly UOP <1
- Bleeding diathesis
- Platelet count <50,000/uL
46
Q
PFO
- Pt: No physical findings or symptoms result.
- NO MURMUR
- Usually, the PFO is small and of no clinical significance in childhood.
A
PFO
- Pt: No physical findings or symptoms result.
- NO MURMUR
- Usually, the PFO is small and of no clinical significance in childhood.
47
Q
Ostium Secundum Defect
- Pt:
- It is rare for an infant to present with symptoms from an ASD until 1yo.
- Cardiac failure is very unusual in infancy.
- It is rare for an infant to present with symptoms from an ASD until 1yo.
- Murmur:
- S1 is normal and S2 is _____ without respiratory variation (“fixed splitting”).
- Systolic ejection murmur that is crescendo decrescendo and heard best at the L upper sternal border.
- The murmur is from increased flow across the RV outflow tract (RVOT) and pulmonic valve.
- EKG shows ____ (R axis deviation), RVH, and a typical rsR or rSR’ pattern in the R precordium (V1)
- Tx:
- Usually, perform closures within the first 5 years of age to prevent complications.
A
Ostium Secundum Defect
- Pt:
- It is rare for an infant to present with symptoms from an ASD until 1yo.
- Cardiac failure is very unusual in infancy.
- It is rare for an infant to present with symptoms from an ASD until 1yo.
- Murmur:
- S1 is normal and S2 is widely split (fixed split S2) without respiratory variation (“fixed splitting”).
- Systolic ejection murmur that is crescendo decrescendo and heard best at the L upper sternal border.
- The murmur is from increased flow across the RV outflow tract (RVOT) and pulmonic valve.
- EKG shows RAD (R axis deviation), RVH, and a typical rsR or rSR’ pattern in the R precordium (V1)
- Tx:
- Usually, perform closures within the first 5 years of age to prevent complications.
48
Q
Ostium Primum Defect
- Pt:
- In addition to typical exam findings, may hear mitral and tricuspid regurgitation murmurs if the clefts occur in these valves.
- EKG shows ____ (L axis deviation) and RVH, demonstrated by an rsR’ pattern in the R precordium.
- The LAD distinguishes the ostium primum defect from the ostium secundum defect.
- Tx:
- Perform early surgical correction in childhood.
A
Ostium Primum Defect
- Pt:
- In addition to typical exam findings, may hear mitral and tricuspid regurgitation murmurs if the clefts occur in these valves.
- EKG shows LAD (L axis deviation) and RVH, demonstrated by an rsR’ pattern in the R precordium.
- The LAD distinguishes the ostium primum defect from the ostium secundum defect.
- Tx:
- Perform early surgical correction in childhood.
49
Q
Complete AV Canal Defect (AV Septal defect, Endocardial Cushion Defect)
- The overall result is a L-to-R shunt and valve regurgitation, leading to a cardiac volume overload and HF.
- Most common heart defect in _____
- Murmur
- Characteristic murmur of VSD (though usually the VSD is large and nonrestrictive and therefore does not cause a murmur), as well as a middiastolic rumble
- Pt:
- Infants most often present with heart failure by 2 months of age.
- EKG usually shows severe _____ (northwest axis) and prominent voltages with biventricular hypertrophy
- Tx:
- Medical management of HF can be helpful, but early surgery is necessary within the first 6-12 mo to prevent pulmonary vascular disease (Eisenmenger syndrome).
A
Complete AV Canal Defect (AV Septal defect, Endocardial Cushion Defect)
- The overall result is a L-to-R shunt and valve regurgitation, leading to a cardiac volume overload and HF.
- Most common heart defect in Down syndrome (trisomy 21)
- Murmur
- Characteristic murmur of VSD (though usually the VSD is large and nonrestrictive and therefore does not cause a murmur), as well as a middiastolic rumble
- Pt:
- Infants most often present with heart failure by 2 months of age.
- EKG usually shows severe LAD (northwest axis) and prominent voltages with biventricular hypertrophy
- Tx:
- Medical management of HF can be helpful, but early surgery is necessary within the first 6-12 mo to prevent pulmonary vascular disease (Eisenmenger syndrome).
50
Q
Pulmonary Hypertension
- Path: 2 causes:
- 1) An increase in R-sided pressure, due to a large septal defect and very high pulmonary flow
- 2) An increase in PVR
- Eisenmenger syndrome
- Pt:
- Pulmonary HTN can present as a narrowly split or single 2nd heart sound with a loud pulmonic component.
- CXR classically shows a large proximal pulmonary artery.
- Tx:
- Correct the underlying cause if present
A
Pulmonary Hypertension
- Path: 2 causes:
- 1) An increase in R-sided pressure, due to a large septal defect and very high pulmonary flow
- 2) An increase in PVR
- Eisenmenger syndrome
- Pt:
- Pulmonary HTN can present as a narrowly split or single 2nd heart sound with a loud pulmonic component.
- CXR classically shows a large proximal pulmonary artery.
- Tx:
- Correct the underlying cause if present
51
Q
Eisenmenger Syndrome
- L-to-R shunts can have serious consequences if not managed appropriately. The persistence of high flow and pressures in the pulmonary arteries from long-term L-to-R shunting can lead to progressive and permanent, or fixed, elevation of pulmonary resistance, irreversible pulmonary HTN, and subsequent R-to-L shunting and cyanosis (as above) - Eisenmenger syndrome.
- Usually symptoms do not develop until the 2nd or 3rd decade of life.
- Physical exam: RV heave, palpable single S2, diastolic murmur of pulmonic insufficiency, and a pulmonary click.
- Can be lethal.
A
Eisenmenger Syndrome
- L-to-R shunts can have serious consequences if not managed appropriately. The persistence of high flow and pressures in the pulmonary arteries from long-term L-to-R shunting can lead to progressive and permanent, or fixed, elevation of pulmonary resistance, irreversible pulmonary HTN, and subsequent R-to-L shunting and cyanosis (as above) - Eisenmenger syndrome.
- Usually symptoms do not develop until the 2nd or 3rd decade of life.
- Physical exam: RV heave, palpable single S2, diastolic murmur of pulmonic insufficiency, and a pulmonary click.
- Can be lethal.
