Pediatric CV and BLT Flashcards
Coarctation
This condition represents 5-8% of all congenital cardiac lesions. It represents 7% of critically ill infants with heart disease. 3% of neonatal death attributable to congenital heart defects due to CoA in US
Birth incidence may be underestimated because many cases not diagnosed until adulthood
Associated with many other cardiac lesions/ syndromes
60% of infants, 30% of older children have bicuspid aortic valve
Pathophysiology:
Narrowing of the aorta, usually distal to the left subclavian artery and proximal to the ductus arteriosis
when symptoms of CoA may begin
Closing of the ductus arteriorsis:
Occurs in the first 2 weeks of life
Closing of the ductus arteriosis with coarctation
Closing of the ductus in the presence of obstruction results in
Decreased blood flow distal to the obstruction
- Brachiofemoral delay
- -Pulse differentials- less detectable distal to obstruction
- Blood pressure differentials- lower BP distal to obstruction
Increased pre-coarctation pressure
- Pulmonary congestion
- Hepatic congestion
- Tachypnea
- Heart failure
Decreased post-coarctation pressure
- Decreased perfusion
- —> Cool skin (cutis marmoratum)
coarctation x-ray
enlarged heart shadow
Effects of coarctation
- mechanical obstruction causes increased pressures proximal to the coarctation (upper extremities), and decreased pressure distal
- decreased pressures distal to the coarctation leads to:
- Hypoperfusion of the kidneys
- Which increase renin secretion
- leads to arterial constriction and hypertension proximal to the obstruction
- Lower extremity circulation is largely dependent on collateral circulation as these children age
Systemic Effects of COA in Older Children and Adults
rib notching
the 3 signs: dilation of the aortic arch and subclavian artery, the “tuck” of the coarctation and the post-stenotic dilation of the descending aorta
Osteopathic Management for coarctation of the aorta (peds)
Prompt recognition of the problem and need for immediate intervention
- Asymptomatic infants can be watched closely
- Those with progressive severity need intervention more rapidly
- –> NICU care, cardiology evaluation, surgical evaluation
Important to maintain patent ductus arteriosus in symptomatic newborns
— Prostaglandin E2 (PGE2)
Surgical intervention is ultimately the ‘cure’
- Surgery (anastomosis), balloon angioplasty, and/or stent placement
Osteopathic manipulative medicine
- Aimed at enhancing tissue repair after surgery and during long term management
Follow up care
Cardiology/primary care: watching for recoarctation
Increase in irritability, decreased feeding, tachypnea, pulse inequalities, perfusion, new/progressing heart murmurs, hypertension
OMM
At growth spurts to augment and support tissues as they move through growth
Osteopathic Management: OMM (coarctation patient)
Balance SNS activity
- Cervical region to affect the cervical ganglia
- Upper thoracics
- Rib raising
Diaphragm and ribs
- To improve gas exchange
- To improve fluid dynamics
Cranial base, ** Occipitomastoid Suture, OA and cervical spine
- Balance parasympathetics (vagus)
- ——- Exits skull in the jugular foramen (occipital and temporal bones)
- To improve fascial mechanical strain that result from intubation
Lymphatic pumps, thoracic inlet
– Can teach parents to do this at home (after healing)
Balanced Ligamentous Tension (BLT) Introduction
Dr. Sutherland used the principle of balanced membranous and ligamentous tension as his approach to treatment in the cranium and the body
Ligaments provide * proprioceptive information that guides the muscle response to positioning
Ligaments * guide the motion of articular mechanisms
His technique includes both direct and indirect methods
The area of strain is brought to the point of balanced membranous/ ligamentous tension
All techniques involve engaging and utilizing the “powers within the patient’s body” from a “point of balanced tension”
Inherent forces: “reset” nervous system, reduce firing of joint receptors and nociceptors, expression of inherent motion (respiration, pulse, PRM)
evaluation and goal of BLT
The evaluation of somatic dysfunction should include the impact on the local expression of inherent motion, such as respiration, pulse, and the primary respiratory mechanism (PRM)
This will provide evidence of the physiological impact the somatic dysfunction is having on local physiology
“The goal of treatment is to improve the interchange of all the fluids of the body across all tissue interfaces.” – A. Wales, DO
the point of blaanced membranous/ ligamentous tension
defined as “the point in the range of motion of an articulation where the ligaments and membranes are poised between the normal tension present throughout the free range of motion and the increased tension preceding the strain…” – H. Lippincott, DO and R. Lippincott, DO
Although the concept is simple, the depth lies in the precision in which it is applied, and the window into body physiology it affords
- The advanced technique is the simple technique done really well
A diagragmatic representation of a ligamentous articular strain- BLT INDIRECT approach
box with straps attached to the lid, one taut and one slack
Partially closing the lid and slacking both straps (ligaments), a point of balanced ligamentous tension would be achieved. This represents an indirect approach.
A diagragmatic representation of a ligamentous articular strain
- BLT DIRECT approach
box with straps attached to the lid, one taut and one slack.
If the articulation is carried into the strain, the articulation would be displaced the slacked strap (ligament), and this would also bring this to a point of balanced tension. This is achieved through direct (into the barrier) positioning.
When positioning into the barrier, do not attempt to overcome resistance.
Match the tension which allows the inherent forces to make the correction.
Balanced Ligamentous Tension (BLT)– Exaggeration
Exaggeration
Indirect
Most commonly used
Takes advantage of natural recoil in tissue
(boxes going in opposite directions)
Balanced Ligamentous Tension (BLT)- Direct Action
Direct Action
Retrace the path of the lesion within range of free motion
(boxes going toward one another)
Balanced Ligamentous Tension (BLT)- Disengagement
Disengagement
Used in conjunction with exaggeration and direct action
(boxes going up and down away from each other)
