Cardiac Abnormalities Flashcards

(40 cards)

1
Q

How can you grade murmurs?

A

Grading works on loudness

  1. Just audible with a quiet child in the room
  2. Quiet but easily audible
  3. Loud but no thrill
  4. Loud with thrill
  5. Audible even if stethoscope only just makes contact
  6. Audible without a stethoscope
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2
Q

When is it normal to hear murmurs?

A

Very common to hear completely innocent early systolic murmurs in children at some time usually due to fever, anxiety and exercise.

Venous hums Due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles

Still’s murmur Low-pitched sound heard at the lower left sternal edge

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3
Q

What features are suggestive of an innocent murmur?

A

Features associated with innocent murmurs:
• Grade ≤ 2
• Softer intensity when patient sitting compared with supine
• Short systolic (not holosystolic or diastolic)
• Minimal radiation
• Musical or vibratory quality

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4
Q
Describe the common pediatric causes of 
Ejection systolic murmur 
Pansystolic
Late systolic 
Continuous murmur 
No murmur with cyanosis
A
Ejection Systolic – ASD or TOF 
Pansystolic – VSD
Late Systolic – COA 
Continuous murmur – PDA
No murmur – TGA
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5
Q

What is Eisenmenger’s syndrome?

A

Reversal of left to right shunt to right to left shunt due to increasing pulmonary resistance or failing left heart. Cyanosis will only be present if there is a right to left shunt. This occurs in: TGA, ToF, tricuspid or pulmonary atresia, total anomalous pulmonary venous return, hypoplastic left heart and truncus arteriosus

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6
Q

What are the risk factors for congenital cardiac abnormalities

A

Family History
Diabetes
Monochorionic twins
Down’s syndrome

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7
Q

When do congenital cardiac abnormalities usually present?

A

Some conditions present early (hours to days): hypoplastic left heart, transposition of the great arteries and shunt dependant circulations. Ventricular septal defect by about a month.
Some present during adulthood: atrial septal defect, and coarctation of the aorta

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8
Q

What are the usual clinical features of congenital cardiac abnormalities?

A
Decompensation and heart failure of which hepatomegaly is an important sign 
Cyanosis (only right to left shunt) 
Poor feeding 
Dyspnoea 
Tachycardia (bradycardia or inappropriately normal rate suggests immediate arrest)
Cool peripheries 
Sweating 
Acidosis 
Pulmonary venous congestion on CXR
Clubbing 
Thrills
Breathlessness which is worse on exertion e.g. feeding
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9
Q

How should a child with suspected cardiac abnormality be investigated?

A
FBC
CXR
Blood gas
O2 sats
ECG
Echocardiogram
Cardiac catheter/advanced imaging
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10
Q

How should heart failure in a child be managed?

A

Sit upright and give oxygen
Calories via NG tube
Diuretics (furosemide +/- spironolactone) to reduce pre-load
Captopril – ACEi to reduce afterload
Increase contractility using Digoxin
If duct dependant and cyanotic need to maintain patency – alprostadil

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11
Q

What are ventricular septal defects and how do they progress?

A

Defect in the ventricular septum. In an otherwise normal heart this results in flow of blood from the left ventricle through the right ventricle and into the pulmonary artery. This presents at about 4-6 months after the pulmonary resistance decreases. The excess blood in the pulmonary vasculature causes pulmonary hypertension and oedema and the reduction in systemic blood flow will cause the heart to have to work harder. Eisenmenger’s syndrome can occur.

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12
Q

What are the risk factors for ventricular septal defects?

A
Rubella 
Drugs, tobacco and alcohol during pregnancy 
Diabetes and Lupus
Obesity 
Mother with PKU
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13
Q

Describe how a child with a ventricular septal defect usually presents?

A
Usually mild and has a pansystolic murmur
Poor eating and failure to thrive
Tachypnoea on exertion 
Fatigability 
Tachycardia
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14
Q

How should a suspected ventricular septal defect be investigated?

A

Echo
ECG will show right heart strain
CXR will show pulmonary engorgement and cardiomegaly.

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15
Q

How are ventricular septal defects managed?

A

Treat Heart failure
Cardiac catheterisation and repair
Small or muscular defects close independently over time, but larger ones will need surgery.

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16
Q

What are atrial septal defects and how do they progress?

A

Defect in the atrial septum. These present late as the pressure difference between the two atria is slight and so overloading of the right ventricle occurs slowly. Eventually they will present with right ventricular hypertrophy which causes pulmonary hypertension and right heart failure. There is also an increased risk of stroke. Seriousness depends on its location i.e. it can be secundum (most common), primum or an AVSD. ASD is fairly common in trisomy 21. Eisenmenger’s syndrome can occur.

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17
Q

What are the risk factors for atrial septal defects?

A
Rubella 
Drugs, tobacco and alcohol during pregnancy 
Diabetes and Lupus
Obesity 
Mother with PKU
18
Q

How do atrial septal defects usually present?

A
Rarely any symptoms 
Systolic murmur
Shortness of breath and exercise intolerance 
Peripheral oedema 
Heart murmur
19
Q

How should atrial septal defects be investigated?

A

Echo
ECG will show right ventricular hypertrophy and a slight RBBB
CXR for cardiomegaly.

20
Q

How are atrial septal defects managed?

A

Manage any heart failure or other symptoms
Cardiac catheterisation and repair
Open heart surgery and repair

21
Q

When is a ductus arteriosus patent vs persistent?

A

DA is termed persistent at >1month past term but simply patent if preterm or before this time.

22
Q

What are the risk factors for patent ductus arteriosus?

A
Premature Birth 
Family history 
Rubella 
Born at high altitude 
Female (x2 compared to male)
23
Q

How do patent DA usually present?

A
Symptoms are rare if small 
CCF 
Pulmonary hypertension
Continuous murmur  
Collapsing pulse
Failure to thrive – poor eating, sweating and crying 
Fatiguability 
Tachycardia 
Pneumonia
24
Q

How should a suspected patent DA be investigated?

A

Echo

CXR and ECG usually normal.

25
How are patent DA managed?
Ensure that no circulation is duct dependant and then close to avoid spontaneous bacterial endocarditis. Closure is done using IV or oral ibuprofen. If persistent and ibuprofen not effective then surgery.
26
What is coarctation of the aorta
Narrowing of the aorta, can be in different locations and to different degrees. Over time this will cause hypertension, increased risk of stroke, aneurysm, aortic rupture, heart failure and cerebral haemorrhage and aneurysms.
27
What are the risk factors for coarctation of the aorta?
Bicuspid aortic valve or stenosis or regurgitation PDA Septal defects Other valve problems
28
How does coarctation of the aorta present?
``` Usually no symptoms unless severe or interrupted arch and so duct dependant which will have symptomatic shock by 3-10 days. Hypertension Radio-femoral delay Reduced volume at femoral pulses Pulseless and pale feet as well as cramps Sweating Feeding and breathing difficulty Nosebleeds Heart failure Ejection systolic murmur Left ventricular hypertrophy. ```
29
How is coarctation of the aorta managed?
Surgery required by 5yrs to avoid pulmonary hypertension and end organ damage. This can be in the form of: stent and/or balloon angioplasty, bypass graft, resection and end to end anastomosis or path aortoplasty.
30
What is transposition of the great arteries and how does it progress?
Right and left circulation switched and so now separate systems with the right side pumping deoxygenated blood around the body via the aorta and the left pumping oxygenated blood to the lungs via the pulmonary artery and back. Only viable if Foramen ovale, or ASD and or ductus arteriosus maintained opened using prostaglandins. PDA allows enough blood to go to the lungs. Overtime without corrective surgery this will cause heart failure, lung damage (from oxygen risk blood) and end organ failure.
31
What are the risk factors for transposition of the great arteries?
Rubella Alcohol and smoking Poorly controlled diabetes
32
How does transposition of the great arteries present?
Cyanosis Shortness of breath Poor feeding and weight gain
33
How should suspected transposition of the great arteries be investigated?
Usually diagnosed prenatally or after birth ECG and echo important CXR Cardiac catheterisation
34
How should transposition of the great arteries be managed?
Alprostadil Cardiac catheter can be used to induce an atrial septal perforation if there isn’t already one Surgery required with arterial switch within first few days including coronary arteries
35
What is tetralogy of fallot?
Cyanotic condition – a collection of 4 cardiac defects as a result of anterior and cephalic misalignment of the outlet septum. These are: Large VSD, overriding aorta, pulmonary stenosis and right ventricular hypertrophy. Risk of MI, stroke and infective endocarditis.
36
What are the risk factors for tetralogy of fallot?
``` Rubella Alcohol Poor nutrition during pregnancy Old mother Family history of ToF Down Syndrome ```
37
How does tetralogy of fallot usually present?
Cyanosis Shortness of breath Fatiguability Lower right parasternal heave Ejection systolic murmur - pulmonary stenosis Cyanosis gradually worsens or with sudden short exacerbations causing distress and pallor. This occurs with crying, coughing and sneezing as the increased thoracic pressure causes pulmonary resistance to increase and peripheral resistance to decrease as vessels vasodilate so less blood goes to the lungs resulting in blood becoming even less oxygenated. Clubbing
38
How should a cyanotic spell be managed?
Change position by pushing child’s knees to their chest Oxygen to dilate pulmonary vessels Fluid bolus to increase systemic resistance Morphine to sedate and stop crying/coughing/sneezing
39
How should suspected Tetralogy of fallot be investigated?
``` Usually diagnosed antenatally Echo ECG CXR Cardiac catheterisation to plan surgery ```
40
How should tetralogy of fallot be managed?
Patient expected to have SATs of around 75%. If higher this is bad as it means the majority of blood is being sent to the lungs and so the heart is having to work very hard to get any around the systemic circulation Interim with shunt formation if premature from the brachiocephalic to the pulmonary artery Corrective intercardiac surgery at 6 months.