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Paeds > Cardio > Flashcards

Cardio Flashcards

1
Q

What is the hyperoxia / nitrogen wash out test?

A

Used to differentiate cardiac from non-cardiac causes of cyanosis

Process:

  • Infant is given 100% O2 for 10 minutes
  • ABG is taken
  • A pO2 of <15 kPa = cyanotic congenital heart disease
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2
Q

Is cyanosis always pathological?

A

Peripheral cyanosis is very common in the first 24 hours of life and may occur when the child is crying or unwell from any cause

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3
Q

What type of CHD is tricuspid atresia?

A

RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE

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4
Q

What is tricuspid atresia?

A

Absent tricuspid valve

  • No connection between R atrium and R ventricle
  • Small, non-functional RV (LAD)
  • Only L ventricle effective
  • Commonly have ASD + VSD
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5
Q

What are the symptoms of tricuspid atresia?

A
  • Central cyanosis (presents very early ~10mins)
  • SOB
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6
Q

What are the signs O/E of tricuspid atresia?

A

Murmur depends on associated abnormalities:

  • Pan systolic - VSD
  • ESM at left sternal edge - pulmonary stenosis
  • Continuous murmur - PDA
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7
Q

What is the management of tricuspid atresia?

A

1. ASAP PGE1 infusion

2. Surgery <2 weeks
(complete corrective surgery not possible in most cases bcos only one functioning ventricle)
1. Glenn operation (connect SVC to pulmonary artery)
2. Fontan operation (connect IVC to pulmonary artery)

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8
Q

What type of CHD is TGA?

A

RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE

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9
Q

What is TGA?

A

Anatomical reversal of the aorta and pulmonary artery

2 closed-loop systems (PA sends oxygenated blood to lungs and A sends deoxygenated blood to body)

Usually fatal immediately

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10
Q

What is a RF for TGA?

A

Maternal diabetes

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11
Q

What are the symptoms of TGA?

A

Postnatal cyanosis within a few hours (at rest)
Unaffected by supplemental O2
Tachypnoea

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12
Q

What are the signs of TGA?

A
  • Single loud second heart sound (S2)
  • Prominent R ventricular impulse
  • No murmur (ES murmur if VSD + pulmonary stenosis)
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13
Q

What are the investigations for TGA?

A

CXR

  • Egg-on-side / egg on a string (narrow upper mediastinum)
  • Increased pulmonary markings

Echo

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14
Q

What is the management of TGA?

A
  1. ASAP prostaglandin infusion e.g. alprostadil (maintain PDA)
  2. Balloon atrial septoplasty (tears atrial septum down to allow mixing)
  3. Arterial switch surgery (within 2wks)
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15
Q

What type of CHD is AVSD?

A

RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE

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16
Q

What is AVSD?

A

Single large defect connecting all 4 chambers (all blood mixes)

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17
Q

What is AVSD commonly associated with?

A

Down Syndrome

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18
Q

What are the S/S of AVSD?

A

Cyanosis at 2-3w of life
No murmur
Found on routine echo of Down’s

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19
Q

What is the management of AVSD?

A
  1. Treat HF medically
  2. Surgery at 3m
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20
Q

What type of CHD is ToF?

A

RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE
Most common cause of cyanotic heart disease

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21
Q

What is the pathophysiology of ToF?

A

Simultaneous occurrence of 4 defects

  1. VSD (large)
  2. Overriding aorta
  3. R ventricular outflow tract obstruction (pulmonary stenosis)
  4. R ventricular hypertrophy
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22
Q

What are the RFs for ToF?

A

Maternal diabetes
Maternal alcohol consumption

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23
Q

What syndromes are associated with ToF?

A

DiGeorge Syndrome
Down Syndrome

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24
Q

What are the symptoms of ToF?

A

Mild to severe cyanosis (depending on RVOTO extent)

Tet spells (crying > increased pulmonary resistance > R-L shunt > cyanosis)

Squatting relieves symptoms

Clubbing

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25
Q

What murmur is heard in ToF?

A

Loud ESM at LUSB
(from pulmonary stenosis)

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26
Q

What are the investigations for ToF?

A

CXR = large boot-shaped (due to RVH)
ECG = RVH / right axis deviation
Echo

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27
Q

What is the management of ToF?

A

Mild cyanosis (<15 mins) = self-limiting

Initial Management
1. Knee-chest position and high-flow O2
2. ASAP Prostaglandin e.g. alprostadil

If prolonged cyanosis:
3. Morphine (sedation and pain relief)
4. IV propranolol (peripheral vasoconstriction and relive sub-pulmonary muscle contraction)
5. IV fluids and bicarbonate (severe acidosis)
6. Muscle paralysis and artificial ventilation to reduce metabolic O2 demand

Temporary Repairs:
1. Shunt
2. Balloon dilation / stent

Complete Repair:
Surgery 6m later (within 1st year)

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28
Q

What type of CHD is Ebstein’s Anomaly?

A

RIGHT-TO-LEFT SHUNT
CYANOTIC HEART DISEASE

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29
Q

What is Ebstein’s Anomaly?

A

Tricuspid Valve is displaced downwards
= small and hypocontractile RV

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30
Q

What is a RF for Ebstein’s Anomaly?

A

Associated with in-utero lithium exposure (maternal BPD)

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31
Q

What are the S/S of Ebstein’s Anomaly?

A

(Presentation depends on the degree of displacement)

Severe = in-utero hydrops fetalis
Mild = cyanosis

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32
Q

What murmur is heard in Ebstein’s Anomaly?

A

Pansystolic (tricuspid regurg)
Mid-diastolic (tricuspid stenosis)

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33
Q

What are the investigations for Ebstein’s Anomaly?

A

Echo = confirmatory
CXR = cardiomegaly (RA enlargement)

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34
Q

What is the management for Ebstein’s Anomaly?

A

Surgery

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35
Q

What type of CHD is ASD?

A

LEFT-TO-RIGHT SHUNT
ACYANOTIC HEART DISEASE

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36
Q

What are the 2 types of ASD?

A

Secundum (80%)

  • Defect in middle of atrial septum (foramen ovale does not close)
  • Usually small
  • Associated with Holt-Oram syndrome (tri-phalangeal thumbs)

Partial/Primum (20%)

  • Defect of AV septum (lower)
  • Usually large / presents earlier
  • Associated with abnormal AV valves
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37
Q

What are the RFs for ASD?

A

Down Syndrome
Maternal alcohol consumption

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38
Q

What are the symptoms of ASD?

A

Usually asymptomatic (until Eisenmenger Syndrome)

  • Shortness of breath, especially when exercising
  • Fatigue
  • Oedema
  • Arrhythmias (from 40+)
  • Palpitations
  • Recurrent chest infections / wheeze
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39
Q

What are the signs of ASD?

A
  • Ejection systolic murmur (loudest at LUSE)
  • Fixed wide splitting of S2

Not until a few weeks old

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40
Q

What are the investigations for ASD?

A

ECG
Secundum = RBBB with RAD
Partial = RBBB with LAD, prolonged PR interval, ‘superior’ QRS axis

Echo = diagnostic

CXR

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41
Q

What is the management of ASD?

A

Usually at 3yrs

Small = heal spontaneously (monitor)

Secundum = cardiac catheterisation and insertion of occlusive device (percutaneous/endovascular closure)

Partial = surgical correction

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42
Q

What is the main complication of ASD?

A

Stroke (embolism may pass from venous system to L side of heart)

43
Q

What type of CHD is VSD?

A

LEFT-TO-RIGHT SHUNT
ACYANOTIC HEART DISEASE

44
Q

What are the RFs for VSD?

A
  • Maternal alcohol consumption
  • Maternal diabetes
  • Congenital infection
  • Chromosomal disorders - DS, ES, PS
  • Post MI
45
Q

How are VSDs classed?

A

Classification is based on size:
Small = <3mm
Large = >3mm

46
Q

What are the symptoms of VSD?

A

Small = Asymptomatic (until Eisenmenger Syndrome)

Large = Heart failure, SOB, exertional dyspnoea, recurrent chest infections, struggling to feed, not gaining weight

47
Q

What are the signs of a VSD?

A

Small:

  • Loud pansystolic murmur at LLSE (intensifies with hand clenching)
  • Soft pulmonary 2nd sound

Large:

  • Soft pansystolic murmur (louder in small defects)
  • Loud pulmonary 2nd sound
  • Hepatomegaly
  • Parasternal heave
  • Systolic murmur at LLSE
48
Q

What are the investigations for a VSD?

A

Echo = diagnostic
Small = all else normal
Large = CXR (HF), ECG (heart hypertrophy, R wave height >8mm)

49
Q

What is the management for a small VSD?

A

Self-limited (close by themselves)
Close monitoring
After they close, no longer at risk of IE

50
Q

What is the management for a large VSD?

A

Usually result in a degree of heart failure in the first few months

  • Nutritional support
  • Medication for heart failure e.g. diuretics
  • Surgical closure of the defect
51
Q

What are patients with small VSDs at risk of?

A

High risk of endocarditis

52
Q

What type of CHD is PDA?

A

LEFT-TO-RIGHT SHUNT
ACYANOTIC HEART DISEASE

53
Q

What is PDA?

A

Failure of the ductus arteriosus to close after birth
(usually after day 1)

Connects pulmonary artery to descending aorta

54
Q

What are the RFs for PDA?

A
  • Premature
  • TORCH infections (Rubella 1st trimester)
  • Maternal alcohol consumption
55
Q

What are the symptoms of PDA?

A

Small = asymptomatic

Large = unspecific symptoms e.g. failure to thrive or resp symptoms (increased work e.g. apnoea, bradycardia, high O2 needs)

56
Q

What are the signs of PDA?

A
  • Continuous machine like / Gibson’s murmur at ULSE
  • Large volume, bounding, collapsing pulse
  • Heaving apex beat
  • Left subclavicular thrill
  • Wide PP
57
Q

What are the investigations for PDA?

A

Symptomatic = echo at 1wk

58
Q

What is the management for PDA?

A

Medical

  • Indomethacin or ibuprofen given to neonate 1w after delivery (inhibits prostaglandin synthesis, promotes duct closure)

Surgical

  • Coil/device closure at cardiac catheter at 1yr
  • or surgical ligation
59
Q

What is Eisenmenger Syndrome?

A

The progression of an untreated left-to-right shunt (acyanotic) to a right-to-left shunt (cyanotic)

60
Q

What is the pathophysiology of Eisenmenger Syndrome?

A
  • Uncorrected left-to-right shunt
  • Chronically raised pulmonary arterial pressure
  • Irreversibly raised pulmonary vascular resistance
  • Eventually shunt decreases and child becomes less symptomatic
  • At 10-15yrs, shunt reverses (right to left shunt)
  • Teenager becomes blue and cyanotic (ES)
  • > Death by right-sided heart failure (40-50yrs)
61
Q

Which CHDs is Eisenmenger Syndrome associated with?

A

VSD, ASD, PDA

62
Q

What are the S/S of Eisenmenger Syndrome?

A
  • CYANOSIS (ASD/VSD = global, PDA = lower body only)
  • Chest pain or tightness.
  • Coughing up blood
  • Dizziness or fainting.
  • Easily tiring and SOB with activity
  • Headaches
  • Numbness or tingling in fingers or toes
  • Original murmur may disappear
  • Clubbing
  • Right ventricular failure
63
Q

What is the management of Eisenmenger Syndrome?

A

»Regular cardiology check-ups
Goals of treatment are to control symptoms, improve quality of life and prevent serious complications.

Medical:

  • Anti-arrythmics
  • Iron supplements
  • Aspirin
  • Mx for pulmonary HTN

Surgical:

  • Heart-lung transplantation
64
Q

What is CoA?

A

Congenital narrowing of the descending aorta

65
Q

What are the types of CoA?

A

Preductal = proximal to ductus arteriosus (most common)

Post ductal = distal to ductus arteriosus

66
Q

What is associated with CoA?

A
  • Turner’s Syndrome
  • Bicuspid aortic valve
  • More common in males
  • Also - Berry aneurysms, Neurofibromatosis
67
Q

What are the symptoms of CoA?

A

3rd day of life > few weeks of life

  • Can be asymptomatic
  • Leg pain
  • Tiredness
  • Headaches
  • Dizziness
  • Epistaxis
68
Q

What are the signs of CoA?

A
  • Brachio-femoral delay
  • High BP in arms, low BP in legs
69
Q

What are the investigations for CoA?

A
  • CXR = ‘Rib notching’ (due to large collateral intercostal arteries forming)
  • Echo
  • MRA (magnetic resonance angiography)
70
Q

What is the management for CoA?

A

Initially = Prostaglandin infusion
Later = Surgical repair or balloon angioplasty

71
Q

What are complications of CoA?

A
  • Secondary HTN
  • Endocarditis
  • Berry aneurysm > cerebral haemorrhage
72
Q

What is aortic and pulmonary stenosis?

A

Abnormal development of the valves

73
Q

What are the S/S of pulmonary stenosis?

A

Harsh ES murmur at LUSE

74
Q

What are the signs of aortic stenosis?

A

Carotid thrill

75
Q

What is the management of aortic/pulmonary stenosis?

A

Transcatheter balloon dilation

76
Q

What is Hypoplastic Left Heart Syndrome?

A

Birth defect where L side of heart extremely underdeveloped > affects normal blood flow through the heart

77
Q

What are the S/S of hypoplastic left heart syndrome?

A

> Usually seriously ill soon after birth

  • Cyanosis of lips/gums
  • Rapid, difficult breathing
  • Poor feeding
  • Cold hands/feet
  • Weak pulse
  • Unusually drowsy/inactive
78
Q

What are the investigations of hypoplastic left heart syndrome?

A

USS = Possible to dx during second trimester

Echo = Can dx > small L ventricle and aorta

79
Q

What is the management of hypoplastic left heart syndrome?

A

Initial = Prostaglandin

Definitive = Surgery
(3 separate operations: Norwood > Glenn > Fontan)

80
Q

What are the S/S of an arrhythmia?

A
  • HR 250-300bpm > poor CO, pulmonary oedema

Neonatal = HF, hydrops fetalis
Foetus = IUD

81
Q

What are the investigations for an arrhythmia?

A
  • ECG = narrow complex tachycardia (delta wave in WPW), T wave inversion due to ischaemia
  • Echo
82
Q

What is the management of an arrhythmia?

A

> Prompt restoration of sinus rhythm is key to improvement

1. Circulatory and respiratory support

  • Tissue acidosis corrected
  • Positive pressure ventilation if needed

2. Vagal stimulating manoeuvres

  • Carotid sinus massage, cold icepack to face (80% success)

3. IV adenosine

  • Tx of choice
  • Induces AV lock after rapid bolus infusion > terminates tachycardia

4. Electrical cardioversion with synchronised DC shock

  • If adenosine fails
  • Once sinus rhythm restored, maintenance therapy required (e.g. flecainide or sotalol)
  • 90% will have no further attacks after infancy
  • Children who relapse or at risk > tx with percutaneous RFA or cryoablation of accessory pathway
83
Q

What is Rheumatic Fever?

A

Inflammatory disease that can develop when strep throat / Scarlet Fever isn’t treated properly

84
Q

What organism causes RF?

A

GAS

85
Q

What age does RF present?

A

Children aged 5-15yrs

86
Q

What can long-term damage from RF cause?

A

Mitral stenosis

87
Q

What are the S/S of RF?

A

Fever and tender joints
»Latent interval of 2-6w after pharyngeal infection

  • Polyarthritis (tender joints, swelling)
  • Pancarditis (endocarditis, myocarditis, pericarditis)
  • Erythema marginatum (map-like outlines)
  • Sydenham’s chorea 2-6m later (involuntary movements)
88
Q

What is the diagnostic criteria for RF?

A

Evidence of recent GAS infection with 2 major / 1 major + 2 minor criteria

Evidence of recent GAS:

  • Raised or rising streptococci antibodies
  • Positive throat swab
  • Positive rapid GAS antigen test

Major criteria: (CASES)

  • Carditis (e.g. new murmur)
  • Arthritis
  • Subcutaneous nodules
  • Erythema marginatum
  • Sydenham’s chorea

Minor criteria: (FRAPP)

  • Fever
  • Raised ESR/CRP
  • Arthralgia
  • Prolonged PR interval
  • Previous RF
89
Q

What is the management of RF?

A

Acute:

  • 1st line = single dose IM benzathine benzylpenicillin
  • With arthritis = NSAID (e.g. aspirin / naproxen)
  • With HF = diuretic +/- ACEi
  • With AF = Amiodarone or digoxin
  • With valve problem = Assessment for emergency surgery
  • With severe chorea = Consider anticonvulsant
  • With severe pain = CS injections

Prophylaxis: ALL PATIENTS FOLLOWING ACUTE TREATMENT

  • IM injection of long-acting benzathine benzylpenicillin every 3-4 weeks
  • Until 10yrs after the last episode or until 21yrs old (lifelong if severe valve disease)
90
Q

What is infective endocarditis?

A

Infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel

91
Q

What are the RFs for IE?

A
  • Strongest RF is previous episode of endocarditis
  • Rhematic valve disease
  • Congenital heart defects
92
Q

What is the most common cause of IE?

A

Strep viridians

93
Q

What are the S/S of IE?

A
  • Pleuritic chest pain
  • SOB
  • Fever / chills
  • Aching joints / muscles
  • Anaemia / pallor
  • Necrotic skin lesions (infected emboli)
  • Splenomegaly
  • Retinal infarcts
  • Microscopic haematuria
  • Clubbing
  • Splinter haemorrhages
  • Changing cardiac signs
  • Neuro signs from cerebral infarct
94
Q

What is the Modified Duke Criteria?

A

IE diagnosis if pathological criteria / 2 major / 1 major + 3 minor / 5 minor

Pathological:

  • Positive histology / microbiology of pathological material obtained at autopsy or cardiac surgery

Major:

  • 2 positive blood cultures
  • Persistently positive blood culture - from 2 blood cultures taken >12hrs apart, or 3 or more positive blood cultures
  • Positive culture for Coxiella
  • Positive echo (vegetations)
  • New valvular regurgitation

Minor:

  • Predisposing heart condition / IVD use
  • Fever >38
  • Vascular phenomena (Janeway lesions, intracranial / conjunctival haemorrhage)
  • Immunological phenomena (Osler’s nodes, Roth Spots)
  • Positive blood culture that doesn’t meet major criteria
95
Q

What is the management for IE?

A

Acute:

  • High dose IV penicillin + aminoglycoside e.g. gentamicin (or streptomycin) for 6w

Prophylaxis:

  • Good dental hygiene
  • Avoidance of body piercings or tattoos

+/- Surgery

  • Removal of infected prosthetic material
96
Q

What are the S/S of cardiac failure?

A
  • SOB / respiratory distress
  • Poor feeding / weight gain
  • Recurrent chest infections
  • Fatigue
  • Increased RR + HR
  • Murmur
  • Gallop rhythm
  • Signs of venous congestion
  • Enlarged heart
  • Hepatomegaly
  • Cool peripheries
  • Insufficient CO
  • FTT
97
Q

What are the causes of cardiac failure in a neonate?

A
  • Hypoplastic L heart
  • Aortic stenosis
  • Severe coarctation of the aorta
  • Interruption of the aortic arch
98
Q

What are the causes of cardiac failure in an infant or older child?

A

Infants: (defect > high pulmonary blood flow > L-R shunt)

  • Persistent VSA, ASD, PDA

Older children: (R- or L-HF)

  • Eisenmenger Syndrome (RHF)
  • Rheumatic HD
  • Cardiomyopathy
99
Q

What are the investigations for cardiac failure?

A
  • Basic obs - O2 sats, BP, HR, RR
  • Bloods - FBC, U&Es, Ca, BNP/ANP
  • ECG
  • CXR
  • Echo
100
Q

What is the management of cardiac failure?

A
  • Diuretics (e.g. furosemide) or GTN (reduce preload)
  • Dopamine or digoxin or adrenaline or dobutamine (enhance cardiac contractility)
  • Oral ACE inhibitors e.g. hydralazine, nitroprusside, alprostadil (reduce afterload)
  • Beta-blockers e.g. carvedilol (improve oxygen delivery)
  • Enhance nutrition
  • If cyanotic = prostaglandin infusion (alprostadil / prostaglandin E2)
101
Q

What is a venous hum murmur?

A

Innocent murmur 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

102
Q

What is Still’s murmur?

A

Low-pitched sound at lower left sternal edge

103
Q

What are the characteristics of an innocent ejection murmur?

A
  • Soft-blowing murmur in the pulmonary area or short buzzing murmur in the aortic area
  • May vary with posture
  • Localised with no radiation
  • No diastolic component
  • No thrill
  • No added sounds (e.g. clicks)
  • Asymptomatic child
  • No other abnormality

Paeds (18 decks)

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