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What is the Jones Criteria?

Clinical and diagnostic criteria for rheumatic fever

5 major & 4 minor criteria and an absolute requirement (microbiologic or serologic) of recent GAS infection.


What are the jones major criteria for RF?

C arditis
A rthritis (migratory polyarthritis)
S (C) sydenham Chorea
E rythema Marginatum
S ubcutaneous nodule


What are the Jones minor criteria?

o Arthralgia (in the absence of polyarthritis as a major criterion)
o Fever (typically temperature of 102°F and occurring early in the course of illness)

o Elevated acute-phase reactants (e.g., C-reactive protein, erythrocyte sedimentation rate)
o prolonged PR interval on electrocardiogram (1st degree heart block)


What is the Absolute Requirement for the diagnosis of RF?

Recent Group A Streptococcus Infection based on elevated or increasing serum antistreptococcal antibody titers

antistreptolysin O


What are the 3 circumstances in which the diagnosis of ARF can be made without strict adherence to the Jones criteria?

o Chorea as the only manifestation
o Indolent carditis may who 1st come to medical attention months after the onset of ARF.
o Finally, although most patients with recurrences of ARF fulfill the Jones criteria, some may not


What is the universal finding in rheumatic carditis?

Endocarditis (valvulitis)


Most common Valvular lesions in RF?

mitral valve> aortic valve> (right sided valves: tricuspid and pulmonic)

Heard as
o Mitral regurgitation: pitched apical holosystolic murmur radiating to the axilla
o Aortic insufficiency: high-pitched decrescendo diastolic murmur at the upper left sternal border


Treatment for RF

o 10 days of orally administered penicillin or erythromycin or a single intramuscular injection of benzathine penicillin to eradicate GAS from the upper respiratory tract
o benzathine penicillin G (600,000 IU for children 60 lb and 1.2 million IU for those 60 lb) every 4 wk until the patient reaches 21 yr of age or until 5 yr have elapsed since the last rheumatic fever attack, whichever is longer.
o alternative: penVK or macrolide

o Aspirin dosage: 100 mg/kg/day in 4 divided doses PO for 3-5 days followed by 75 mg/kg/day in 4 divided doses PO for 4 wk
o Prednisone dosage: 2 mg/kg/day in 4 divided doses for 2-3 wk followed by a tapering of the dose that reduces the dose by 5 mg/24 hr every 2-3 days for cardiomegaly or CHF
o salicylates & corticosteroids should be withheld if arthralgia or atypical arthritis is the only clinical manifestation which may interfere with the development of the characteristic migratory polyarthritis
o paracetamol for pain relief


Treatment for Sydenham Chorea of RF

o Phenobarbital (16-32 mg every 6-8 hr PO) is the drug of choice

o If phenobarbital is ineffective, then haloperidol (0.01-0.03 mg/kg/24 hr divided bid PO) or

o Chlorpromazine (0.5 mg/kg every 4-6 hr PO) should be initiated


Most common valvular involvement in children with RHD

Mitral Insufficiency


Characteristic heart murmur in RHD with mild Mitral Insufficiency

high-pitched holosystolic murmur at the apex that radiates to the axilla


Most common valvular involvement in adults with RHD

Mitral Stenosis

-usually takes 10 yr or more for the lesion to become fully established


an apical presystolic murmur resembling that of mitral stenosis sometimes heard and is a result of the large regurgitant aortic flow in diastole preventing the mitral valve from opening fully in RHD with aortic insufficiency

Austin Flint murmur


murmur in pulmonary insufficiency secondary to RHD which is similar to that of aortic insufficiency, but with absent peripheral arterial signs (bounding pulses).

Graham Steell murmur


Define Sinus bradycardia in

A. Neonates
B. Older children

A. Neonates: HR <60


Treatment for PVC

Correct underlying cause
IV lidocaine

-intravenous lidocaine bolus and drip is the 1st line of therapy, with more effective drugs such as amiodarone reserved for refractory cases or for patients underlying ventricular dysfunction or hemodynamic compromise.


most common type of shock in children worldwide, usually related to fluid losses from severe diarrhea

Hypovolemic shock


When hypovolemia occurs as a result of third spacing of intravascular fluids into the extravascular compartment, the shock is described as

Distributive Shock (sepsis and burn)


profound myocardial dysfunction as cause of shock

Cardiogenic shock (due to congenital heart disease, myocarditis, and cardiomyopathies)


occurs when cardiac output is lowered by obstruction of blood flow to the body, as occurs when a ductus arteriosus closes in a child with ductus-dependent systemic blood flow in pericardial tamponade, tension pneumothorax, or massive pulmonary embolism

Obstructive shock


factors known to cause bradycardia, referred to collectively as the 6Ts and 4Hs

6 Hs
hypoxia, hypovolemia, hydrogen ions [acidosis], hypokalemia or hyperkalemia, hypoglycemia, hypothermia

4 Ts
toxins, tamponade, tension pneumothorax, and trauma [causing hypovolemia, intracranial hypertension, cardiac compromise or tamponade]


Rescue breaths given to Infants and children ≤8 yr old

Infants and children ≤8 yr old should receive rescue breathing at a rate of roughly 15-20 breaths/min, or roughly 1 breath every 3-5 se


Rescue breaths given to Children >8 yr old

Children >8 yr old should receive 10-12 breaths/min, or 1 breath every 5-6 sec.


How to give chest compressions to <1yo

Chest compressions in infants <1 yr old may be performed by placing 2 thumbs on the midsternum with the hands encircling the thorax or by placing 2 fingers over the midsternum and compressing


How to do chest compressions in >1yo

For children >1 yr old, the care provider should perform chest compressions over the lower half of the sternum with the heel of 1 hand, or with 2 hands as used for adult resuscitation


What is universal ratio of chest compressions for a lone rescuer?

universal ratio of 30 compressions to 2 ventilations


most common form of cardiomyopathy and is characterized predominantly by left ventricular dilation and decreased left ventricular systolic function

Dilated Cardiomyopathy


Cardiomyopathy that demonstrates increased ventricular myocardial wall thickness, normal or increased systolic function, and often, diastolic (relaxation) abnormalities

Hypertrophic Cardiomyopathy


cardiomyopathy characterized by nearly normal ventricular chamber size and wall thickness with preserved systolic function, but dramatically impaired diastolic function leading to elevated filling pressures and atrial enlargement

Restrictive cardiomyopathy


Cardiomyopathy characterized by specific morphologic abnormalities and heterogeneous functional disturbances

Arrhythmogenic right ventricular cardiomyopathy and left ventricular non-compaction


Bacterial infection that is unique as bacterial toxin may produce circulatory collapse and toxic myocarditis characterized by atrioventricular block, bundle branch block, or ventricular ectopy

Diphtheritic myocarditis


Normal fluid volume found in the pericardial space in a healthy child

10-15 ml

*Fluid in excess of 1,000 mL may accumulate in an adolescent with pericarditis


What is the diagnosis?
chest pain, described as a sharp, stabbing sensation over the precordium and often the left shoulder and back, exaggerated by lying supine and relieved by sitting, especially leaning forward

Muffled or distant heart sounds, tachycardia, narrow pulse pressure, jugular venous distension, and a pericardial friction rub

pulsus paradoxus greater than 20 mm Hg

Acute pericarditis with cardiac tamponade

*Pulsus paradoxus
- Caused by the normal slight decrease in systolic arterial pressure during inspiration
- excessive fall of systolic blood pressure (>10 mm Hg) with inspiration


Radiologic finding in acute pericarditis

water bottle configuration

A relatively large pericardial effusion must be present to cause an enlarged cardiac shadow with the usual "water bottle" configuration


o Signs and symptoms of systemic venous hypertension such as jugular venous distension, peripheral edema, hepatomegaly, and ascites

o Signs of more significant cardiac compromise include tachycardia, hypotension, and pulsus paradoxus

o Physical exam: pericardial knock, rub, and distant heart sounds

o Abnormalities of liver function tests, hypoalbuminemia, hypoproteinemia, and lymphopenia may be present

Constrictive pericarditis

- Impaired cardiac distensibility and filling secondary to pericardial scarring
- Fibrosis, calcification, and thickening of the pericardium may result from chronic pericardial inflammation


Results in the development of signs and symptoms of heart failure when there is no basic abnormality in myocardial function and cardiac output is greater than normal

High Output Cardiac Failure

- may eventually result in a decrease in myocardial performance as the metabolic requirements of the myocardium are not met


cardiac neurohormone released in response to increased ventricular wall tension in heart failure

Serum B-type natriuretic peptide (BNP)

o Elevated in adult patients with congestive heart failure
o In children, elevated in patients with heart failure due to systolic dysfunction (cardiomyopathy) as well as in children with volume overload (left-to-right shunts such as ventricular septal defect)


Metabolic abnormality that results from renal water retention and Chronic diuretic treatment in heart failure



Factors that may potentiate digitalis toxicity

Hypokalemia, hypomagnesemia, hypercalcemia, cardiac inflammation secondary to myocarditis, and prematurity