0
Q
Murmur ID:
- MLSB or between LLSB and apex
- grade 2-3/6
- “twanging string”, groaning, squeaking or musical
- ages 3-6yrs, occasionally in infancy
A
Classic vibratory/Still’s murmur
1
Q
Characteristics of innocent murmurs:
A
Short duration
Low intensity (grade I/II)
Vibratory or musical in quality
2
Q
Murmur ID:
- ULSB
- Early to midsystolic ejection murmur
- 1-3/6
- “blowing”
- ages 8-14yrs
A
Pulmonary ejection murmur
3
Q
Murmur ID:
- Premature and full-term newborns
- Usually disappears by 3-6mos
- ULSB
- transmits to axilla and back
- 1-2/6
A
Pulmonary flow murmur of newborn (PPS?)
4
Q
Murmur ID:
- continuous, grade 1-2/6
- R or L supraclavicular and infraclavicular areas
- inaudible in supine position
- intensity changes with rotation of the head and compression of the jugular vein
- ages 3-6yrs
A
Venous hum
5
Q
Murmur ID:
- R supra-clavicular area and over the carotids
- 2-3/6
- occasional thrill over carotid
- any age
A
Carotid brunt (systolic)
6
Q
Time of functional closure of the ductus arteriosus?
A
12-24hrs of life
7
Q
Time of anatomic closure of the ductus arteriosus?
A
2-3 weeks of age
8
Q
Types of CHD that present with shock?
A
2/2 left heart obstruction:
- CoA
- HLHS
- interrupted Ao arch
- critical AS
- obstructive TAPVR
(systemic perfusion dependent on PDA, symptoms worsen after PDA closure)
9
Q
Treatment of shock 2/2 CHD
A
- PGE1
- Avoid excess O2 –> pulm vasodilation (decr PVR) –> increased left to right shunting
- Gentle fluid resuscitation (10mL/kg boluses etc)
- Inotropic agents to improve CO (dobutamine, dopamine, epi)
10
Q
Most common causes of central cyanosis?
A
CHD, pulmonary disease, and CNS depression
11
Q
Amt of hgb that must be reduced to perceive cyanosis.
A
5g/dL
- In infants with nml hgb levels, apparent at 75-80%
- In polycythemic infants, cyanosis at higher O2 saturations
- In anemic infants, no cyanosis until more significant desaturation occurs
12
Q
How do you interpret a hyperoxia test?
A
PO2>100mmHg or incr in PO2>30mmHg above on RA = pulmonary etiology likely
PO2L shunt (CHD or PPHN) or a mixing lesion
13
Q
Preductal > postductal saturations
A
PPHN and cardiac conditions with decr systemic pressures (LV obstructive lesions = AS, interrupted arch, CoA)
14
Q
Postductal>preductal saturations
A
TGA with obstruction (interrupted arch or CoA)
15
Q
Acyanotic Congenital Heart Defects
A
- VSD
- PDA
- ASD
- AV canal (complete endocardial cushion defect)
16
Q
Name the CHD:
- asymptomatic to CHF at 6-8wks of age
- loud, harsh, holosystolic murmur at LLSB +/- thrill (+/- in newborn period)
- CXR = cardiomegaly, incr PVM
- EKG = LVH +/- LAE
- Most common CHD requiring f/u and intervention
A
VSD
17
Q
Name the CHD:
- Asymptomatic to hemodynamically unstable (preterm infants)
- Continuous machinery-like murmur at LUSB
- Bounding pulses with wide pulse pressure
- CXR = cardiomegaly, incr PVM
- EKG = LVH, BVH with large lesion
A
PDA
- normally closes by 72HOL
- treated with surgery, indomethicin or ibuprofen
18
Q
Name the CHD:
- rarely symptomatic before 30-40’s
- may present with CHF and pulm HTN
- wide, fixed split S2 +/- SEM at the LUSB
- CXR = cardiomegaly +/- RA and RV enlargement
- EKG = RAD, RVH, RBBB (rsR’ in V1)
- Can lead to atrial arrhythmias in adults
A
ASD
19
Q
Name that CHD:
- CHF at 4-6wks of age
- holosystolic murmur of VSD
- CXR = cardiomegaly with four-chamber enlargement, incr PVM
- EKG = superior QRS axis, RVH or RBBB
- common in pts with Down syndrome
A
Complete endocardial cushion defect (AV canal)
20
Q
Name that CHD:
- critical lesions –> cyanosis, tachypnea, exertional dyspnea, fatigue, CHF
- loud SEM at ULSB radiating to back and lung fields
- CXR - prominent PA segment, normal to decreased PVM
- EKG - RAD, RVH
A
Pulmonary stenosis (PS)
- treated with PGE1 to incr pulmonary perfusion and ultimately balloon valvuloplasty for surgical correction
21
Q
Name that CHD:
- Neonates: hypoperfusion, resp distress, cyanosis with R–>L ductal flow
- Children: chest pain, syncope, dyspnea
- Ejection click, harsh midsystoloic murmur, systolic thrill at suprasternal notch
- CXR = cardiomegaly, incr PVM
- EKG = LVH +/- strain
A
Aortic stenosis
- PGE1/balloon valvuloplasty or surgical correction
- supravalvular AS is common in Williams Syndrome
22
Q
Name that CHD:
- Infants: CHF, respiratory distress, shock, diminished pulses and cyanosis of the lower extremities, BP differential (RA>leg)
- Children: HTN in right arm, decr femoral pulses
- no murmur in 50% VS ejection click, SEM
- CXR: cardiomegaly, incr PVM, E-shaped esophagus on barium esophagram, rib notching
- EKG: LAD, LVH
- 70% with associated aortic valve abnormality
A
Coarctation of the aorta (CoA)
- surgery, then balloon angioplasty for recoarctation
- present in 30% of pts with Turner’s syndrome
23
Q
Name that cyanotic CHD:
- initially cyanosis/dyspnea on exertion, later hypoxic spells
- single S2; long, loud SEM at MULSB
- CXR: decr PVM, “BOOT-SHAPED” heart, R aortic arch in 25%
- EKG: RAD, RVH
- degree o cyanosis and symptoms is related to severity of PS
- MOST COMMON CYANOTIC CHD
A
Tetralogy of Fallot:
- large VSD
- RVOT obstruction (PS)
- RVH
- overriding aorta
- PGE1 if cyanotic, primary surgical repair, occasionally palliative Blalock-Taussig shunt (subclavian artery to ipsilateral PA)
24
Name that cyanotic CHD:
- severe cyanosis and tachypnea in pt with normally related great vessels
- murmur from associated lesions (VSD, PDA)
- CXR: decr PVM
- EKG: leftward or superior QRS axis, RAE, minimal positive forces in V1 and V2
- 30% with TGA
Tricuspid Atresia
* PGE1, rare balloon atrial septostomy, BT shunt 1st stage of repair, definitive repair is a single ventricle Fontan-type repair
* Associated mixing defects needed for survival
25
Name that cyanotic CHD:
- severe cyanosis and tachypnea n the neonatal period
- intra-atrial communication necessary for survival
- single S2, murmur absent +/- PDA murmur
- decr PVM, dark lung fields
- EKG = LVH, RAH
* commonly associated with coronary artery anomalies
Pulmonary atresia with intact ventricular septum
26
Name that cyanotic CHD:
- cyanosis, arrhythmias (SVT). ASD or PFO always present
- triple or quadruple rhythm (wide split S2 +/- split S1, S3 or S4)
- CXR: decr PVM, massive cardiomegaly with BALLOON-SHAPED HEART
- EKG: RBBB, RAH, 1st degree AV block, delta wave
- Frequently associated with WPW
Epstein's anomaly = downward displacement of TV, resulting funcitonal RV hypoplasia
27
Name the cyanotic CHD:
- severe cyanosis, signs of CHF in the 1st week of life
- single S2, often no murmur
- CXR = incr PVM, EGG-SHAPED HEART, or EGG ON A STRING
- EKG = RAD, RVH
- VSD present in 30-40%
Transposition of the great arteries
28
Name that cyanotic CHD:
- mild cyanosis immediately after birth, CHF in days to weeks
- large VSD located beneath truncal valve
- single S2, systolic ejection click at the apex, murmur of VSD
- bounding pulses with wide pulse pressure
- CXR = incr PVM, cardiomegaly, R aortic arch in 30%
- EKG = BVH
* Coronary artery anomalies are common
Truncus arteriosus
* Digeorge syndrome in 1/3 of pts
29
Name that cyanotic CHD:
- resp distress, CHF
- types vary with vessel insertion:
Supracardiac - SVC = most common
Cardiac - RA or coronary sinus
Infracardiac - portal veins, IVC; commonly leads to obstruction of venous return
- quadruple rhythm (S1, widely splitS2, and S3 or S4, hepatomegaly)
- CXR = cardiomegaly, sign incr PVM, SNOWMAN SIGN or FIGURE 8 SIGN
- EKG = RVH, rsR' in V1
Total anomalous pulmonary venous return (TAPVR)
* PGE1 may worsen condition in obstructed TAPVR
30
Name that cyanotic CHD:
- respiratory distress, shock and CHF within the 1st week of life
- loud single S2, commonly no murmur, hepatomegaly
- CXR = incr PVM, pulmonary venous congestion, edema +/- cardiomegaly
- EKG = RVH, RAE, minimal positive forces in V5 and V6
Hypoplastic left heart syndrome (HLHS)
31
Causes of CHF in 1st week of life?
Severe obstructive CHD = HLHS, critical AS or PS, obstructive TAPVR, interrupted aortic arch
TGA
Volume overload = severe tricuspid or pulmonary insufficiency, systemic arterio-venous fistula
Genetic or metabolic cardiomyopathy
32
Causes of CHF at 1-4 weeks of life
Less severe obstructive lesions = coarctation, AS or PS, TAPVR
Truncus arteriosus
Genetic or metabolic cardiomyopathy
33
Causes of CHF in infants >1 month of age:
Large L-->R shunts = ECD @ 4-6wks, large VSD or PDA at 6-8wks
Arrhythmias (SVT)
Myocarditis
Genetic or metabolic cardiomyopathy
34
Causes of CHF in older children
Inflammatory - Kawasaki, myocarditis, rheumatic fever
Acute HTN (HUS)
Genetic or metabolic cardiomyopathy
35
List the JONES criteria for rheumatic heart disease:
Laboratory evidence of prior streptococcal infection **PLUS** 2 major criteria or 1 major and 2 minor criteria
```
J = joints (migratory, polyarthritis of large joints)
O = carditis (1 Endocarditis, 2 myocarditis, 3 pericarditis)
N = nodules (SQ, on extensor surfaces of extremities, "Aschoff bodies" on histology)
E = erythema marginatum
S = sydenham chorea
```
MINOR CRITERIA: arthralgia, prolonged PR interval, fever, elevated ESR +/- CRP, elevated WBC, previous rheumatic fever
Pediatric Board Review
flashcards
Decks in class (17)
# Cards
-
Cardiology36
-
Syndromes104
-
Hematology-Oncology132
-
Pulmonary18
-
Orthopedics5
-
Infectious Disease76
-
Poisoning71
-
Neonatology/Critical Care121
-
General Pediatrics51
-
Gastroenterology90
-
Development/Behavior127
-
Endocrinology107
-
Miscellaneous81
-
Nephrology64
-
Allergy/Immunology59
-
Neurology80
-
Adolescent19
