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Cardiovascular disorders Flashcards

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1
Q

Name signs and symptoms suggestive of cardiac disease in children

A 
Central cyanosis unresponsive to oxygen
Pallor
Sweatiness
Failure to feed
SOB when feeding
Sweating when feeding
Tachypnoea
Tachycardia
Palpable spleen
Recurrent LRTI
FTT
Puffy eyes
Sudden weight gain
Sudden oedema
Hepatomegaly
Heart murmurs
Abnormal pulse rate/rhythm 
Apnoea
Syncope
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2
Q

Which children is idioipathic congestive cardiomyopathy more common in?

A

Black children

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3
Q

Why is cor pulmonale common in children?

A

Enlarged adenoids and tonsils -> upper airway obstruction

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4
Q

Although less likely than in adults, what is the arrythmia in children almost certainly?

A

Supraventricular tachyarrythmia

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5
Q

Why does a VSD take time to become audible in neonates and how long can it take?

A

High pulmonary pressure at birth -> fall in pulmonary pressure and vascular resistance
6-8 weeks

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6
Q

Give a differential diagnosis for cyanosis

A 
Cyanotic congenital heart defect
Pulmonary conditions
CNS issue
Metabolic issue 
- hypoglycemia
- hypocalcemia
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7
Q

Why should you stop giving oxygen if a cyanosis is of cardiac origin?

A

Oxygen -> closure of ductus arteriosus -> aggravate situation

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8
Q

Discuss your short term management of a child with a cyanosis of cardiac origin?

A
  1. Maintain infant’s temperature
  2. Give 5% IV glucose
  3. Give IV sodium bicarbonate for acidosis if confirmed
  4. Give oral prostraglanding E2
    - - 30-60mcg/kg hourly
    - dissolve 500mcg tablet in 10ml sterile water
    - 1ml = 50mcg
    - alternative is IV
  5. Give IV prostaglandin E1 as continuous infusion
    - 0.05-0.1mcg/kg
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9
Q

What is stunted growth in a cardiac child a sign of?

A

Increased pulmonary blood flow

Cardiac failure

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10
Q

How can cyanosis affect the anterior fontanelle?

A

Delayed closure

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11
Q

What haematocrit do you expect in a severe cyanosis case?

A

Raised haematocrit

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12
Q

Why must we correct an iron deficiency in cardiac patients, especially in children below the age of 2?

A

May lead to cerebral thrombosis

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13
Q

Why is it a priority to treat septic lesions and dental caries in children with cyanotic heart defects?

A

Risk of paradoxical embolisation -> cerebral abscesses

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14
Q

Give signs of a brain abscess in children

A

Intractable headache
Unexplained fever
Neurological signs

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15
Q

Name the potential cardiac anomalies that are known as congenital cyanotic conditions

A
  1. Transposition
  2. Pulmonary atresia w/ intact ventricular septum
  3. ricuspid atresia
  4. Tetralogy of Fallot
  5. Ebstein’s anomaly
  6. Eisenmenger syndrome
  7. Crticical pulmonary stenosis
  8. Truncus arteriosus
  9. Total anomalous pulmonary venous connection
  10. Atrioventricular communis canal
  11. Hypoplastic left-heart syndrome
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16
Q

Concerning transposition of the great vessels

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Cyanosis within 1st week of life
Normal pulse
Auscultation: usually without murmur but may be a precordial systolic murmur
Plethora on CXR
ECG
- right axis, RVH
- upright  wave in V4R, V1
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17
Q

Concerning pulmonary atresia with intact ventricular septum

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Cyanosis from birth
Poor/normal pulse
Auscultation: pansystolic xiphisternum (T1) and single HS2
Oligaemia on CXR
ECG
- normal to left access
- poor RV forces
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18
Q

Concerning tricuspid atresia

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Cyanosis from birth
Poor/normal pulse
Auscultation: no murmur/soft systolic over precordium and single HS2
Oligaemia on CXR
ECG
- left axis, poor RV forces
- P pulmonale
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19
Q

Concerning tetralogy of fallot

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Cyanosis is variable 
Normal pulse
Auscultation: ejection systolic murmur at LSB and single HS2
Ologaemia on CXR
ECG
- right axis, RVH
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20
Q

Concerning ebstein’s anomaly

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A

Cyanosis from birth that tends to improve
Normal pulse
Auscultation: pansystolic murmur and diastolic scratch at xiphisternum
Oligaemia on CXR
ECG
- large RA, poor RV forces, RBBB

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21
Q

Concerning eisenmenger syndrome

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Initially not cyanosed -> progressive
Normal pulse
Auscultation: ejection systolic click at LSB + soft ejection systolic murmur + very loud pulmonary HS2
Oligaemia on CXR
ECG
- right axis, RVH
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22
Q

Concerning critical pulmonary stenosis

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Cyanosis is mild to moderate
Normal pulse
Auscultation: ejection systemic murmur at 2nd LICS and soft pulmonary HS2
Oligaemia on CXR
ECG
- right axis
- RVH
- P pulmonale
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23
Q

Concerning truncus arteriosus

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Cyanosis is moderate
Collapsing pulse
Auscultation: systolic ejection click and long systolic murmur at LSB w/wo early diastolic murmur
Plethora on CXR
ECG
- normal to right axis
- biventricular hypertrophy
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24
Q

Concerning total anomaly pulmonary venous connection

  • when does cyanosis appear
  • what is the pulse
  • what would you hear on auscultation
  • what would you see on chest x ray
  • what would you see on ECG?
A 
Cyanosis is mild to moderate
Small pulse
Auscultation: ejection systolic murmur 2nd LICS + wide split of HS2 + middiastolic murmur at xiphisternum
Plethora on CXR
ECG
- right axis
- RVH
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25
Concerning atrioventricular communis canal - when does cyanosis appear - what is the pulse - what would you hear on auscultation - what would you see on chest x ray - what would you see on ECG?
``` Cyanosis is variable Normal pulse Auscultation: precordial systolic murmur Plethora on CXR ECG - left axis - biventricular hypertrophy - prolonged PR ```
26
Concerning hypoplastic left-heart syndrome - when does cyanosis appear - what is the pulse - what would you hear on auscultation - what would you see on chest x ray - what would you see on ECG?
``` Cyanosis is mild to moderate Very poor pulse Auscultation: precordial systolic murmur + ejection systolic click + gallop Plethora on CXR ECG - right axis - RVH - poor LV forces ```
27
Name causes of heart failure in infancy
``` Acyanotic CHD w/ increased PBF or severe ventricular outflow obstruction Cyanotic CHD w/ increased PBF Myocarditis Cardiomyopathy Tachyarrythmias Bradyarrythmias ```
28
Name signs of cardiac failure in children
``` Tachypnoea Inspiratory crepitations at lung base Elevated JVP Hepatomegaly Dependent oedema ```
29
Discuss your treatment of heart failure in a child
1. Nurse baby at 60 degrees 2. Give oxygen 3. Restrict fluid intake 4. Give inotropes - digoxin 5. Diuretics - furosemide - spirinolactone 6. Vasodilators - ACE-I
30
What formulations of digoxin are there?
Elixir 0.05mg/ml Tablets 0.125mg/0.25mg Injection 0.25mg/ml
31
What is the dose of digoxin used to treat heart failure in a child?
5-10mcg/kg/day in 2 divided doses
32
What precaution must you take when administering IV digoxin?
3/4 of oral/intramuscular dose under ECG control
33
What infusion can you add to the digoxin in severe cardiac failure?
Dobutamine 5-20mcg/kg/min OR Dopamine 3-20mcg/kg/min
34
What is the dose and administration of furosemide in acute heart failure?
IV initially then oral maintenance | 1-6mg/kg/day in 2-4 divided doses
35
What is the dose of captopril in acute heart failure?
0.5-6mg/kg/day in 3-4 doses
36
What must you give if you are administering a diuretic that causes potassium loss?
Potassium supplement 1-2mmol/kg/day OR Spirinolactone 2-3mg/kd/day in 2-3 doses orally
37
What systolic murmurs in children should be considered significant?
Persists Loud Assoc w/ signs of cardiac disorder
38
Which murmurs in children are always significant?
Diastolic murmurs
39
Name common features of a functional systolic murmurs
Usually
40
What does a pectum carinatum with Harrison sulci in children suggest?
Intrathoracic ariway obstruction
41
What is pectum carinatum usually due to in the cardiac context?
Pulmonary arterial hypertension
42
How common is CHD?
7-10/1000 live births (1%)
43
What is the cause of CHD in the majority of instances?
Unknown 85-90% of the time
44
What is the top congenital cardiac anomaly?
VSD
45
List the top congenital cardiac anomalies from most common to least
1. VSD 2. PDA 3. Coarctation 4. TOF 5. AS 6. ASD 7. PS
46
What is the pressure and oxygen saturation in the aorta
Pressure 105/75-85 | Oxygen 98%
47
What is the pressure and oxygen saturation in the LA
Pressure 6-8 | Oxygen 100%
48
What is the pressure and oxygen saturation in the LV
Pressure 105/0-5 | Oxygen 98%
49
What is the pressure and oxygen saturation in the RA
Pressure 0-4 | Oxygen 72%
50
What is the pressure and oxygen saturation in the RV
Pressure 20/0-4 | Oxygen 72%
51
What is the pressure and oxygen saturation in the pulmonary trunk
Pressure 20/10-14 | Oxygen 72%
52
Name signs of cyanotic CHD with increased PBF
``` CYANOSIS SOB FTT CCF Sweating Chest deformities Tachycardia Tachypnoea Cardiomegaly Plethora ```
53
Name causes of cyanotic CHD with increased PBF
``` TGA Truncus arteriosus TAPV HLHS Single ventricle complex with no PS ```
54
Name signs of cyanotic CHD with decreased PBF
``` CYANOSIS No cardiomegaly No CCF Oligaemia Stunting ```
55
Name causes of cyanotic CHD with decreased PBF
``` TOF PA TA Critical PS Ebstein anomaly Eisenmenger syndrome Single ventricle complex with PS ```
56
Name signs of acyanotic CHD with increased PBF
``` Acyanotic SOB FTT Sweating CCF Recurrent LRTIs Chest deformities Tachycardia Tachypnoea Cardiomegaly Plethora ```
57
Name causes of acyanotic CHD with increased PBF
VSD PDA ASD AVSD
58
Name signs of acyanotic CHD with normal PBF
Asx unless severe Ventricular hypertrophy Low CO
59
Name causes of acyanotic CHD with normal PBF
``` AS PS Coarctation Tricuspid regurgitation Mitral regurgitation ```
60
Name the potential cardiac anomalies that are known as congenital acyanotic conditions
``` Coarctation Aortic stenosis VSD Endocardial cushion defect (ASD+MI) ASD PDA PS ```
61
Concerning coarctation of the aorta - comment on the pulse - comment on systolic murmur - comment on diastolic murmur - comment on 2nd heart sound - what do you see in CXR - what do you see in ECG
``` Brachial bounding and delayed/absent femorals Ejection systolic at back Mid diastolic at apex Normal 2nd heart sound CXR - large proximal aorta - 3 sign descending aorta (older children) ECG - normal - LVH ```
62
Concerning aortic stenosis - comment on the pulse - comment on systolic murmur - comment on diastolic murmur - comment on 2nd heart sound - what do you see in CXR - what do you see in ECG
``` Small volume pulse Ejection systolic at 2RS radiates to neck and click if valvar (with thrill = severe) Early diastolic Normal 2nd heart sound CXR - large proximal aorta ECG - normal axis - LVH if severe ```
63
Concerning VSD - comment on the pulse - comment on systolic murmur - comment on diastolic murmur - comment on 2nd heart sound - what do you see in CXR - what do you see in ECG
``` Normal pulse Pansystolic at 4LS grade 3-5 + can have thrill Mid diastolic at apex Loud P2 CXR - cardiomegaly - pulmonary plethora ECG - biventricular enlargement ```
64
Concerning endocardial cushion defect - comment on the pulse - comment on systolic murmur - comment on diastolic murmur - comment on 2nd heart sound - what do you see in CXR - what do you see in ECG
``` Normal pulse Ejection systolic at 2LS Mid diastolic at 4LS Fixed split and loud P2 CXR - cardiomegaly - pulmonary plethora ECG - QRS axis -60 - RsR in V1 ```
65
Concerning ADS - comment on the pulse - comment on systolic murmur - comment on diastolic murmur - comment on 2nd heart sound - what do you see in CXR - what do you see in ECG
``` Normal pulse Ejection systolic at 2LS in infants Continuous machinery sound Mid diastolic at 4LS Fixed split CXR - RA enlarged - RV enlarged - pulmonary plethora ECG - Rt axis RsR in V1 ```
66
Concerning PDA - comment on the pulse - comment on systolic murmur - comment on diastolic murmur - comment on 2nd heart sound - what do you see in CXR - what do you see in ECG
``` Collapsing pulse Ejection at 2LS with click (thrill = severe) Mid diastolic at apex Loud P2 CXR - cardiomegaly - asx pulmonary plethora ECG - normal - biventricular enlargement ```
67
Concerning pulmonary stenosis - comment on the pulse - comment on systolic murmur - comment on diastolic murmur - comment on 2nd heart sound - what do you see in CXR - what do you see in ECG
``` Normal pulse No diastolic Soft P2 and wide split CXR - large MPA - RV enlargement - normal lung vascularity ECG - Right axis - RVH ```
68
Name the cardiovascular adaptations of the foetus
``` Umbilical vein Ductus venosus Foramen ovale Ductus arteriosus Umbilical artery ```
69
What is the physiological mechanism of clamping the umbilical vessels?
Wharton's jelly exposed to air -> temperature falls -> contraction
70
Which chemical is the ductus arteriosus sensitive to?
Prostaglandin E2
71
What are the mechanisms by which the ductus arteriosus closes?
1. Oxygen from aortic blood flowing into pulmonary artery causes smooth muscle to constrict 2. Decrease in prostaglandins due to lack of placenta 3. Lungs release bradykinin
72
What are the mechanisms by which the umbilical arteries close?
1. Oxygen from iliac veins causes smooth muscle to constrict | 2. High pressure from lack of placenta
73
What % of PDAs are isolated?
90% isolated | 10% associated eg congenital rubella syndrome
74
What is the continuous murmur of PDA also known as?
Gibson's murmur
75
How can a PDA become an Eisenmenger syndrome?
R to L shunt -> increased pulmonary volume -> pulmonary hypertension -> L to R shunt becomes R to L shunt
76
Where is the continuous murmur of PDA found?
ULSB
77
Why is the PDA murmur continuous?
Pressure in systole AO >PA | Pressure in diastole AO>PA
78
Why is PDA Eisenmenger syndrome only cyanotic in the lower extremities?
Blood before the PDA is oxygenated and goes to the upper extremities and head
79
Which infants does the ductus arteriosus often remain patent?
Preterm infants esp with respiratory distress
80
How is a PDA treated?
``` Preterm infant -- NDAIDs eg indomethacin, ibuprofen Term infant - before 6 to 12 months of age EVEN if asx - device closure in cath lab - surgical ligation ```
81
What defect are the majority of VSDs caused by?
Defect in membranous septum
82
Which conditions are VSDs associated with?
FAS | Down syndrome
83
Give another term for a pansystolic murmur
Holosystolic murmur
84
What is the most common CHD?
VSD
85
What heart sounds are heard in a VSD?
Pansystolic murmur LLSB Smaller VSD= louder murmur Mid-diastolic murmur at apex if VSD large enough Loud P2 if pulmonary hypertension
86
Name the changes with time in VSD
Left heart dilates -> PA pressure rises -> CCF better -> right heart hypertrophies -> PA pressure rises higher -> CCF better -> RH hypertrophies more -> CCF -> pressures balance -> shunt reverses
87
How does VSD present clinically?
``` Left heart dilates - CCF - tachypnoea - dyspnoea - failure to feed PA pressure rises - cyanosis RVH - parasternal heave - epigastric heave ```
88
What is a left parasternal heave a sign of?
RVH
89
How does the pansystolic murmur in VSD change?
As PA pressure rises, less pressure difference between LV and RV -> softer murmur
90
Discuss management of VSD
Manage CCF Prophylactic amoxicillin for IE 1hr before teeth extraction ``` Small defects -> spontaneous Moderate defect -> smaller Large defect -> CCF -> requires closure - surgery - device closure in cath lab ```
91
If a child with a VSD fails to respond to anti-failure treatment, what should you expect?
A coexistent defect
92
What is the most common CHD in ADULTS?
Ostium secundum ASD
93
Why is ASD often missed until adulthood?
Low pressure shunt
94
What is heart sounds are heard in ASD?
Ejection systolic at ULSB Split S2 Can hear tricuspid diastolic at LLSB
95
Discuss the changes with time in ASD
Right heart dilates -> RV dilates -> pulmonary hypertension -> CCF
96
How can you differentiate a VSD using ECG?
Ostium primum = right axis deviation | Ostium secundum = left axis deviation
97
Discuss management of ASD
Manage CCF Monitor for arrythmias ``` Refer for closure: Secundum - before school going age Primum - large ```
98
What is a complete AVSD?
Ostium primum ASD + inlet VSD with common AV valve
99
What is a partial AVSD?
Ostium primum ASD
100
What would you see on an ECG of AVSD?
Left anterior hemiblock with left QRS axis between 0 and -90 degrees and Rsr' pattern in V1
101
Name the signs of aortic stenosis
Displaced apex (LVH) Suprasternal thrill Carotid thrill
102
What heart sounds are heard in aortic stenosis?
Ejection systolic 2nd RICS and into neck | 25% early diastolic murmur
103
Which gender predominates in congenital aortic stenosis?
Males 4:1
104
What kind of aortic valve is often found in congenital AS?
Biscupid
105
What sign of AS is seen on CXR?
Enlarged proximal aorta | Cardiomegaly if severe
106
What does absence of a click in AS suggest?
Subvalvar stenosis | Supravalvar stenosis
107
If the lower limb pulse are reduced or absent what do you suspect?
Coarctation of the aorta
108
What heart sounds are heard in coarctation of the aorta?
Systolic betw L scapula and spine 1/3 apical mid-diastolic Suprasternal thrill
109
Why must the right arm always be used for BP recordings in suspect coarctation of the aorta?
L subclavian aa is occasionally involved
110
What is the figure '3' sign?
Indentation to in descending aorta to the L of vertebral column - coarctation of the aorta
111
Why can notching of the inferior edges of the 3rd to 8th ribs in older children be seen in coarctation of the aorta
Formation of collaterals -> enlarged collateral intercostal arteries
112
What age should elective surgical repair of an asymptomatic aortic coarctation take place?
Two years
113
What should you suspect in a child >1year with signs of coarctation and CCF?
Aortic arteritis
114
What is aortic arteritis also known as?
Takayasu's arteritis
115
Name the causes of mitral incompetence
Congenitally abnormal mitral valve OR 2nd to L heart dilation
116
What heart sound is heard in mitral incompetence?
Pansystolic murmur at the apex
117
What is a sign of pulmonary stenosis?
Left parasternal heave
118
What heart sound is heard in pulmonary stenosis?
Ejection systolic 2nd LICS and into lungs
119
What is a sign of severe tricuspid incompetence?
Palpable liver
120
What heart sound is heard in tricuspid incompetence?
Pansystolic murmur at LLSB
121
Which test do you use to differentiate respiratory and cardiac cyanosis?
Hyperoxia test
122
Name the causes of cyanosis in children
``` ABCs Airway obstruction - choanal atresia - laryngomalacia - vocal cord paralysis - tracheal stenosis - vascular ring - external mass ``` Breathing - pneumonia - bronchiolitis - congenital lung abnormality - congenital DH - hypoventilation Circulation - methaemoglobinaemia - congenital cardiac lesions - persistent pulmonary hypertension
123
Name the features of tricuspid atresia
Hypoplastic right ventricle Pansystolic murmur LLSB -> VSD Single heart sound Left axis deviation on ecg
124
What is wall-to-wall heart on CXR diagnostic of?
Ebstein's anomaly Pulmonary atresia Critical pulmonary stenosis
125
What syndrome is Ebstein's anomaly associated with?
Wolff-Parkinson-White (WPW)
126
What is a common cause of Ebstein's anomaly?
Mother's with bipolar -> lithium
127
What word is associated with the right ventricle in Ebstein's anomaly?
Atrialisation of the right ventricle
128
How does a child fare with Ebstein's as it gets older after birth?
Gets better after birth (less cyanotic)
129
What heart sound can be heard in Ebstein's anomaly?
Pansystolic LLSB (tricuspid regurgitation)
130
What are the 4 abnormalities of TOF?
Right ventricular outflow tract obstruction RVH VSD Overriding aorta
131
What is the most common cyanotic CHD?
TOF
132
What is TOF associated with?
Chromosome 22 deletion | DiGeorge Syndrome
133
What are signs of TOF in a child?
Cyanosis Clubbing Polycythaemia
134
What is a hypercyanotic spell in TOF also known as?
"Tet" spell
135
Why do TOF children squat?
Squatting -> kinks femoral arteries -> incr SVR -> pressure L > right -> shunt reverses
136
Discuss management of a hypercyanotic spell
Place child in knee-chest/squatting position Administer morphine 0.1-0.2mg/kg Administer fluid bolus 10-29ml/kg crystalloid/colloid Administer esmolol 0.5mg/kg stat then 0.1mg/kg/min Phenylephrine Administer sodium bicarbonate 1mmol/kg IV Check hct and treat
137
What is a bootshaped heart on CXR diagnostic of?
TOF (RVH)
138
What heart sound is heard in TOF?
Ejection systolic LUSB
139
How will a pulmonary atresia with VSD appear on CXR?
Boot shaped heart
140
How will a pulmonary atresia without VSD appear on CXR?
Wall-to-wall heart
141
What are the trouble 3Ts?
Cyanotic heart lesions with increased PBF 1. Transposition 2. Truncus arteriosus 3. TAPVD 4. HLHS
142
At what age do cyanotic heart lesions with increased PBF present?
Young age <6months
143
What is complete TGA also known as?
Right TGA (aorta on right)
144
What is supportive management of PDA-dependent lesions?
Prostaglandin E1 IVI | Oral prostaglandin E2 orally
145
What TGA is acyanotic?
Levo-TGA | 'Congenitally corrected'
146
What is egg-on-side/string cardiac silhoutte on CXR diagnostic of?
TGA
147
What syndrome is truncus arteriosus associated with
DiGeorge Syndrome
148
What is 22q11.2 deletion syndrome also known as?
DiGeorge Syndrome
149
What are characteristics of a truncus arteriosus?
``` To-and-fro murmur - pansystolic LLSB - mid-diastolic Bounding/collapsing peripheral pulses Wide PP Loud ejection click Single S2 Cardiomegaly w/ plethora ```
150
What is TAPVD also known as?
TAPVC | Drainage vs connection
151
Where are the 3 potential locations of TAPVD?
Supracardiac (SVC) Infracardiac (IVC) Infradiaphragmatic (hepatic vv) Cardiac (RA/coronary sinus)
152
What is a snowman CXR diagnostic of?
TAPVD
153
What heart sounds can be heard in TAPVD?
Pulmonary stenosis = ejection systolic LUS | Tricuspid stenosis = mdm LLSB
154
What is snowman CXR also called?
Figure of 8
155
Name complications of right to left shunting
``` Chronic hypoxia Myocardial and somatic tissue dysfunction Paradoxical emboli Neurological sequelae Hemiplegia/paresis Cerebral abscess Polycythaemia Hyperuricacidaemia Thrombocytopenia Iron deficiency Exercise intolerance ```
156
What does HLHS usually comprise of?
Aortic valve atresia Mitral atresia Hypoplastic ascending aorta Diminutive LV
157
What does HLHS require for survivability?
ASD | PDA

Coovadias Paediatrics (10 decks)

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