Ch 17 - Cardiac disorders Flashcards Preview

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Flashcards in Ch 17 - Cardiac disorders Deck (55):
1

Heart disease in children is mostly congenital. The most common congenital abnormalities (account for 80%) can be categorized into 5 groups - name these

Left-to-right shunts (breathless)

Right-to-left shunts (blue)

Common mixing (breathless & blue)

Outflow obstruction in well child (asymptomatic with murmur)

Outflow obstruction in sick neonate (collapsed with shock)

2

Give 3 examples of left-to-right shunts (breathless)

  1. VSD
  2. presistent arterial duct (PDA)
  3. ASD

3

Give 2 examples of right-to-left shunts (blue)

tetralogy of fallot

transposition of great arteries

4

Give 1 example of common mixing defect (blue and breathless)

Atrioventricular septal defect (complete)

5

Give 2 examples of outflow obstruction in a well child

Pulmonary stenosis

aortic stenosis

6

Give an example of outflow obstruction in a sick neonate

coarctation of aorta

7

The most common presentation of congenital heart disease is a heart murmur; give 4 hallmarks of an innoSent ejection mumur

aSymptomatic

Soft blowing murmur

Systolic murmur only (not diastolic)

Left Sternal edge

8

Causes of HF in neonates (4)

Hypoplastic left heart syndrome (severely underdeveloped LH - small LV & aorta)

Severe AS

severe aortic coarctation (narrowing at area of ductus arteriosus)

interruption of aortic arch (gap between ascending & descending thoracic aorta - in a sense the complete form of coarctation of aorta)

9

Causes of HF in infants (3)

VSD

ASD

large PDA

10

causes of HF in older children (3)

Eisenmenger syndrome (RH failure only)

rheumatic HD

cardiomyopathy

11

Features of HF (6)

Tachycardia,

tachypnoea

murmur

creps oedema

cool peripheries sacral oedema cardiomegaly hepatomegaly

12

HF in 1st week of life usually results from LH obstruction e.g. coarctation of aorta. What is the pathophysiology? how would you manage?

If very severe coarctation, the only thing that can maintain perfusion is if the ductus arteriosus is open - allowing a R to L shunt "duct dependent circ".

When this duct closes, the baby rapidly devlopes severe acidosis, collapse & death - unless you restore the ductal patency via PROSTAGLANDIN infusion. 

Followed by prompt surgical repair 

13

After 1st week of life progressive HF is probably due to L to R shunt. Explain the pathophysiology (3)

L to R shunt (e.g. VSD) results in eventual increase in pulmonary blood flow > pulmonary oedema > dyspnoea

14

If an L to R shunt is left untreated will develop Eisenmenger syndrome - explain pathophysiology (4)

Eventually in response to the L to R shunt, the pulmonary vasc resistance will rise (at about 3 months age) > symptoms will improve but if left untreated will develop Eisenmenger syndrome - which is irreversibly raised pulmonary vascular reistance (resulting from chronically raised pulmonary arterial pressure/flow) this also causes the shunt to become from R to L - and the teenager becomes blue. (requires heart lung trasnplant)

15

Causes of cyanosis (6) (physical sign that causes bluish discoloration of the skin and is due to lack of oxygenated blood)

Cardiac - R to L shunts, common mixing, outflow obstruction

Resp - RDS, meconium aspiration Persistent pulmonary HTN of newborn (pulmonary resistance fails to fall post natally) Septicaemia Inherited metabolic disorders

16

Name the types of ASDs (2), and where the defects are in these specifically (2)

Secundum ASD (80%) - defect in CENTRE of ATRIAL SEPTUM involving foramen ovale

Partial atrioventricular septal defect (pAVSD) - defect of AV septum (both present with similar signs and symptoms)

17

Partial AVSD is a defect of AV septum and is characterised by: (2)

An inter-atrial communication between bottom of atrial septum & AV valves Abnormal AV valves (left AV valve has 3 leaflets & leaks - regurgitates)

18

Features of ASDs (6)

symptoms - usually none,

can get reccurent chest infections,

arrythmias - after 4th decade

Physical signs: Ejection systolic murmur best heard at upper left sternal edge - due to increased flow via pulmonary valve (because of L to R shunt) Fixed & split 2nd heart sound

if partial AVSD will hear an apical pansystolic murmur (due to regurg)

19

CxR signs of ASDs (3)

Cardiomegaly

Larger PAs

increased vascular markings

20

ECG signs of ASDs (3)

Secundum ASD shows partial RBBB + RAD (due to RV hypertrophy)

pAVSD shows superior QRS axis

21

Management of ASDs (2)

treatment only if significant ASD (ie large enough to cause RV dilation)

Secundum ASDs - cardiac catheterization with insertion of an occlusion device pAVSD - require surgery

22

Murmur of Small VSDs (1)

asymptomatic loud pansystolic murmur at lower left sternal edge

quiet pulmonary 2nd sound (p2) (NO PULMONARY htn)

23

Ix (3) and management (1) of VSDs

Ix - CxR & ECG (normal), echo + doppler

Management - spontaneous closure - murmur disappears

prevent bacterial endocarditis via good dental hygiene

24

Large VSDs - same size/larger than aortic valve, features (6)

HF + SOB + failure to thrive after 1 week old recurrent chest infections tachycardia tachypnoea

soft pansystolic mumur/ no mumur (implying larger defect)

apical mid-diastolic murmur - from increased blood flow across the mitral valve after the blood has circulated through the lungs

25

Ixs (3) & management (3) of VSD

CxR - cardio megaly + large PAs + increased vascular markings + pulmonary oedema ECG - biventricular hypertrophy Echo - pulmonary HTN management - diuretics + ACEis, surgery

26

PDA - definition, associations (3), features (3)

Failure of DA closure by 1 month

associations - Down's, prematurity, female, rubella

features - loud P2, continous mumur at upper left sternal edge, bounding pulse (increased pulse pressure)

27

PDA - Ix (3), management (3)

Ix - CXR, ecg - usually normal, echo management - prostaglandin synthetase inhibitors e.g. ibuprofen; occlusion device closure via catheter, surgery

28

Hyperoxia (nitrogen washout test): defintion (1), method (3), management (1)

Used to determine heart disease in a CYANOSED infant

give 100% oxygen for 10 min > check right radial PO2, if remains less than 15kPa = congenital cyanotic heart disease (if >20 then not)

managemnet - prostaglandin infusion to maintain ductal patency

29

Tetralogy of fallot - the 4 cardinal features

PROV: subPulmonary stenosis (causing RV outflow obstruction) RV hypertrophy (as a result of above) Overriding aorta - with respect to septum large VSD

30

Tetralogy of fallot features (4)

Clubbing

hypercyanotic spells - rapid increase in cyanosis, inconsolable crying + SOB + pallor squatting on exercise in infants loud harsh ESM at left sternal edge

31

Tetralogy of fallot Ix (3)

CxR - small heart, 'boot shaped' because RVH will cause uptilting of apex. pulmonary artery 'bay' echo ecg - RVH signs

32

Tetralogy of fallot management (3)

surgical VSD closure + RV obstruction relief Blalock-taussig shunt - connects a branch of subclavian artery with PA - allowing more blood to flow to lungs symptomtatic treatment of hypercyanotic episodes - propanol, ventilation, morphine

33

Transposition of great arteries: definition

RV connected to aorta & LV connected to PA = deoxygenated blood to body & oxygenated blood to lungs = INCOMPATIBLE with life; unless mixing occurs - which often does (as ppl with this often have other congenitatl defects) e.g. ASD/VSD/PDA

34

Transposition of great arteries: features (2)

Consistenly present cyanosis starting from day 2 Loud S2 may have systolic murmur

35

Transposition of great arteries: Ix (3)

CxR - narrow upper mediastinum (due to anterposterior relationship of great vessels) 'egg on side' appearance ECG - norm Echo

36

Transposition of great arteries: management (3)

Prostoglandin infusion

balloon atrial septostomy

arterial switch procedure

37

Complete atrioventricular septal defect (common mixing): features (3), Ix (2), management (2)

F - Down's, cyanosis at birth, SOB

Ix - ECG - superior axis,

Echo - 5 LEAFLET VALVE (in centre of heart)

M - treat HF (diuretics etc.), surgical repair at 3 months

38

Complex congenital heart disease e.g. tricuspid atresia: definition, features (2), management (3)

D - basically only LV is effective (small and non functional RV)

F - cyanosis in neonate if duct dependent, SOB

M - Blalock Taussig shunt (increase blood flow to lungs) palliation - 'hemi-fontan operation' = connect SVC to RPA 'fontan operation' = connect IVC to RPA

39

Outflow obstruction in well child: AS: features (5)

ES murmur Slow rising pulse carotid bruits low volume pulse exertional chest pain syncope

40

Outflow obstruction in well child: AS: Ix (2), management (2)

CxR - normal/ LVH + post-stenotic ascending aorta dilatation ECG - LVH signs Management - Balloon valvotomy, AV replacement

41

Outflow obstruction in well child: PS: features (3)

most asymptomatic if critical stenosis neonates have duct dependent circ & will therefore present in 1st few days of life with cyanosis ESM, prominent RV heave (if severe), ejection click

42

Outflow obstruction in well child: PS: Ix (2) & management (2)

CxR - post-stenotic PA dilation ECG - RVH signs (upright T wave in V1) M - trans-catheter balloon dilation

43

Outflow obstruction in well child: Adult type aortic coarctation: definition + features (3)

uncommon lesion that is not duct dependent - so presents later as it becomes more severe over yrs

F - asymp, systemic HTN in R arm, ES murmur, collaterals heard wit continuous murmu at the back, radio-femoral delay

44

Outflow obstruction in well child: Adult type aortic coarctation: Ix (CxR 2 signs, ECG)

CxR - 'rib-notching' due to large intercostal collateral arteries for bypassing obstruction. '3 sign' - visible notch in descending aorta at site of coarctation ECG - LVH signs

45

Outflow obstruction in well child: Adult type aortic coarctation: management (2)

Stent insertion surgical repair

46

Outflow obstruction in sick neonate: aortic coarctation: features (3), Ix (2), Management (3)

F - acute circ collapse at day 2 (as DA closes), absent femoral pulses, severe acidosis

Ix - CxR - cardiomegaly & normal ECG

M - prostaglandin infusion, stent insertion, surgical repair

47

Outflow obstruction in sick neonate: interruption of the aortic arch: defintion, features (4), management (3)

D - no connection between proximal aorta & distal to DA - so CO is dependent on R-L shunt 

F - VSD is usally present; present with shock, associated with Di George syndrome, absent femoral pulses + left brachial pulse

M - Prostaglandin infusion, VSD closure + Aortic arch repair

48

Outflow obstruction in sick neonate: hypoplastic LH syndrome: definition, features (3), management (2)

D - basically underdevelopment of LH - LV small non functional, mitral & aortic valve atresia, aortic coarctation

F - all peripheral pulses absent, collapse, acidosis

M - norwood procedure, hemi-fontan at 6 months, fontan at 3 years

49

SVTs: features (3), ix (1)

F - most common childhood arrythmia, HR rapid - 250-300bpm; hydrops fetalis; intrauterine death I

x - ECG - narrow complex tachy 250-300, if WPW syndrome short PR interval + delta wave

50

SVT management: acute (2), maintenance (2)

Acute - Vagal manoeuvres - carotid sinus massage IV adenosine - breaks re-entry circuit - terminating SVT DC cardioversion

maintenance - Flecainide; ablation of accessory pathway

51

Congenital complete heart block: defintion, features (3), management (1)

D - prevention of development of normal conductive tissue in heart by anti-ro/la abs in maternal serum (these mumus have connective tissue disorders e.g. sjogrens)

F - most asymptomatic for years, syncope, in utero death, HF

M - Endocardial pacemaker implantation

52

long QT syndrome: feature (1), complication (1), associations (3)

Feature - sudden LOC during exercise/stress/emotion complication - sudden death from VT if goes unrecognised associations - autsomal dominant inheritance, erythromycin therapy, electrolyte disorders, head injury

53

Syncope: causes (4),

Common in teenagers, mostly not cardiac cause neurocardiogenic - prolonged standing, vagal symptoms situational - defacation, coughing, urination, swallowing orthostatic - BP fall > 20 mmHg Ischaemic Arrythmic - Heart block, SVT, VT (increase suspicion of cardiac cause if FH of sudden death, exercise symptoms, palpitations)

54

Rheumatic fever: causes, features (5), Ix (1), management (3)

C - S. Pyogenes (5-15yr olds) F - Joints - migrating polyarthralgia, myocarditis, subcutaneous nodules, erythema marginatum, syndenham's chorea mitral stenosis most common long term damage Ix - ECG - prolonged PR interval M - NSAIDs, steroids, ABs

55

IE: causes (2), features (4), Ix (3), mangement (2), prophylaxis (1)

C - S. viridans, enterococcus, S. aureaus F - roth spots, janeway, oslers, splinter haemorrhages, clubbing, splenomagly, haematuria, changing murmur Ix - blood culture, Echo, CRP/ESR M - high dose penicillin, aminoglycoside P - good dental hygiene