Infant or child with a heart murmur Flashcards Preview

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Flashcards in Infant or child with a heart murmur Deck (49):
1

Characteristic of innocent murmurs

Have no clinical significance
systolic
Localised
Soft
vary with position of the child
vary with respiration
Rest of CVS is normal.
- Venous hum - blowing continuous murmur in systole and diastole and heard below the clavicles, disappears on lying down.
- Pulmonary flow murmur- brief high-pitched murmur at second left intercostal space. Best heard with child lying down
- Systolic ejection murmur - short systolic murmur at left sternal edge or apex. Musical sound, Changes with child's position. Intensified by fever, exercise and emotion

2

Characteristic of pathological murmur

Pan systolic or diastolic
Are harsh or long
May radiate and have a thrill
Often have associated cardiac symptoms or signs
- Aortic stenosis
- Atrial septal defect
- pulmonary stenosis
- ventricular septal defect
- Coarctation of the aorta

3

Congenital heart disease that present with a murmur

Pulmonary valve stenosis
Atrial septal defect
Ventricular septal defect
Coarctation of the aorta
Patent ductus arteriosus
Aortic valve stenosis
Tetralogy of Fallot
Transposition of great arteries

4

Stage of embryology when heart is developed

3-8 wks, Insults in this time result in CHD

5

Ix for CHD

Echocardiogram
ECG
CXR

6

Signs of cyanotic heart disease

Blue mucous membranes
Nail beds and skin secondary to an absolute concentration of deoxygenated haemoglobin of at least 3g/dL

7

Characteristic CXR finding in CHD

Boot shaped heart = tetralogy of ballot, tricuspid atresia
Egg shaped heart = transposition of great arteries
"Snowman" heart: total anomalous pulmonary venous return.

8

Types of CHD

Acyanotic
- Left to right shunts - most common: Atrial septal defect (ASD) - clinical commonest, Ventricular Septal Defect (VSD) - commonest at birth, Patent Ductus Arteriosus (PDA)
- Obstructions: Coarctation of aorta (CoA) - Turners, Aortic stenosis, Pulmonic stenosis

Cyanotic - 5 T lesion
- Right to Left shunts: Tetralogy of Fallot (FT), Epstein’s anomaly
- Other: Transposition of great arteries, Total anomalous pulmonary venous drainage, Tricuspid atresia, Hypoplastic left heart syndrome,

9

CHD that presents as Heart failure

VSD
ASD
PDA

10

CHD that present with shock

Coarctation of aorta
Aortic valve stenosis

11

CHD that present with cyanosis

Tetralogy of ballot
Transposition of the great arteries.

12

CHD that typically present in the newborn period

Coarctation of the aorta
Transposition of the great arteries
Tetralogy of Fallot
Patent ductus arteriosus

13

Types of ASD

Ostium primum - common in down syndrome
Ostium secundrum - most common 50-70%
Sinus venosus - entry at SVC entrance

14

Symptoms and signs of ASD

Asymptomatic
Murmur
Grade 2/3
Systolic murmur at 2rd left interspace
Widely split S2 and fixed.
Breathlessness
Tiredness on exertion
recurrent chest infection
HF
Pulmonary HTN
Pulmonary vascular abnormalities

15

Cx of ASD

Eisenmenger’s complex
infective endocarditis
Paradoxical immobilisation
Cardiac arrhythmias

16

Ix findings in ASD

ECG - Right axis deviation, mild RVH, RBBB
CXR - Increase pulmonary vascular

17

Tx for ASD

80-100%

18

Types of VSD

Membranous 90%
Muscular

19

Clinical presentation of VSD

Asymptomatic
Murmur: Harsh pan systolic at lower left sternal edge, May radiate over chest if large enough
Parasternal thrill
HR 4-6 week if lg
Large
breathlessness on feeding or crying
poor growth
recurrent chest infections

20

Cx of VSD

Increase pulmonary HTN -> Eisenmenger’s syndrome

21

Ix of VSD

CXR - increase pulmonary marking, cardiomegaly
ECG - RVH, LVH
Echo - confirms diagnosis

22

Tx of VSD

Many close spontaneously (small)
Prevention of endocarditis
Large membranous defect and cardiac failure need medical tx for CHF and Surgical closure by 1 year

23

Clinical presentation of PDA

Murmur: Continuous machinery murmur below left clavicle
bounding pulse
Asymptomatic
Apnoea or decreased HR episodes
Poor feeding
Accessory muscle use
Tachycardia
Hyperactive precordium
Wide pulse pressure

24

Ix findings in PDA

ECG - LAE, LVH, RVH
CXR - mildly enlarged heart, increase pulmonary vasculature, prominent pulmonary artery
Echo - diagnostic test

25

Tx for PDA

Premature - spontaneous closure or medical closure with indomethacin or ibuprofen: PGE2 antagonist only effective in premature.
Restrict fluids
blood transfusion if anaemic
Treat HF - furosemide
Surgery - if medical treatment fails, significant HF, ventilator dependence or prolonged failure to close. surgical ligation or by transcatheter occlusion device.

26

Clinical presentation of coarctation of aorta

Mild
HF
Murmur - absent or systolic with late peak over apex, left axilla, left back
Older children develop HTN
severe
Infant goes into shock when ductus arteriosus closes
Key features - WEAK OR ABSENT FEMORAL PULSES - RADIAL FEMORAL DELAY
Ass with turner’s syndrome (bicuspid aortic valve and aortic dissection.

27

Ix of coarctation of aorta

ECG - infancy RVH, Childhood LVH
Echo - diagnostic

28

Tx of coarctation of aorta

Immediately - IV prostaglandin E2 = keeps ductus arteriosus patent
Surgery - Neonate for repair, Older children stunt or balloon to dilate.

29

Clinical presentation of Aortic stenosis

- Mild - asymptomatic with murmur - ejection systolic on RUSB +/- ejection click, radiates to neck and A2 soft and delayed
- Severe - shock or HF when duct closes
- Older children
Syncope
decreased exercise tolerance
dizziness
exertion chest pain
- peripheral pulse sml volume
- Reduced BP
- Palpable thrill at L sternal border and carotid artery

30

Ix findings for aortic stenosis

CXR - prominent LV and ascending aorta
ECG - LVH
Echo

31

Cx of aortic stenosis

Sudden death

32

Tx of aortic stenosis

Severe - ballon valvoloplasty or open heart surgery
Avoid strenuous activity or sport = sudden death.

33

Clinical presentation of pulmonary stenosis

Murmur
short systolic ejection murmur
Upper left chest
Conducted to back
Preceded by ejection click
Thrill palpable in severe
Wide split S2 on expiration
mild - asymptomatic
Severe - palpable in pulmonary area, CHF

34

Ix of pulmonary stenosis

CXR - dilated pulmonary artery, severe - enlarge R atrium and ventricle
Echo to diagnosis

35

Tx of pulmonary stenosis

Severe - balloon valvuloplasty, usually successful.

36

Causes of cyanotic heart disease

One big trunk - trunks arteriosus
Two interchanged vessels - transposition of the great vessels
Three leaflets - tricuspid atresia
Four anatomical abnormalities - tetralogy of Fallot
Five words - Total anomalous pulmonary venous return

37

What is Tetralogy of Fallot

Causes - genetic and seen in fetal alcohol syndrome.
Defective septum development - classic
large VSD - venticular septum defect
RVH (result) -
Pulmonary infundibular stenosis
Overriding aorta - aorta gets blood from both right and left

38

Clinical features of tetralogy of fallot

intermittent Cyanosis since birth
Clubbing
Murmur - ejection systolic murmur, loud P2
Hyper cyanotic spells on exertion which are relieved by squatting down
presents common at 2-4 months. most common cyanotic CHD beyond infancy

39

Cx of tetralogy of Fallot

Subacute bacterial endocarditis - right to left shunt predisposes to infection

40

Ix findings of tetralogy of Fallot

ECG - RVH
CXR - boot shaped heart and oligaemic lung fields, decreased pulmonary vasculature, right aortic arch

41

Tx for tetralogy of Fallot

Mx of spells - O2, knee chest position, fluid bolus, morphine sufate, propanolol
surgical correction at 2-3 months old or earlier if marked cyanosis.
Protective factors
if patients have PDA and ASD may be there (protective)

42

Clinical features of transposition of great vessels

severe Cyanosis and acidosis since birth.
Chronic heart failure
Right sided ventricular hypertrophy
Pulmonary hypertension
IF VSD murmur - cyanosis = presents with CHF in first couple of weeks
If no VSD = no murmur but marked cyanosis.

43

Ix finding for transposition of great vessels

ECG- RAD, RVH or normal
CXR - Egg shaped heart with narrow mediastinum

44

Tx for transposition of great vessels

Emergency
Prostaglandin infusion
ventilatory
circulatory support
Surgery - Requires atrial septostomy urgently
followed by definitive switch operation within the first couple of weeks- where two great vessels are switched over and coronary arteries are reconnected to the new aorta.
Prognosis
Die in the first month is not treated with surgery.

45

Neonatal circulation

Placenta -> umbilical vein -> ductus veniosus ->IVC ->RA -> foramen ovale or ductus arteriosus to systemic circulations -> descending aorta -> common iliac -> to umbilical arteries

46

Diagnostic criteria for Acute rheumatic fever

2 major or 1 major & 2minor +evidence of preceding GAS infection.
Major manifestations
Carditis- excluding subclinical evidence of rheumatic valve disease of Echo
Polyarthritis
Sydenham Chorea
Erythema marginatum
Subcutaneous nodules
Minor
Fever
ESR >/= 30mm/hr or CRP >/= 30mg/L
Prolonged P-R interval on ECG
Polyarthralgia or aseptic mono-arthritis

47

Diagnostic criteria for actor rheumatic fever in high risk groups

2 major or 1 major & 2minor +evidence of preceding GAS infection.
Major
Carditis - including subclinical evidence of rheumatic valve disease on echocardiogram
Polyarthritis, aseptic mono-arthritis or polyarthralgia
Sydenham Chorea
Erythema marginatum
Subcutaneous nodules
Minor
Fever
ESR >/= 30mm/hr or CRP >/= 30mg/L
Prolonged P-R interval on ECG

48

Ix for rheumatic fever

Echo
WCC
ESR
CRP
Blood cultures if febrile
ECG
Throat swab
Anti-streptolysin serology (anti-streptolysin O, Anti-DNase B titres)

49

Mx of rheumatic fever

Regular secondary prevention treatment for people at risk of recurrent ARF
First line = Benzathine penicillin G - 1200 000 U (body wt >/= 20 kg) IM 4 weekly or 3 weekly in selected groups.
second line if IM routine not possible or refused
Phenoxymethylpenicillin (penicillin V) 250mg Oral Twice daily
If penicillin allergy = Erythromycin 250mg oral twice daily
Duration of treatment
all people with ARF or RHD for minimum of 10 years after most recent episode of ARF or until age 21 yrs (which ever is longer)
Status after initial period has elapsed
No RHD or mild RHD = discontinue at that time
Moderate RHD: continue until age 35 yr
Severe RHD: continue until age 40 yrs or longer
Acute management
- Bed rest
- anti-inflammatory drugs e.g. aspirin
- Corticosteroids 2-3 weeks
- diuretics/ACEi if HF
- Antibiotics eg penicillin V for 10 days