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Flashcards in Paediatric Cardiology Deck (36):
1

Diagnostic criteria of acute rheumatic fever

Jones Criteria (SPACE CAFE) 2 major OR 1 major + 2 minor
MAJOR:
Subcutaneous nodules
Pancarditis
Arthritis (poly-)
Chorea
Erythema Marginatum
MINOR:
CRP/ESR raised
Arthralgia
Fever
ECG: prolonged PR

2

Circulatory changes after birth

Activation of breathing - distension of lungs - dilation of pulmonary vasculature - reduced resistance - reduced RA pressure - LA pressure forces septum primum closed - functional closure of foramen ovale in first few minutes (complete closure by 12m)
Clamping of cord + temperature fall - contraction of Wharton's jelly - high resistance in umbilical vein and artery - blood ceases to flow through umbilical vein and ductus venosus by few days after birth
Increased O2 saturation + rapid fall in PG levels (after placenta removed) - contriction of smooth muscle in ductus arteriosus and imbilical arteries within first few hours - complete obliteration after a few weeks (ligamentum arteriousus)

3

Red flags for pathological mumurs

Holosystolic
Diastolic
Grade 3 or higher
Harsh quality
Abnormal S2
Maximal murmur intensity at ULSB
Systolic click
Increased intensity on standing

4

7 S's of innocent murmurs

Systolic
Short duration (not pansystolic)
Single (no clicks or added HS)
Small (limited to small area, non-radiating)
Soft (low amplitude)
Sensitive (changes with position or respiration)
Sweet (not harsh sounding)

5

The 8 benign murmurs

5 systolic:
- Stills (vibratory murmur) - 2-6, rare in infants
- Pulmonary flow (young kids - adults)
- Peripheral pulmonary arterial stenosis (kids under 1, or older kids recovering from RTI)
Supraclavicular or brachiocephalic systolic murmur (any age)
Aortic Systolic flow murmur (high output states - fever, anaemia, hyperthyroid)
3 Continuous:
Venous hum (3-6y)
Patent ductus arteriosus (physiologic in first few months)
Mammary souffle (late pregnancy and lactating women)

6

Acyanotic Congenital Heart Lesions (6)

Atrial septal defect
Ventricular septal defect
Patent Ductus Arteriosus
Pulmonic Stenosis
Coarctation of the Aorta

7

Cyanotic Congenital Heart Lesions

Tetralogy of Fallot (most common after neonatal period)
Transposition of the Great Arteries (more common cause of cyanosis in first days of life)
Truncus Arteriosus

8

Congenital heart lesions associated with trisomy 21

atrioventricular septal defect
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Tetralogy of Fallot

9

Congenital heart lesions associated with Turner syndrome

Coarctation of aorta, aortic stenosis (due to bicuspid valve), left ventricular hypertrophy

10

Congenital heart lesions associated with Marfan syndrome

Mitral valve prolapse
Aortic root dilatation
Aortic regurgitation
(Aortic dissection develops in later life)

11

What are the components of the Tetralogy of Fallot?

1. Pulmonic stenosis (subvalvular)
2. RV hypertrophy
3. Overriding aorta
4. Ventricular septal defect

Due to abnormal anterior cephalad displacement of infundibulur portion of interventricular septum

12

CXR in patient with tetralogy of Fallot

"Boot-shaped" heart - prominent RV with small pulmonary artery
+ Reduced pulmonary vascular markings

13

Management of acute rheumatic fever

Oral antibiotics (benpen or amoxyl first line - macrolides, cephs or clindamycin if allergic to penicillins)
Symptom/complication management:
Arthritis: NSAIDs or aspirin
CHF: frusemide, ACE-i (if severe), steroids
A Fib: digoxin
Severe Chorea: CBZ

14

Complications of acute rheumatic fever

Rheumatic heart disease (30-50%)
Typically affects mitral valve, may have mixed mitral and aortic disease

15

Jones criteria

Space cafe

16

Diagnostic criteria for acute rheumatic fever

Jones Criteria: evidence of GAS + 2 major OR 1 major and 2 minor
SPACE CAFE
Subcutaneous nodules
Pancarditis
Arthritis (poly)
Chorea
Erythema Marginatum

CRP/ESR elevated
Arthralgia
Fever
ECG: Prolonged PR interval

17

Presentation of heart failure in children of different ages

(Basically a sick child presentation)
Infants:
tachypnoea and diaphoresis during feeds + reduced volume of feeds and poor weight gain
Easy fatigability
Irritability

Young children:
GI symptoms (abdo pain, n+v, reduced appetite), FTT
easy fatigability
Recurrent cough with wheeze

Older children:
similar to adult

18

Causes of heart failure in utero

foetal hydrops due to anaemia (most commonly haemolysis due to blood group incompatibility)

19

Management of Heart failure in children

Similar to that of adults + increased caloric intake
High-flow O2, diuretics, ACE-i, inotropes, non-invasive positive pressure ventilation, correct metabolic acidosis, hypolygaemia or anaemia if present

20

ASD: symptoms, murmur, management, complications

2nd most common CHD
Usually asymptomatic OR SOBOE, fatigue, recurrent LRTI
Murmur: systolic at ULSB (+/- mid-diastolic rumble at LLSB), RV heave and wide, fixed split S2
Should be repaired by school-age if asymptomatic
Indications for repair earlier: significant shunt, symptomatic
Complications: Heart failure (less commonly than VSD), pulmonary vascular disease, Stroke

21

VSD: symptoms, murmur, management

Presentation: either asympotmatic or will develop heart failure (10% by 12m)
Murmur: harsh pansystolic, best heart at LSB +/- mid-diastolic rumble at mitral area
Mx: Closure indicated if CHF or pulmonary vascular disease (50% will close spontaneously by 2y, therefore leave until that point unless symptomatic)

22

Patent ductus arteriosus presentation, murmur, management

Symptoms: asymptomatic OR tachycardia, poor feeding, FTT, recurrent LRTI, fatigue, SOB, palpitations
Murmur: continuous machine-like murmur, heard best at subclavicular region
Mx: indomethacin in premature infants, surgical repair or ligation by minimally invasive techniques

23

Causes of heart failure in neonates and infants

o Congenital heart disease
o Sepsis
o Anaemia
o Inborn errors of metabolism
o Respiratory illness

24

Causes of heart failure in children older than 2m

o L sided obstructions (often missed earlier in life)
 Aortic stenosis
 Coarctation of aorta
o Renal failure
o Hypertension

25

Causes of heart failure in adolescents

o Cocaine, amphetamines
o Arrhythmia
o Cardiomyopathy

26

Congenital heart malformation associated with Noonan syndrome

Pulmonary stenosis

27

What kind of genetic abnormalities are NOT associated with pulmonary stenosis

Chromosomal defects e.g T21, T18 or T13

28

Causes of hypertension in children

Primary (uncommon in children)
Renal (75% of secondary) = glomerulonephritis, HUS, obstructive uropathy, VUR, polycystic kidneys)
CVS(15%) - coarctation
Endocrine (5%) - phaeo, hyperthyroid, CAH, Addison's, Cushing's
Other (5%) - neuroblastoma, neurofibromatosis, steroid therapy, raised ICP

29

Management of SVT in children

Valsalva (blow into blocked straw)
Ice pack held to face for few seconds
Adenosine

30

Possible causes for tachycardia in a child

Heart failure
Hypovolaemia
Hypoxia
Hyperthyroidism
Hyperglycaemia (DKA)

31

How to best hear a venous hum

Above the right clavicle with the child sitting upright

32

At what age is a VSD normally detected, why

Usually not until after 1 months, normal decrease in pulmonary vascular resistance allows left to right shunting to occur, causing murmur

33

How do you explain coarctation of the aorta with normal femoral pulses

Preductal coarctation of the aorta (femoral pulses normal because of blood flow from pulmonary artery to aorta through a patent ductus arteriosus)
Associated with other cardiac defects

34

Most valuable signs of heart failure in infancy

Hepatosplenomegaly is the most reliable sign

Oedema and ascites occur less commonly
Raised JVP is not reliable

35

Cardiac sequelae of congenital rubella

Persistent PDA
Pumonary stenosis
ASD

36

Fixed splitting of S2 + murmur =

ASD