Pediatric CHD, part 2 Flashcards
(27 cards)
What are Tet Spells
A tet spell is caused by right-sided outflow tract obstruction leading to right-to-left shunting through a VSD
Hypoxia and acidosis cause pulmonary arterial vasoconstriction, thus increasing pulmonary arterial vasoconstriction thus incrasing pulmonary resistance and exacerbating shunting.
Management goals in tet spells
To increase pulmonary blood flow by
- increasing preload
- providing pulmonary vasodilation
- and increasing afterload in order to revise right-to-left shunting and promotepulmonary blood flow
Therapeutic maneuvers in tet spells
Administering 100% O2
Calming the child and placing in parent’s arms
Flexing the child’s knees to the chest in order to incresae VR and incraese systemic vascular resistance to mitigate right-to-left shunting
2nd-line intervention in tet spells
Morphine
Isotonic fluid (5-10 mL/kg bolus) to increase preload
Sodium bicarbonate (2 mEq/kg) to promote pulmonary vasodilation
Propranolol
Phenilephrine
Acyanotic CHD that cause shock
Severe coarctation of the aorta
Critical aortic stenosis
Hypoplastic left ventricle
Cyanotic CHD that cause shock
TGA
Pulmonary atresia
Hypoplastic right heart syndrome
Essential to diagnosis a coarctation
Decreased pulses in the lower extremities
Most common form of aortic stenosis
biscuspid aortic valve
Williams’ syndrome
Supravalvular aortic stenosis
Elfin facies
Mental retardation
Pumonary artery stenosis
An ashen or gray color is charateristic of the infant with
left-sided outflow obstruction in systemic shock
Charateristic of hypoplastic left heart syndrome
a single heart sound
Heard in aortic stenosis
harsh systolic murmur transmitted to the neck
Oxygen in shock in CHD
Oxygen is a potent pulmonary vasodilator and decrases right-to-left flow through the ductus arteriosus, potentially worsening systemic perfusion
Oxygen is also a vasoconstrictor of the ductus arteriosus, which further worsens perfusion
Single most important therapeutic intervention for duct-dependent lesions
Infusion of IV prostaglandin E1 to restore ductal patency and improve left-to-right shunting and systemic blood flow
Dosing of prostaglandin E1
0.1 mcg/kg/min
Improvement occurs within minutes
Subsequent titration to lowest effective dosage is recommended, typically 0.05 mcg/kg/min
In shock in CHD, sepsis cannot be excluded on clincial grounds, so also give
ampicillin 100 mg/kg
gentamicin 4mg/kg
or cefotaxime 50-100 mg/kg
Treatment strategies in CHD patients in shock
Prostaglandin E1
Fluid boluses with careful reassessment
Antibiotics
Strongly associated with down syndrome
endocardial cushion defects
Pathognomonic with endocardial fushion
Superior QRS axis
with RVH, RBBB LVH, and prolonged PR interval
Hallmarks of congestive heart failure with elevated left-sided pressure
pulmonary rales and increased work of breathing
Mainstays of treatment in congestive heart failure in CHD
Furosemide 1-2 mg/kg IV
For diuresis and inotropic support
Oxygen in CHF in CHD
Oxygen saturation of >95% may cause pulmonary vasodialtion and worsen CHF in overcirculating lesions such as VSD and PDA
For patients in CHF in stable condition, this is the inotrope of choice
Digoxin
improves cardiac contractility and output
Digoxin is less helpful in the acute setting as it takes time to reach theraputic levels
The digitalizing dose is administered how?
Half given as initial IV bolus
1/4 in the next 6-12 hours
1/4 in the next 6-12 hours
