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Flashcards in Peds Cardio Deck (52)
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What Heart Sound is this?

•Respiratory inspiration:

↑ blood flow to right heart

↑ blood into RV

Delays emptying of RV

Prolongs the closure of S2

S2:  Pulmonary Component



What abnormal heart sounds are these 5 assocaited? 

1.Widely Split-Electrical delay (RBBB), VSD repair (TOF)

2.Fixed Split- Volume overload (ASD)

3.Narrowed Split Pulmonary hypertension (loud S2)

4.Paradoxical Split-Electrical delay (LBBB)

5.Single  Complex heart defect (TGA) or single ventricle defect (only 1 semilunar valve)




Abnormal S2 Sounds




What are the Inspiratory, Expiratory, and Both Sound Splits?



Inspiration: Normal Split, Narrow Split

Expiratory: Paradoxical

Both: Wide and Wide Fixed



What are the Other Adventitious Heart Sounds?

S3 Sound 

Best heard at apex

Rapid ventricular filling/volume overload

Pregnancy, MR/TR

Common variant in children


S4 Sound

Low pitch sound in late diastole

Best head at apex

Obstruction, ↓ ventricular compliance


Hypertension, cardiomyopathy

Pulmonary stenosis



What does a Friction rub mean?







What are the 3 innocent Murmurs?



•Still’s murmur

•Venous hum murmur 

•Peripheral pulmonary stenosis




What are the 3 Pathologic Murmurs









How can you Eval Murmurs?


1.Timing of cardiac cycle


3.Grade, intensity



Neck > aortic stenosis

Back > pulmonary valve stenosis

Axilla > peripheral pulmonary murmur

6. Positional changes




What Murmur grade are thrills present?



4/6 and above




How can you Evaluate Murmurs?



•Standing position: ↑ Hypertrophic cardiomyopathy,↑ Mitral valve prolapse,↓ Aortic stenosis

•Valsalva:↓ Innocent heart murmur, ↑ HCM

•Standing & Valsalva ↓ all murmurs, except… (↓ blood flow to left heart)


What Murmur is this?


Most common innocent heart murmur

•3 – 6 years of age

•Normal EKG 

Low frequency, musical, vibratory sound

•LMSB, LLSB, apex

•Loudest in supine position & stress (fevers)

•Changes intensity with sitting position

•Outgrow in adolescent years

•No echocardiogram needed



Still's Murmur


What Murmur is this?


AKA cervical hum murmur

•3 – 6 years of age 

Turbulence due jugular venous drainage

•Continuous murmur (right side > left side)

•Base of the heart

•Diastolic component louder than systolic

•Loudest with upright position

•Decreased with supine or turning neck

•No echocardiogram needed




Venous Hum Murmur


What type of Cyanosis is this?


•Normal saturations & PaO2

•Normal transitional newborn physiology



Peripheral Cyanosis


What Cyanosis is this?


•Blue lips, tongue

•Low saturations

•Low saturations & PaO2

•Congenital heart defect



Central Cyanosis


What type of Cyanosis is this?


Benign variant

Vasospasm of small arterioles

•Normal pulses

•No oxygen desaturations

•No pathological murmur









What are the 3 Fetal Circulation Shunts?



Ductus venosus

Foramen ovale

Ductus arteriosus



What Shunt is this?

•Post-natal can provide pulmonary of systemic BF

Functional closes 12-90 hours

•Anatomically closes 2-3 weeks



Patent Ductus Arteriosus


PDA helps Mix blood. What color is the baby?


1) Clue to congenital heart defect, PDA closing


2) Poor prognosis: intracardiac shunt closed, Need PGE to open PDA


3) PDA patency open, Palliation to provide PBF or systemic blood flow, Saturations 75-90%


1) Blue Baby


2) Grey Baby


3) Blue or Purple Baby



What are Congenital Heart Defect Sxs?

Think DNA nucleotides (ATGC)


1.Tachypnea: (L-R shunt), CXR: pulmonary edema, cardiomegaly

2.Cyanosis: (R-L shunt or obstruction to lungs), “Blue baby” = Cyanosis

3.“Grey baby”: (↓ or no systemic blood flow), Poor perfusion, Lactic acidosis


What are the 4 Congenital Heart Defects?

* associations*


2) TOF, TGA, TA (X2)

3) PS, COA




1) Acyanotic Defects

2) Cyanotic Defects

3) Obstructive Defects

4) Complex heart defect/ signle ventricle



What type of CHD?


Usually left-to-right shunt

Considered a “volume load” on the ventricles

The ventricle is carrying additional cardiac output

Volume loading dilates the ventricles (and atria)

No prostaglandins (PGE) are required to treat!



Acyanotic Defects




What are the Left -to- Right Shunting Sxs?

(think low CO)


* Large ASDs may be Asymptomatic*




•Poor feeding

•Exercise intolerance

•Poor growth



What type of Septal Defect is this?


•5-10% of all heart defects (relatively common)

•Can be seen as a part of more complex defects

•Can occur in several locations of the atrial septum

•Up to 25% of US population may have a patent foramen ovale (PFO - This is not and ASD)

RA, RV & PA can become enlarged as a result of _____



Atrial Septal Defect (ASD)



What Septal Defect has these Physical Exam Findings?

Precordial bulge

Hyperdynamic precordium


•Normal S1

Fixed split of S2

Grade 2-3/6 systolic ejection murmur at LUSB

•May hear diastolic “rumble” at RLSB

•Exam is similar to Still’s murmur, but doesn’t change with position

•EKG may have right axis deviation & right ventricular conduction delay



Atrial Septal Defect (ASD)




What is the Treatment for Atrial Septal Defect (ASD)?





Surgey to repair the defect

*Pulmonary vascular disease, arrhythmias, embolic events*



What is the Most common congenital heart defect?

•Most are small and asymptomatic

•Defects can occur within any part of the _________septum

•Muscular (most common)


•Conal septal hypoplasia

•Malalignment, AV canal type



Ventricular Septal Defect (VSD)



This defect (if moderate to large) can cause Death, Hepatomegaly, or diaphoresis with feeding.

May become irreversible during childhood



Ventricular Septal Defect (VSD)



What CHD is most commonly seen in premature newborns and newborns with primary pulmonary HTN.

Seen with hypoplastic left heart syndrome and pulmonary atresia.

May be seen in patients who are asymptomatic with a continuous murmur.

Closes within 72 hours of birth.



Patent Ductus Arteriosus (PDA)




Cause of cyanosis in newborn with lower ext sats < upper ext sats with R-L shunt is _____until proven otherwise. Continuous “machinery-like” murmur at LUSB/axilla


*requires mandatory pulse-ox screening of both RUE and LLE*



Patent Ductus Arteriosus (PDA)




Treatements for what CHD?

•Preemies:  NSAIDs and ductal ligation

•Small in older child that is audible:  coil/device occlusion, ductal ligation

•Rationale is to reduce risk of endocarditis

Incidentally found an non-audible:  no treatment needed



Patent Ductus Arteriosus (PDA)




What are the 5 Ts of Cyanotic Heart Defects?

T/F: do you treat with prostoglandins (PGE)?

Tetralogy of Fallot (TOF)

Transposition of the great arteries (TGA)

Truncus arteriosus

Total anomalous pulmonary venous return (TAPVR)

Tricuspid atresia


TRUE: all require PGE tx




When do you prescible PGEs?


•Blue or Grey baby

•5 cyanotic heart defects

•Obstruction to lungs or systemic blood flow

•Abnormal CXR, EKG, ABG (acidosis, low PaO2)

•Failure to improve with oxygen 

•Failed pulse oximetry testing




What condition arise from one embryologic malformation– anterior malalignment of conal septum

Has 4 abnormalities: VSD, PS/RVOT, Overriding Aorta, RVH




Tetralogy of Fallot (TOF)



What CHD is this?

•Patients with minimal pulmonary annular hypoplasia or RVOT obstruction may present similar to those with large VSD



Tetralogy of Fallot (TOF)



These Physical Exam findings suggest what CDH?

Harsh systolic LUSB

•Blue TET (severe)

•Pink TET (less severe)

•CXR: boot shaped

•Associated with DiGeorge syndrome



Tetralogy of Fallot (TOF)


What is this Spell, and what disease is it associated with?

* baby's fingers and toes turn blue*


•Cyanotic spells, Spasms of the RVOT infundibular muscle, Loss of systolic heart murmur

•Intervention: Keep infant calm, Oxygen, Volume (NS bolus)

•Maneuvers:, ‘Knee to chest’

•Sedation:, Morphine

•Medications:, Propranolol 



TET Spells in TOF




How do you treat TOF?



Ductal-dependence- Provider preference (early repair vs. delayed/staged repair)



What CHD is this?

•State of parallel circulation: Oxygenated blood is recirculated through the lungs

- vicious cycle of hypoxemia and acidosis (sat 40-60%)

- Death is imminent unless mixing occurs (PFO, VSD or PDA)

•Physiology:  pulmonary artery saturation > aortic saturation

•VSD present in about 40% patients

•Coronary abnormalities found in about 33% patients

•Tx:  Arterial switch operation



Transposition of the Great Arteries (TGA)



What CHD is this?

•Comprised of aortic arch abnormalities, VSD, coronary artery % conductive system abnormalities

•Associated with DiGeorge syndrome

Heart failure symptoms develop in the first several weeks of life

•Diagnosed by echocardiography

•Tx:  surgical repair



Truncus Arteriosus



What type of stenosis is this?

•Often occurs as isolated condition

•PE:  Harsh systolic ejection murmur at LUSB, with a click

•May be soft in newborns despite severe stenosis


•Cyanosis will not occur unless there is an intracardiac R-L shunt

•This is seen with PFO, ductus



Pulmonary Stenosis (PS)




How do you treat Pulmonary Stenosis and Aortic Stenosis



Balloon valvuloplasty



What CHD is this?


Narrowing of aortic isthmus, Pressure load on LV, Systolic murmur at the precordium

•↓ LE pulses

•Blood pressures: > 20mmHg

•↑ upper extremity

•↓ lower extremity

• Severe (shock, ↓ renal perfusion)

•PGE used to treat

•Associated bicuspid aortic valve & Turner syndrome



Coarctation of the Aorta (COA)


What CHD is this?


•Associated with bicuspid aortic valve at Systolic ejection murmur @ RUSB

•Diastolic murmur apex may be heard

•Association with COA

•EKG: LVH (strain)

•Echo:  concentric LV hypertrophy

•Severe/critical (present in shock)

•PGE (maintains systemic BF)




Aortic Stenosis


What CHD is this?

•Complete mixing of systemic and pulmonary venous return blood within the atria

•Usually there is obstruction of pulmonary or systemic blood flow




Hypoplastic Left Heart Syndrome (HLHS)




Why do providers do a Cardiac Sports Screening?

What is the pathology?

What Sport is most assocaited with SCD?



Preventing sudden cardiac death!






Does the USA require Routine EKGs?






What cardiac disease is this?

Autosomal dominant, Family history of SCD

•Disarray of hypertrophic myocardial cells

•Concentric hypertrophy with a stiffness of LV

Impaired diastolic filling

Preserved systolic function

•↑ ventricular arrhythmias

Restricted from sports



Hypertrophic Cardiomyopathy (HCM)




What is this Syndrome?


•Aortic root dilation

•Aortic root rupture

•Mitral valve prolapse






What is this disease?

All children universally screened between 9 & 11 years of age - Lipid Panel 

Risk factors: Obese, Fx of CAD, Acanthosis, HTN

Referral: TC > 200 or LDL > 130 TG > 200

Treatment: Diet, exercise, weight loss - Statin (10 years of age)




Pediatric Dyslipidemia



What disease is this?

High spiking fevers > 5 days

•Swelling extremities, Peeling of fingers or toes, Polymorphous exanthema 

Bilateral conjunctival injection (no exudate)

•Changes lips & mouth (lips cracking, strawberry tongue, red mouth)

•Unilateral cervical lymphadenopathy


Sterile pyuria

•↑ LFTs



Kawasaki Disease




How do you treat Kawasaki Disease?




•High dose ASA