Cardiology Approach to Pediatric Cardiac Patients PDF

Cardiology : Approach to Pediatric cardiac patient HENOK TADELE, MD ASSISTANT PROFESSOR OF PEDIATRICS AND CHILD HEALTH  Learning Objectives List common symptoms of cardiac dysfunction in children list the cardinal steps of cardiac physical exam and what to look for in ped...

Cardiology : Approach to Pediatric cardiac patient HENOK TADELE, MD ASSISTANT PROFESSOR OF PEDIATRICS AND CHILD HEALTH  Learning Objectives List common symptoms of cardiac dysfunction in children list the cardinal steps of cardiac physical exam and what to look for in pediatric patient. List common investigation for Pediatric cardiac patient and know their significance. list the basic classification of congenital heart disease  History Postnatal history:  weight gain, development, and feeding pattern  Symptoms of heart failure in infants and children are age specific.  In infants, feeding difficulties are common.  In older children, heart failure usually presents with exercise intolerance.  History cont’d  cyanosis, “cyanotic spells,” and squatting Cyanosis: - the onset (at birth, several days after birth?), - severity of cyanosis, permanent or paroxysmal nature - parts of the body(e.g., fingers, toes, lips), and whether the cyanosis becomes worse after feeding A “cyanotic spell” is seen most frequently in infants with tetralogy of Fallot and requires immediate attention tachypnea, dyspnea, and puffy eyelids - are signs of congestive heart failure  Frequent lower respiratory tract infections.  chest pain : is a common reason for referral and parental anxiety. It is unusual presentation of cardiac problem.  syncope is an unusual presentation  Palpitation - is a subjective feeling of rapid heartbeats.  joint symptoms : migratory in nature and involving large joints (acute rheumatic fever)  A history of stroke suggests thromboembolism secondary to cyanotic congenital heart disease with polycythemia or infective endocarditis  medications : cold medications or antiasthmatic drugs  Family History  hereditary disease: marfan’s syndrome, Holt- Oram syndrome  congenital heart disease(CHD): The incidence of CHD in the general population is about 1%. A history of CHD in close relatives increases the chance of CHD in a child. In general, when one child is affected, the risk of recurrence in siblings is about 3%, which is a threefold increase.  hypertension and atherosclerosis - Essential hypertension and coronary artery disease show a strong familial pattern  rheumatic fever - There is a higher incidence of the condition among relatives of rheumatic children.( Genetics)  Physical examination  Inspection : do not disturb  General appearance and nutritional state: distress, well nourished or undernourished.  chromosomal syndromes: Down syndrome and others.  color: cyanosis, pallor or jaundice  clubbing  respiratory rate, dyspnea, and retraction  sweat on the forehead  Vital signs: PR\RR\BP\sao2\Toc  Physical exam cont’d Inspection of the chest - Precordial bulge, with or without actively visible cardiac activity, suggests chronic cardiac enlargement - substernal thrust indicates the presence of right ventricular enlargement - an apical heave is noted with left ventricular enlargement - Apical impulse - Pigeon chest (pectus carinatum) - Pectus excavatum(undue depression of the sternum) - Harrison's groove  Palpation: - Thrill and Heave Auscultation - Heart sounds: The heart sound should be identified and analyzed before the analysis of heart murmurs. Muffled and distant heart sounds are present in pericardial effusion and heart failure.  A gallop rhythm is a rapid triple rhythm resulting from the combination of a loud S3, with or without an S4, and tachycardia. pericardial friction rub pericardial knock  Each heart murmur must be analyzed in terms of - intensity (grade 1 to 6) - timing (systolic or diastolic) - location - Transmission - quality (musical, vibratory, blowing, and so on).  Abnormal Physical Findings In Neonates Cyanosis which does not improve with the administration of oxygen Decreased or absent peripheral pulses in the lower extremities suggest Coarctation of aorta. Irregular cardiac rhythm and abnormal heart rate Heart murmur Hepatomegaly Tachypnea  Investigation Chest X-ray - Cardiac size and shape - Pulmonary blood flow (vascularity) - Pulmonary edema, and associated lung and thoracic anomalies - When the maximal cardiac width is more than half the maximal chest width (cardiothoracic ratio >50%), the heart is usually enlarged. CXR Pictures: “boot-shaped”\ “egg- shaped”\ “snowman”  Investigation cont’d Electrocardiography Hematologic Data: polycythemia Echocardiography Exercise Testing Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) Diagnostic and Interventional Cardiac Catheterization  Fetal and perinatal circulation Changes at birth : An increase in systemic vascular resistance Cessation of blood flow in the umbilical vein resulting in closure of the ductus venosus reduction of the pulmonary vascular resistance (PVR) Functional closure of the foramen ovale  Evaluation of the Infant or Child with Congenital Heart Disease i. congenital cardiac defects can be divided into 2 major groups based on the presence or absence of cyanosis. (cyanotic or acyanotic) ii. chest radiograph shows evidence of increased, normal, or decreased pulmonary vascular markings iii. ECG: right, left, or biventricular hypertrophy Acyanotic Congenital Heart Lesions A. Lesions Resulting in Increased Volume Load - atrial septal defect, ventricular septal defect (VSD), AV septal defects (AV canal), and patent ductus arteriosus. b. Lesions Resulting in Increased Pressure Load - valvular pulmonic stenosis, valvular aortic stenosis, and coarctation of the aorta  Cyanotic Congenital Heart Lesions a. Cyanotic Lesions with Decreased Pulmonary Blood Flow - tricuspid atresia, tetralogy of Fallot, and various forms of single ventricle with pulmonary stenosis b. Cyanotic Lesions with Increased Pulmonary Blood Flow - Transposition of the great vessels - Truncus arteriosus