Pediatric Considerations in Cardiology Part 2 Lecture PDF

Pediatric Considerations in Cardiology Part 2 Principles and Practices of Osteopathic Medicine II Thomas Chan D.O. Associate Professor Department of Clinical specialties [email protected]  Session Objectives 1. Students will be able to recognize signs and symptoms suggestive of ca...

Pediatric Considerations in Cardiology Part 2 Principles and Practices of Osteopathic Medicine II Thomas Chan D.O. Associate Professor Department of Clinical specialties [email protected]  Session Objectives 1. Students will be able to recognize signs and symptoms suggestive of cardiac issues in infants 2. Student will be able to discuss factors which suggest an innocent murmur vs a murmur that needs further evaluation 3. Student will be able to identify clinical, anatomical, and physiologic aspects of atrial septal defects (ASD) and ventricular septal defects (VSD) 4. Student will be able to identify clinical, anatomical, and physiologic aspects of other acyanotic congenital heart lesions including A-V Canal, Patent ductus arteriosus, and Coarctation of the aorta 5. Student will be able to identify clinical aspects of specific cardiac arrhythmias- Supraventricular tachycardia, Prolonged Q-T syndrome, and Congenital heart block in infants 2  Infants with possible cardiac problem History Physical Poor weight gain/ Failure to thrive Prenatal Hx Congenital defects/ Malformations Tachypnea Tachycardia/ Bradycardia Feeding difficulty- Prolonged Murmurs Poor perfusion Central cyanosis Sweating with Pale/grey/ poor perfusion feeding Absent/Delayed femoral pulse Quality of pulses Irritability Respiratory issues- infections/ wheezing Hepatomegaly Color change- pale or blue  Principles… Blood flows They are called from high Look, Listen, Vitals for a pressure to low Feel reason pressure No Murmur Growth charts Murmurs don’t doesn’t always matter in always mean mean No Pediatrics cardiac Dz Cardiac Dz 4  Evaluation of Murmurs in Infants/Children Grade 1-6 Where? Don’t forget the back in infants What? Holosystolic, systolic, diastolic, clicks, gallops (S3,S4) Position? Sitting, supine, left lateral decubital 5  Innocent Murmurs Very….very Common Benign history and physical Fever, Anemia may exacerbate murmur Reassurance Common Innocent Murmurs Still Murmur Venous Hum Peripheral/ Branch Pulmonic Stenosis  Stills Murmur Musical/ Vibratory Low pitch SEM Grade 1-3 Increases while supine/ lying down and high flow states Still murmur  Venous Hum From venous return Medium pitch/ Blowing Continuous murmur Upper Rt sternal border/ infraclavicular area Disappears when supine or turning neck  Murmurs suggesting further evaluation Loud (grade 4-6), Harsh qualities, thrills History suggesting a cardiac issue, pul issues, constitutional complaints Other Physical- eg, poor weight gain, doesn’t look well, abnormal vitals  Acyanotic Heart disease Volume load- Left to Rt shunts Obstructive Lesions-pressure load ASD Coarctation of the aorta VSD PDA Valvular Pulmonic A-V canal/ Endocardial Stenosis cushion defect Valvular Aortic stenosis Atrial Septal Defect (ASD) Ostium Secundum defects: most common L  R Shunt Murmur: Loud S1, fixed split S2 (no change with resp) Assoc Fetal Alcohol Syndrome Normal ASD First Aid for the USMLE  ASD Diagnosis Treatment: Usually asymptomatic, hear Watch and wait- murmur spontaneous closures Echocardiogram (small and med) Many go undiagnosed and cause issues much later in Antibiotic prophylaxis life NOT usually recommended Surgical Transcatheter device Ventricular Septal Defect (VSD) Most common L  R Shunt Murmur Holosystolic Assoc with Down Syndrome First Aid for the USMLE  Ventricular Septal Defect (VSD) Symptoms depend on size of VSD and Pul pressures/ blood flow Holosystolic murmur- harsh, blowing, left lower sternal border, thrill (May not have murmur in newborn period) Resp, growth problems, heart failure if mod/large VSD Risk: Eisenmenger Syndrome over long term  VSD Small VSD Large VSD Most small and muscular Control heart failure and ones close spontaneously prevent pul vasc Dz Reassurance/ monitor Tx Medically or surgically clinically in office and Surgical repair excellent regular f/u with cardio prognosis No restrictions in activity No ABX prophylaxis for dental/ surgical procedures  Eisenmenger Syndrome Result of uncorrected L  R shunt over time Volume overload of R heart  increase R sided pressure Shunt REVERSAL from L  R to R L Deoxygenated blood spilling into general circulation  step down in O2  cyanosis International Journal of Cardiology, Volume 177, Issue 1 Complete Atrioventricular (AV) Septal Defect VSD, ASD, & Common AV valve L  R shunt & severe AV regurgitation Result: Volume Overload  excess pulmonary blood flow RA LA Common RV LV CXR: increased pulmonary AV Valve markings & cardiomegaly Assoc Down syndrome Pulmonic Aortic Valve Valve Pulmonary Aort Artery a  A-V canal/ Endocardial cushion defect Murmur: ASD/VSD Rt sided overload Eventual pul HTN leads to Rt to Lt shunting (cyanosis) Eisenmenger Syndrome Surgical Repair Patent Ductus Arteriosus (PDA) Persistent connection between aorta and pulmonary artery L  R shunt: Murmur – Machine like continuous – Thrill 2nd left interspace- radiation down Assoc Congenital Rubella Netter’s Infectious Diseases First Aid for the USMLE Patent Ductus Arteriosus Premies more common- may close on own Term infant with PDA unlikely to close on own Large acts like VSD (L to R shunt) and cause shunt reversal over time Need to close ALL PDA’s that remain open Treatment: Indomethacin (premies), Surgical correction- coils, ligation, umbrellas Coarctation of the Aorta Narrowing of the aorta Juxtaductal – near insertion of Ductus Arteriosus Distal to the aortic arch Lower extremity… Claudication Hypotension (lower BP legs) Absent femoral pulse or Brachial-femoral delay Cyanosis (legs) Upper extremity Hypertension Berry Aneurysm Heart Failure Body Compensates Collateral circulation Intercostal arteries grow  erode ribs (“rib notching” on CXR) Bicuspid Aortic Valve, Turner’s Syndrome Perloff’s Clinical Recognition of Congenital Heart Disease, 6th ed.  Coarctation of the Aorta Diagnosis 4 limb Blood pressure and pulse ox Absent femoral pulse… …or Brachial Femoral delay (palpate together) Varying murmurs (murmur maybe in the back) Older patients Hypertension LVH Rib notching on CXR Stroke  Coarctation Cont…. Turner Syndrome XO Rib Notching- later finding older child/adult Electrical Problems Get an EKG!!!!  Long QT syndrome Sudden Death/SIDS Clinically: syncope (esp after a startle, sudden fright), or with Genetic mutations exercise Romano Ward May present with: Jervell-Lange-Nielsen Palpitations, syncope, (hearing loss) seizures Family history Medications may precipitate/ prolong QT QTc (QT corrected)  Long QT syndrome Malignant arrhythmia Avoid certain Torsades de pointes medications if known Ventricular fibrillation Prolonged QT Any medication needs to be checked and cleared Cardio/ Genetics consult Beta blockers Implantable cardiac defibrillator  Congenital Heart Block- 3rd degree heart block HR TOO SLOW!!! Maternal autoimmune HR- very slow 60-80 disease beats…sometimes Systemic Lupus slower (ventricular Erythematous(SLE) rate) Sjogren syndrome Infants may be Autoimmune injury to asymptomatic fetal conduction Many detected system by IgG intrauterine- fetal Anti-SSA/Ro, anti- echo SSB/La  Neonatal Lupus Syndrome Congenital Heart block Rash http://www.jpgo.org/2014/05/congenital-heart-block-due-to-maternal.html  Supraventricular Tachycardia –SVT HR TOO FAST!!! HR > 180 Bpm Treatment Abrupt onset and Vagal maneuvers cessation Icebag to face- infants Irritable infant, Face in Ice water in restless older Valsalva, carotid Narrow complex QRS massage No discernable P Stable Pts- Adenosine rapid waves IV push Wolf Parkinson White Unstable Pts- synchronized cardioversion association  SVT https://litfl.com/supraventricular-tachycardia-svt-ecg-library/  A 3 year old girl present to the clinic for a well check. Asymptomatic, no complaints, dev appropriate. Growth charts are normal. Picky eater, drinks a lot of milk and not much else. Vitals normal You note a 2/6 SEM, heard best to left side of chest, tricuspid, erbs and mitral areas. Louder when lying down. Nl femoral pulse. Chest clear, no HSM What is the most likely next course of action? Echo ECG Give PGE1 Give Indomethecin Reassure and follow  Question 2 week old male infant presents to the clinic for a follow up weight check. Parents say that he has been fussy and taking over an hour to finish a 3 oz bottle, he will stop every few minutes and seems to be sweating. They say his color is good and he has never turned blue. Weight today is the same as it was at DOL 4 Q: are you worried about this infant? YES PE HR 128, Pox 92%, RR 42, Wt 7lb-2 oz, (BW 7lb-3oz) Alert, NAD Pale color, 4/6 murmur systolic and diastolic, rales to the base posterior chest, mild hepatomegaly, femoral pulse present, no edema What is the most likely diagnosis? Atrial Septal Defect Atrio-Ventricular Canal Transposition of the great vessels Peripheral pulmonic stenosis Coarctation of the aorta  Summary Slide It’s hard to gain Infant sweating while Not all murmurs are weight if you have a taking a bottle is not pathological: Stills, significant heart normal Venous Hum problem Hypertension, absent PDA- Indomethacin to femoral pulses and rib Murmur of an close, Prostaglandin notching- Coarctation ASD?..VSD? to keep open of the Aorta-turner syndrome Too fast: SVT –vagal Fam Hx sudden Too slow: Congential maneuvers, death, syncope, Heart Block- think adenosine, ECG hearing loss: Maternal Lupus findings Prolonged Q-T 33 THE END THANK YOU! =) Lecture Feedback Form: https://comresearchdata.nyit.edu/redcap/surveys/?s=HRCY448FWYXREL4R