peds cardiology

what normally occurs in the CV system at birth?

foramen ovale closes as pressure of left atrium exceeds pressure in right atrium, ductus arteriosus closes in the presence of increased oxygen concentration

what to know about cardiac assessment?

hx (family hx, prenatal hx, birth hx, developmental milestones), exposure (infections, environmental teratogens), presentation (HR, RR, diaphoresis, pain)

what is a rare symptom when assessing potential congenital heart defects?

chest pain

how to check BP when assessing for any abnormalities?

compare upper and lower extremity BPs → if there is a 20 pt difference between the two, there could be an aortic arch anomaly

where is the point of maximal impulse on children?

under 6 yrs: fourth intercostal space, over 7 yrs: left sternal border at fifth intercostal space

what are the s/s of congenital heart defects in neonates?

central cyanosis, heart murmur, tachypnea, resp distress, CHF, signs of poor cardiac output, abnormal heart rhythm → timing of presentation depends on where and how severe the defect is

what are some physical indications of cardiac defects?

failure to thrive, small for gestational age, poor weight gain, dysmorphic features, chest wall deformities, clubbing

when is pulmonary artery banding used?

in small neonates and early infants where there is excessive pulmonary blood flow and they are unable to withstand heart surgery → puts small band around pulm artery but sometimes doesn’t help

what are the four classifications of congenital heart defects?

incr pulmonary blood flow, decr pulmonary blood flow, obstructive disorders, mixed disorders

what are some disorders that cause CHD incr pulmonary blood flow?

patent ductus arteriosus, atrial septal defects, ventricular septal defects → abnormal connections through septum or great vessels that incr blood volume in right side of heart to incr pulm blood flow and decr systemic blood flow

what are some disorders that cause CHD decr pulmonary blood flow?

tetralogy of fallot, tricuspid atresia, eisenmenger syndrome

what are some CHD obstructive cardiac disorders?

coarctication of the aorta, aortic stenosis, pulmonary stenosis, pulmonary atresia, TOF with PA

what are some CHD mixed disorders?

transpotision of the great vessels, truncus arteriosus, total anomalous pulmonary venous return, hypoplastic left heart

what are the two problems that occur when the alveoli are flooded?

bloodstream can’t get enough oxygen and body is unable to get rid of CO2

what is patent ductus arteriosus?

where the vessel connecting the aorta and pulmonary artery stays open after birth causing left to right shunting (from aorta to pulm artery)

what would you see/hear on assessment for patent ductus arteriosus?

murmur (smaller hole, louder murmur), crackles, tachypnea, incr work of breathing, poor weight gain/growth pattern → managed with NSAIDS, surgical ligation, coil occlusion

what diagnostics are used for patent ductus arteriosus?

wide pulse pressures, enlarged heart, prolonged cap refill, hyperactive precordium

interventions for patent ductus arteriosus?

provide frequent rest periods, do not cluster care, strict I&Os, fluid restrictions, thrombocytopenia, daily weights

what are atrial septal defects?

allows for blood to flow from right side to left atrium; incr pulm blood flow → left to right shunting

assessment findings for atrial septal defects?

murmur, atrial dysrhythmias, emboli, resp infections, poor weight gain, liver enlargement → managed with digoxin, diuretics, surgical trans-septal closure

diagnostics for atrial septal defects?

imaging will show enlarged heart (right side will be enlarged/thickening of muscle), CHF may develop, left to right shunting

interventions for atrial septal defects?

frequent rest periods, monitor for CHF, decr WOB, track growth pattern

what are ventricular septal defects?

most common defect; hole between ventricles causing left to right shunting incr pulm blood flow causing decr pulmonary compliance (stiffening of lungs with ineffective ventilation)

assessment for ventricular septal defect?

asymptomatic, murmur, thrill, incr WOB, feeding difficulties → tx when 6-12 months and 2 kg in weight with surgical repair

diagnostics for ventricular septal defects?

large left atrium, left sided cardiomegaly, incr pulmonary vasculature → want to give freq rest periods, monitor for CHF, decr WOB, track growth pattern

what are some characteristics of tetralogy of fallot?

3rd most common lesion, non-ductile cyanotic heart defect, associated with 22 deletion chromosomal disorders like DiGeorge and down syndroms, most often in males, results in right to left shunting (cyanotic)

assessment findings for tetralogy of fallot?

tet spells (sudden episodes of cyanosis leading to syncope, hypoxic brain injury, death), cyanosis with irritability, clubbing, poor growth → manage with vasopressors, O2 to reduce pulm vasoconstriction, may require multiple surgeries

diagnostics for tetralogy of fallot?

wide pulse pressures, enlarged heart, boot shaped heart, prolonged cap refill, hyperactice precordium, right to left shunting → want to cluster care, provide calming environment, natural sleep/wake cycle, tet positioning (also use prostaglandin E to keep patent duct art open)

assessment findings for coarctation of the aorta?

few symptoms, murmur, decr femoral pulses, BP higher in upper ext, HTN in older children, dyspnea, diaphoresis → want to manage CHF, severity of symptoms dictate timing of repair

diagnostics for coarctation of the aorta?

newborn congenital heart defect testing may be normal, echo will show severity of narrowing, cardiomegaly, “3” sign on x-ray → give frequent rest periods, decr WOB, obtain 2-4 extremity BPs to compare

what is most important to maintain with transposition of the great vessels?

maintaining a patent ductus arteriosus via administration of PGE

assessment findings for transposition of the great vessels?

cyanosis, O2 sat lower in upper extremities, murmur, tachypnea, s/s of CHF

diagnostics for transposition of the great vessels?

heart looks like egg on a string, hyperoxia test (measuring ABGs of pt while on room air then measuring again after breathing 100% O2 for 10 mins)

what is a hyperoxia test used for?

to distinguish a congenital heart defect from pulmonary disease → CHD usually won’t get PO2 above 100 but pulm artery disease can usually get to 100

interventions and management for transposition of the great vessels?

maintain preductal pulseox >75% and monitor CHF → tx with PGE, digoxin, diuretics, ACE inhibitors, beta blockers, inotropes, surgical repair

what is hypoplastic left heart syndrome?

underdevelopment of the left side of the heart leading to pulmonary venous congestion and edema → fatal within first days of life unless treated

assessment for hypoplastic left heart syndrome?

asymptomatic until ducts close, tachypnea, dyspnea, difficulty feeding → want to maintain venous access, create artificial airway, and anticipate transport

diagnostics for hypoplastic left heart syndrome?

incr pulmonary blood flow and decr systemic blood flow → need to administer PGE to keep duct open and anticipate surgical repair or transplant

how does prostaglandin E1 (PGE) work?

maintains PDA by relaxing smooth muscle, increases pulmonary blood flow, improves blood oxygenation, and perfusion to lower body → dosing requires large vein or umbilical venous catheter

what are some characteristics of kawasaki disease?

leading cause of acquired heart defects, multisystem disease, primarily affects kids 5 and younger, not contagious or congenital, dx of exclusion → thought to be caused by infective organisms seen seasonally late winter/early spring

what causes the mortality of kawasaki disease?

results from scarring or stenosis in main coronary arteries or MI that’s related to coronary thrombosis

what is crash & burn for kawasaki disease?

conjunctivitis, rash, adenopathy, strawberry tongue, hands (rash on palms/feet) → s/s last longer than 5 days and include fever over 38.5 (burn)

assessment for kawasaki disease?

crash & burn for 5+ days, joint pain, prolonged immobility → will see high WBC, dx through exclusion; want to get baseline EKG

what are interventions and management for kawasaki disease?

maintain venous access, monitor CHF, symptom relief → manage with high-dose salicylate, gamma globulin, prevention of complications (MI, coronary artery aneurysm, valvular regurgitation, myocarditis, pericarditis)

what are some important things to discuss with caregivers prior to discharge?

compliance with meds/dr visits, positioning to prevent tet episodes or causing damage to open heart wounds, adequate nutrition via frequent smaller feeds, activity tolerance, coming to terms with prognosis, supporting caregivers