Cardiac Disorders (Peds)

Risk factors of congenital heart defects

1. exact cause unknown

2. maternal diabetes

3. maternal PKU

4. alcohol consumption

5. family history of defects

-will get fetal echos

6. chromosomal anomalies such as down syndrome

Acyanotic heart defects

-HF symptoms and pink skin

1. defects with increased pulmonary blood flow

2. obstructive defects

defects with increased pulmonary blood flow

1. Atrial septal defect (ASD)

2. Ventricular septal defect (VSD)

3. Patent ductus arteriosus (PDA)

Obstructive defects

1. Coarctation of the aorta

2. Aortic stenosis

3. Pulmonic stenosis

Cyanotic heart defects

- HF symps and signs of poor perfusion; blue skin

1. defects with decreased pulmonary blood flow

2. mixed defects

defects with decreased pulmonary blood flow

Tetralogy of Fallot

mixed defects

1. Transposition of the great vessels

2. hypoplastic left heart syndrome

Artial Septal Defect

Abnormal opening between the atria, allowing blood to flow higher pressure left atrium and lower pressure right atrium

-causes increased flow of oxygenated blood to right side of heart

-3 types with diff locations of whole

Manifestations of atrial septal defects

1. often asymptomatic with spontaneous close in young pts with small defects

2. larger hole= more symps

3. can lead to heart failure if undiagnosed

4. systolic murmur with fixed second sound

5. risk of developing atrial dysrhythmias, pulmonary vascular obstructive disease, and emboli later in life

Ventricular septal defects

abnormal opening between the ventricles

- small pinhole to absense of septum

-blood flows through defect to pulmonary artery and then pumped into lungs from increased pressure

-will spontaneous close in first year of life in small defects

manifestations of ventricular septal defects

1. Heart failure is common

2. risk of endocarditis

3. loud holosytolic murmur heard at the left sternal border

Patent Ductus arteriosus (PDA)

failure of the fetal ductus arteriosus (artery connecting the aorta to the pulmonary artery) to close within the first weeks of life

-causes right to left shunt

Patent ductus arteriosus (PDA) manifestations

1. amount of shunting determines degree of symps

2. machinery like murmur

3. widening pulse pressure

4. bounding pulses

5. may be asymptomatic

6. may show signs of HF

coarctation of the aorta

narrowing near the ductus arteriosus which results in increased pressure to the upper extremities and decreased pressure to the lower extremities

manifestations of coarctation of the aorta

1. high blood pressure and bounding pulses of the upper extremites

2. weak or absent femoral pulses with lower BP and cool extremities

Infants vs older children manifestations for coarctation of the aorta

1. infant-> HF, severe acidosis and hypotension

-mechanical ventilation and inotropic support may be needed before sugery

2. older children-> dizziness, headache, fainting, epistaxis, hypertension

-risk for ruptured aorta, aortic aneurysm (watch for rupture), and stroke

Postop care for coarctation of the aorta

1. monitor for hypertension

2. may need IV treatment followed by PO of ace inhibitors or beta blockers

aortic stenosis

narrowing of the aortic valve

-decreased cardiac output

-left ventricular hypertrophy

-pulmonary vascular congestion (pulmonary edema)

aortic stenosis manifestations

1. faint pulses

2. hypotension

3. tachycardia

4. poor feeding

5. exercise intolerance

6. chest pain

7. dizziness when standing

8. systolic ejection murmur

9. risk of endocarditis

pulmonic stenosis

narrowing of pulmonic valve

-causes ventricular hypertrophy and decreased pulmonary blood flow

pulmonic stenosis manifestations

1. may be asymptomatic

2. mild cyanosis

3. HF

4. loud systolic ejection murmur

5. cardiomegaly on chest Xray

6. risk of endocarditis

Tetralogy of Fallot

congenital malformation involving four distinct heart defects

- VSD, PS, overriding aorta, and right ventricular hypertrophy

manifestations of tetralogy of fallot

1. acutely cyanotic at birth or cyanosis that progresses in first year of life

2. loud systolic ejection murmur

3. tet spells

4. anoxic spells

5. risk for emboli, seizures, and sudden death

Transposition of the great arteries

Aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle

-septal defects and PDA may present

manifestations of transposition of the great vessels

1. cyanotic at birth

2. depressed function

3. HF symps

4. cardiomegaly

-vary depanding on type and size

hypoplastic left heart syndrome

underdevelopment of the left side of the heart

manifestations of hypo plastic left heart syndrome

1. mild cyanosis

2. signs of HF until PDA closes which leads to increased cyanosis and decreased cardiac output

3. usually fatal

Heart failure

inabillity of the heart to pump sufficient blood to meet body's needs

general symptoms of HF

early= tachycardia, tachypnea, fatigue, irritability

late= hypotension, weak pulses, pale/cool extremities, and decreased urinary output

Right sided HF manifestations

systemic

1. edema

2. enlarged organs *hepatomegaly

3. weight gain

4. JVD (older children)

5. ascites

6. anorexia or GI distress

Left sided heart failure

pulmonary symptoms

1. respiratory distress

2. dyspnea

3. retrations

4. nasal flaring

5. wheezing

6. cyanosis

7. activity intolerance

diagnosis of Heart failure

1. chest xray (cardiomegaly)

2. ECG

3. echocardiogram

Meds given for HF

1. digoxin

2. ace inhibitors

3. beta blockers

-improve cardiac fcn

4. diuretics

- remove fluid and sodium

Management of HF

1. fluid restriction-> space fluids through shift; small cups that are full

2. sodium restriction-> if increased edema; no added salts, soups, salad dressings

3. semi fowlers and energy conservation

4. cool humidified oxygen

5. feedings q 3 hrs, half hour for feeding, increased caloric needs

6. stroke cheek to promote sucking

7. premie nipple to decrease energy

8. if resp rate > 80 hold feedings and use gavage feedings

9. daily weights for retained fluid and abd circumferences for ascites

10. may give potassium-> has to be in pump or mixed if liquid

11. 1 mL/kg/hr urine output

hypoxemia vs hypoxia

hypoxemia is low oxygen in the arterial blood and hypoxia is low oxygen in the tissues resulting in low O2 stat

manifestations of hypoxemia

1. polycythemia -> increased RBCs making blood thicker

2. clubbing of nails

3. tet spells

-rarely seen before 2 mos

- occur in morning after feeding, crying, or stressfull procedures

4. cyanosis with low O2 stats

If a patient is having a tet spell...

1. place in knee-chest position or squat

2. remain calm

3. administer 100% O2 via blowby

4. morphine

5. iv fluids

managing hypoxemia

1. prostaglandin E for vasodilation and smooth muscle relaxation

2. monitor for anemia

3. prevent dehydration by giving Iv fluids as this can increase already viscous blood

4. treat pulm infections with chest PT, antibiotics etc

Postop care for congenital heart defect pts

1. VS for 1 full minute

2. lung auscultation

3. hypothermia expected immediately after

4. A-line may be in place to measure direct arterial blood pressure

-lots of drainage can indicate hemorrhage

5. may have chest tube in place or require suctioning

6. fluid restriction

7. watch HR and RR with activity

Rheumatic Fever

autoimmune response to untreated strep, leading to inflammation of heart joints and brain

diagnosis of rheumatic fever

-Jones' criteria

-- 2 or more major symptoms

OR

--1 major & 2 minor with evidence of strep

- will have elevated ESR and CRP but just indicate inflammation is present

--if improving will come down

Major symptoms of rheumatic fever

1. carditis -> tachycardia, cardiomegaly, muffled heart sounds, pericardial friction rub, new or chaned murmur

2. polyarthritis -> red, hot painful swollen joints

3. chorea -> sudden, irregular involuntray p disturbances

4. erythema marginatum rash -> circular, nonpruritic rash

5. subq nodules on bony prominences

minor symptoms of rheumatic fever

1. fever

2. arthralgia (joint pain)

3. elevated ESR or CRP

4. prolonged PR interval on ECG

evidence of strep

1. positive throat culture

2. rapid strep test

3. elevated ASO strep antibody titer lab test

prevention of rheumatic fever

1. strep tests for culture and treatment if positive

2. treat with penicillin and take all antibiotics until gone

3. long term prophylactic antibiotics to prevent future infections for 5 years or until 21; 10 years to 21 if carditis; 40 yrs or indefinite if carditis and residual heart defect

treatment of carditis from rheumatic fever

1. corticosteroids

2. activity restriction until fever subsides, then can resume full activity

3. adequate rest

treatment for polyarthritis from rheumatic fever

salicylates (aspirin)

infective endocarditis

bacterial infection of the endocardium especially involves the valve tissues

manifestations of endocarditis

1. unexplained fever, anorexia and weight loss

2. splinter hemorrhages-> black lines in fingernails

3. osler nodes-> painful red intradermal nodes on fingers

4. HF, dysrhythmias, or change in murmur

5. petechiae of mucosa, conjunctiva, or extemities

6. janeway lesions-> painless hemorrhagic spots or palms/soles

diagnosis of infective endocarditis

1. blood cultures-> show inf in blood stream

2. echocardiogram -> shows infection in heart

3. ESR/CRP elevated -> go down when symptoms resolve

Treatment of endocarditis

1. high dose IV antibiotics for 8 wks after cultures

2. frequent echos

3. prophylactic antibiotics before procedures

4. valve replacement if unresponsive to treatment

Kawasaki Disease

acute systemic vascular inflammation

acute phase of kawaski disease

1. fever 102-106 unexplained, >5 days, unresponsive to antipyretics

2. irritability

3. increased platelets, increased WBCS, increased LFT and increased ESR/CRP

4. edema, erythema of palms and soles

subacute phase of kawaski disease

1. starts resolution of fever

2. ends with total symp resolution

3. desquamation of palms and soles

-risk of coronary aneurysm, thrombosis, and MI

convalescent phase of kawasaki disease

symptoms resolved but labs do not normalize

-for 6 to 8 wks

diagnosis criteria for kawaski disease

febrile for >5 days with 4 or 5 of these criteria

1. changes in extremities (erythema or desquamation)

2. bilateral conjunctival inflammation

3. erythematous lips or strawberry tongue

4. rash

5. unilateral cervical lymphadenopathy

Cardiac Involvement with kawaski disease

1. aneurysms -> found on follow up echos

-watch for rupture

2. MI-> abd pain, n/v, restlessness, crying, pallor, chest pain

Treatment for Kawasaki disease

IVIG and aspirin

- deferred from live vaccines for 11 months after IVIG

-shut off if allergic reaction

management of kawaski disease

1. may have skin discomfort when new skin grows after desquamation

- cool cloths and lotions

2. mouth is swollen

-use lip lubricants, clear liquids and soft foods

3. get daily temps for first 1-2 wks after discharge

4. I&Os and daily weights

5. irritability may persist for 2 months

-maintain a quiet enviornment

-normal to be difficult to console

6. passive ROM

digoxin

1. increases cardiac contractility for increased cardiac output

2. apical pulse for 1 min prior to administration

3. hold if infants pulse below 90 and 70 in children

4. monitor theraupeutic blood level and K level

5. hypokalemia increases risk of toxicity

6. hyperkalemia diminishes digoxin effects

digoxin toxcity

1. blurred/halo vision in older children

2. N/V

3. anorexia

4. dysthymias

5. bradycardia

ACE inhibitors

1. block the conversion of angiotension I to angiotension II allowing vasodilation, decreasing BP

2. monitor BP before and after treatment; hold if hypotensive

3. can cause hyperkalemia

4. do not give with potassium supplements or spiraloctone

5. end in -pril

side effects of Ace inhibitors

1. hypotension

2. cough

3. renal dysfunction (BUN + creatine increase)

4. hyperkalemia

Beta blockers

1. cause decreased HR, BP and vasodilation

2. check BP and pulse prior and after administration

3. hold if hypotensive or bradycardic

4. end in -lol

side effects of beta blockers

1. dizziness

2. headache

3. hypotension

furosemide (lasix)

1. blocks reabsorption of sodium and water causing exerction of NA and K

2. used for severe heart failure

3. monitor I and O

4. watch for dehydration

5. foods high in potassium or potassium supplements

-mix in liquid or pump for IV

foods high in potassium

1. bananas

2. oranges

3. whole grains

4. legumes

5. leafy vegetables

side effects of furosemide

1. N/V

2. diarrhea

3. ototoxcity

4. hypokalemia

-watch for digoxin toxcity

5.dermatitis

6. postural hypotension

Chlorothiazide (Diuril)

1. causes hypokalemia and acidosis by decreasing absorption

2. monitor I &O and electrolyes

3. encourage foods high in potassium or give supplements

side effects of chlorothiazide

1. N/V

2. weakness

3. dizziness

4. paresthesia

5. muscle cramps

6. skin eruptions

7. hypokalemia and acidosis

spironolactone (aldatone)

1. blocks action of aldosterone which promotes retention of sodium and excretion of potassium

-often used with thiazide or furosemide

2. monitor I&O and electrolyes

3. do not give potassium supplements or with ACE inhibitors