Exam 2: Pedi/OB: Heart

What is pediatric heart failure (congestive heart failure)?

Impaired myocardial function in children, usually caused by a structural abnormality of the heart that leads to the heart's inability to pump blood effectively.

What are the signs and symptoms of impaired myocardial function in pediatric heart failure?

Tachycardia, exercise intolerance, respiratory distress, sweating, weakness, weak pulse, anorexia, anxiousness, restlessness, and clubbing of nails from chronic hypoxia.

What are the signs and symptoms of pulmonary congestion in pediatric heart failure?

Tachypnea, dyspnea, exercise intolerance, wheezing, grunting, and retractions.

What are the signs and symptoms of systemic venous congestion in pediatric heart failure?

Weight gain, hepatomegaly, edema, ascites, and neck vein distention.

How is pediatric heart failure diagnosed?

Based on signs and symptoms, chest X-ray (CXR), echocardiogram (ECHO), CT or MRI, electrocardiogram (EKG), and cardiac catheterization.

What are important nutrition guidelines for a child with heart failure?

Feed in a relaxed environment, allow time away from other activities, provide frequent feedings every 3 hours, hold the child upright while feeding, limit feedings to 30 minutes, use nasogastric (NGT) feeding if oral intake is insufficient, use higher calorie formula if needed, and monitor for tachypnea, diaphoresis, and emesis as signs of feeding intolerance.

What medication improves contractility and cardiac output in pediatric heart failure?

Digoxin (Lanoxin); always take the apical pulse for 1 full minute before administering.

What medication reduces afterload and makes it easier for the heart to pump in pediatric heart failure?

ACE inhibitors (angiotensin-converting enzyme inhibitors); they promote vasodilation, decrease pulmonary and vascular resistance, and lower blood pressure.

What medication removes excess fluid and sodium in pediatric heart failure?

Diuretics, with furosemide (Lasix) being the drug of choice; monitor for dehydration and hypokalemia.

What are the four defects in Tetralogy of Fallot?

Pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect (VSD).

What are the signs and symptoms of Tetralogy of Fallot?

"Tet" or hypercyanotic spells, systolic murmur, polycythemia, dyspnea, tachypnea, cyanosis, and clubbing of fingers.

What is the treatment for Tetralogy of Fallot?

Palliative shunt and staged surgical repairs, preferably performed within the first year of life.

How do you manage a hypercyanotic (Tet) spell?

Place child in a squatting or knee-chest position to decrease pulmonary vascular resistance and reduce the right-to-left shunt, administer oxygen, give morphine SQ or IV (or fentanyl) to relieve heart spasm, keep the child calm and comforted, provide IV fluids or volume expansion if needed, and administer sodium bicarbonate if acidosis occurs.

What is Kawasaki Disease?

An acute systemic vasculitis of unknown cause that involves small and medium blood vessels and may cause dilation, aneurysm, or infarction; inflammation usually subsides in 6-8 weeks.

What are the diagnostic criteria for Kawasaki Disease?

There is no specific test; the child must have a high fever lasting more than 5 days plus 4-5 of the following clinical criteria: (1) changes in extremities (acute phase: erythema of palms/soles; subacute phase: desquamation of hands/feet), (2) bilateral conjunctival infection without exudate, (3) oral mucous membrane changes, (4) polymorphous rash, (5) cervical lymphadenopathy.

What diagnostic tests are used for Kawasaki Disease?

Echocardiograms to monitor cardiac status and laboratory tests for inflammation.

How is Kawasaki Disease managed?

Administer immune globulins (IVIG) and salicylate therapy, provide symptom relief, continuous oxygen, and cardiac monitoring.

What are the phases of Kawasaki Disease and their features?

Acute phase (10-14 days)

High fever lasting 5 days or more, conjunctivitis, desquamation of soles/palms, oral changes (cracked lips, strawberry tongue), and irritability.

Subacute phase (15-25 days)

Greatest risk for coronary aneurysm formation.

Convalescent phase (26 days-8 weeks)

Symptoms resolve, but myocardial infarction is the most serious complication.

What are the common signs and symptoms of Kawasaki Disease?

Bilateral conjunctival injection without exudate, high fever >5 days unresponsive to meds, oral mucous changes (red lips, strawberry tongue), cervical lymphadenopathy, polymorphous rash, erythema of palms/soles followed by peeling, and prolonged irritability for several months.

What is Acute Rheumatic Fever (ARF)?

An inflammatory disease affecting collagen tissue of the heart, joints, CNS, and subcutaneous tissue caused by an abnormal immune response to Group A strep infection.

What is the most significant complication of Acute Rheumatic Fever?

Valve damage leading to rheumatic heart disease (in about 50% of cases).

What increases the risk for developing Rheumatic Fever?

Increased or untreated infections and co-infections with Group A strep.

How is Acute Rheumatic Fever diagnosed?

Physical exam, lab tests (elevated ESR, CRP, ASO titer), echocardiogram, and Jones criteria.

What is the prevention for Acute Rheumatic Fever?

Prompt diagnosis and complete treatment of Group A strep infections.

How is Acute Rheumatic Fever treated?

Treat strep infection, administer salicylates or steroids to reduce inflammation, bedrest until murmur and labs (ESR, CRP) improve, maintain good nutrition and hydration.

What is the prophylactic treatment for preventing recurrence of Rheumatic Fever?

Intramuscular benzathine penicillin G every 28 days for 5 years or until age 21 (whichever is longer). Alternative: oral penicillin or erythromycin daily.

How long should prophylactic treatment continue for Rheumatic Fever?

Without carditis- 5 years or until age 21 (whichever is longer). With carditis- 10 years or until age 21 (whichever is longer).

What are the Jones criteria for diagnosing Rheumatic Fever?

Diagnosis requires 2 major criteria or 1 major + 2 minor criteria, plus proof of recent strep infection (positive ASO titer or culture).

What are the major criteria for Rheumatic Fever?

Carditis (murmur often first sign), polyarthritis, erythema marginatum, chorea, and subcutaneous nodules.

What are the minor criteria for Rheumatic Fever?

Arthralgia, fever, elevated ESR/CRP, prolonged PR interval on EKG, and leukocytosis.

What is a Ventricular Septal Defect (VSD)?

An abnormal opening between the ventricles where oxygenated blood from the left ventricle is shunted to the right ventricle and recirculated through the lungs.

What are the signs and symptoms of a Ventricular Septal Defect?

Loud murmur at the left sternal border, cardiomegaly, congestive heart failure, respiratory distress, and increased risk for complications later in life.

How is a Ventricular Septal Defect treated?

Surgical repair with a Dacron patch for large defects, sutures for small defects (may close spontaneously), and palliative pulmonary banding as needed.

What can a Ventricular Septal Defect lead to if untreated?

Congestive heart failure or Eisenmenger's syndrome (pulmonary hypertension).

What is an Atrial Septal Defect (ASD)?

An abnormal opening between the atria where blood is shunted left to right, often due to a patent foramen ovale.

What are the signs and symptoms of an Atrial Septal Defect?

Murmur, may be asymptomatic, possible congestive heart failure, and increased lifetime risk of pulmonary disease, pulmonary embolism, or dysrhythmias.

How is an Atrial Septal Defect treated?

Surgical patch closure or nonsurgical cardiac catheterization with septal occluder (usually before school age), followed by low-dose aspirin therapy for 6 months post-op.

What is Aortic Stenosis?

Narrowing or stricture of the aortic valve causing obstruction of left ventricular outflow and decreased cardiac output.

What are the signs and symptoms of Aortic Stenosis?

Murmur, faint pulses, hypotension, tachycardia, poor feeding (infants), exertional dyspnea, fatigue, exercise intolerance, and pulmonary hypertension.

How is Aortic Stenosis treated?

Balloon dilation or surgical valve replacement.

What is the difference between congenital and acquired heart disease in children?

Congenital heart disease is present at birth and caused by structural defects; acquired heart disease develops after birth due to infections, autoimmune processes, or other conditions.

What are the signs and symptoms of congenital heart disease?

May be subtle or absent early on; cyanosis lasting longer than 3 hours after birth, murmur (grade I-VI), persistent tachycardia, poor oxygen perfusion (clubbing), grunting, retractions, tachypnea, hypoxia, dyspnea or cyanosis during feedings, activity intolerance, failure to thrive or poor weight gain, recurrent respiratory infections, risk for endocarditis, and positive family or prenatal history.