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Multidisciplinary Congenital heart disease understood Quality Education for a Healthier Scotland Multidisciplinary Objectives Understand physiology and relate to clinical findings Quality Education for a Healthier Scotland Facts and Figures Multidisciplinary • Congenital Heart Disease (CHD) – incidence 8:1000 live births • 4:1000 are symptomatic • Up to 60% of neonates have a murmur at some stage • Up to 1.6% have murmur at routine exam. • 54% of babies with murmurs have CHD • Routine neonatal examination fails to detect more than half of babies with CHD • Normal examination does not exclude CHD Quality Education for a Healthier Scotland Purpose of Screening for CHD Early identification before failure or hypoxia develop Prevention of irreversible damage Remember heart rate and rhythm Quality Education for a Healthier Scotland Multidisciplinary Multidisciplinary Quality Education for a Healthier Scotland Normal cardiac circulation Quality Education for a Healthier Scotland Multidisciplinary Postnatal Anatomy and Function (picture from British Heart Foundation – www.bhf.org.uk) Quality Education for a Healthier Scotland Multidisciplinary Congenital Heart Problems Multidisciplinary Cyanotic Congenital Heart Disease = blue Acyanotic Congenital Heart Disease = pink Cardiac Arrhythmias – fast or slow Quality Education for a Healthier Scotland Multidisciplinary Why Cyanosis / blue? Low or no pulmonary blood flow - less oxygen picked up Transposition streaming Complete intra-cardiac mixing i.e mixed blue and pink Quality Education for a Healthier Scotland Low pulmonary flow Quality Education for a Healthier Scotland Multidisciplinary Separate streaming of blue and pink blood – transposition great arteries Quality Education for a Healthier Scotland Multidisciplinary Tetralogy of fallots Quality Education for a Healthier Scotland Multidisciplinary Cyanotic Congenital Heart Defects •Tricuspid Atresia •Pulmonary Atresia •Transposition of the Great Arteries (7%) •Tetralogy of Fallot (10%) •Total Anomalous Pulmonary Venous Drainage Quality Education for a Healthier Scotland Multidisciplinary Cyanotic summary Not pick up enough oxygen Mix blue and pink blood Quality Education for a Healthier Scotland Multidisciplinary Acyanotic Congenital Heart Defects ie. pink Ventricular Septal Defect (25%) Atrial Septal Defect (7%) Atrio-ventricular Septal Defect Patent Ductus Arteriosus (12%) Coarctation of Aorta Aortic Stenosis (5%) Pulmonary Stenosis (5%) Quality Education for a Healthier Scotland Multidisciplinary Ventricular septal defect Quality Education for a Healthier Scotland Multidisciplinary Aortic stenosis Quality Education for a Healthier Scotland Multidisciplinary Congenital Arrhythmias Multidisciplinary Irregular Rhythm – atrial or ventricular extrasystoles Bradycardia – sinus bradycardia, congenital heart block Tachycardia – supraventricular tachycardia Quality Education for a Healthier Scotland Prior to Examination Multidisciplinary Note family history Note maternal drug/alcohol/illness history Note antenatal pointers to cardiac abnormality eg. Scan reports, high risk of Down’s Syndrome, irregular fetal heart Parents view of baby’s well being Ensure baby’s comfort Quality Education for a Healthier Scotland Examination of Cardiovascular System • • • • • • • • Colour ( Dysmorphic features ) Respiratory rate and effort Palpation of apex beat Palpation for thrills and heave Heart rate and rhythm Heart sounds and murmurs Peripheral pulses Quality Education for a Healthier Scotland Multidisciplinary Murmurs Multidisciplinary • Timing – pan systolic, ejection systolic, continuous, diastolic • Intensity – graded 1-6 • Location – maximal intensity and radiation • (May be innocent – quiet and short at left sternal edge with no accompanying symptoms or signs) Quality Education for a Healthier Scotland Site of Murmurs Multidisciplinary Quality Education for a Healthier Scotland Abnormal Symptoms • • • • • • Feeding difficulties Poor Colour Dyspnoea Restlessness Lethargy Sweating Quality Education for a Healthier Scotland Multidisciplinary Abnormal Signs • • • • • • • • • Poor colour or cyanosis Tachypnoea Displaced apex beat Hyperdynamic praecordium Thrill or heave present Abnormal cardiac rate or rhythm Added heart sounds or murmurs Poorly palpable or absent peripheral pulses Hepatomegaly Quality Education for a Healthier Scotland Multidisciplinary Referral pathway • • • • Refer registrar or ANNP Assessment of well-being and saturations echo telelink? Seek feedback Quality Education for a Healthier Scotland Multidisciplinary CONTROVERSIES Should saturation monitoring be part of routine assessment? Prevent Mortality and Morbidity Estimate MISS 50% Only Detect Hypoxia- Blue Duct Dependant Lesions more critical Routine antenatal screening picks up most and introduced to practise Multicentre UK study to assess benefits Quality Education for a Healthier Scotland Multidisciplinary “pulseOx test accuracy study” Multidisciplinary Multi-centre study to recruit 20,055 Saturations before discharge or 24 hours If less than 95% - examine and repeat Access to reliable echo and follow up 53 major CHD with 24 critical. 34 known from antenatal screen Sensitivity= 75% for critical and 49% for major Miss low output e.g aortic stenosis Lancet august 2011, issue 9793,p 785-794 WWW.HTA.AC.UK/1624 Quality Education for a Healthier Scotland Summary Multidisciplinary • Newborn examination is an opportunity to identify CHD early • Normal examination does not exclude CHD • Cardiac assessment includes consideration of family and antenatal factors as well as clinical examination • Symptomatic babies may require urgent referral for further assessment • If in doubt … ASK FOR HELP Do not be afraid to refer Quality Education for a Healthier Scotland