* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Ask Doctor Clarke
Survey
Document related concepts
Cardiovascular disease wikipedia , lookup
Electrocardiography wikipedia , lookup
Aortic stenosis wikipedia , lookup
Antihypertensive drug wikipedia , lookup
Heart failure wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Coronary artery disease wikipedia , lookup
Hypertrophic cardiomyopathy wikipedia , lookup
Myocardial infarction wikipedia , lookup
Mitral insufficiency wikipedia , lookup
Cardiac surgery wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
Lutembacher's syndrome wikipedia , lookup
Atrial septal defect wikipedia , lookup
Dextro-Transposition of the great arteries wikipedia , lookup
Transcript
Ask Doctor Clarke in association with BMA Careers Paediatric Cardiology Paediatric cardiology • Examination of the cardiovascular system • Acyanotic congenital heart disease: ventricular septal defect, atrial septal defect and patent ductus arteriosus • Cyanotic congenital heart disease: Fallot’s tetralogy • Down’s syndrome and the heart Extras: post course notes on • Kawasaki’s disease • Heart failure • Rheumatic heart disease • Co-arctation • Transposition of the great arteries • Subacute bacterial endocarditis Examination of the cardiovascular system M Radford: with permission Approach to examination • Wash hands, introduce yourself and ask permission • Look: scars, clubbing, oxygen, breathlessness, cyanosis, respiratory rate, activity, JVP • Feel: pulses, praecordium, liver • Listen: heart, lung bases • Finally thank child and parents and wash hands Please note • It is reasonable to perform auscultation first while the child is quiet • “Babies don’t have a neck” so check for enlargement of liver instead of assessing the JVP Auscultation: question stop What causes the first and second heart sounds? Normal heart sounds lub dub ventricular systole © Dr R Clarke 2012-2013 www.askdoctorclarke.com diastole 6 Ask Doctor Clarke in association with BMA Careers Normal splitting of the second heart sound • During inspiration, there is an increase in the negative intra-thoracic pressure • This increases venous return from the body into the right atrium • And therefore increases the volume of blood to be ejected by the right ventricle • Causing a slight delay in the closure of the pulmonary valve (P2) Lub dub Lub Inspiration de Expiration Wide fixed splitting of the second heart sound with an atrial septal defect (ASD) Lub splat Lub Inspiration splat Expiration Please note • You are not expected to diagnose wide fixed splitting of the second sound! • It is a subtle sign and many paediatricians have never heard it • This is why it is much harder to diagnose ASDs compared with VSDs • But it is still useful to be aware of this sign as it is often asked about in exams Pansystolic murmur: “burrr” no gap between murmur and HS2 lub dub Pansystolic murmur © Dr R Clarke 2012-2013 www.askdoctorclarke.com diastole 7 Ask Doctor Clarke in association with BMA Careers Ejection systolic murmur: “burr de” audible gap between mumur and HS2 lub dub diastole ventricular systole Murmurs: above or below the nipple line? Radiates to neck Radiates to back Aortic stenosis Pulmonary stenosis PDA machinery murmur Ejection systolic above VSD (MR) Pansystolic below The Nipple Line Continuous murmur: BurrrDurrr lub dub diastole © Dr R Clarke 2012-2013 www.askdoctorclarke.com 8 Ask Doctor Clarke in association with BMA Careers Four useful sounds • ASD (Lub splat) • Pansystolic murmur (Burrr) • Ejection systolic murmur (Burr de) • Machinery murmur (BurrrDurrr) Innocent murmurs • Heard at some time in about 25% of children • Soft ejection systolic murmur at left sternal edge • May occasionally sound harsh • No radiation to carotids and no thrills • No symptoms • Often heard with fever (tachycardia with increased cardiac output) The 7 S’s • Short • Soft • Systolic • S1 & S2 normal • Standing and sitting variation • Symptomless and • Special tests normal (ECG, CXR, Echo) Fetal Circulation Placenta Umbilicus Umbilical vein Joins inferior vena cava Ductus venosus Two umbilical arteries From internal iliac arteries SVC SVC Pulmonary veins IVC Pulmonary veins IVC Foramen ovale Right atrium Right ventricle Left ventricle Ductus arteriosus Pulmonary artery Crosses Foramen ovale Left atrium Oxygenated blood from umbilical vein (via ductus venosus and IVC) Aorta Pulmonary artery Ductus arteriosus Aorta Fetal circulation • In utero, oxygenated blood is provided by placenta • Fetal lung is bypassed by most circulating blood • High pulmonary blood pressure means blood follows alternate path via: • Foramen ovale (from RA to LA) • Ductus Arteriosus (from PA to aorta) © Dr R Clarke 2012-2013 www.askdoctorclarke.com 9 Ask Doctor Clarke in association with BMA Careers Normal transition At birth first breath triggered by • Hypoxia secondary to cord clamping • Stimulation SVC Pulmonary veins IVC RA Air drawn into lungs • Oxygen is powerful pulmonary vasodilator • Large drop in pulmonary blood pressure RV LA LV Blood redirected through lungs Ductus closes within a day or two Pulmonary artery Aorta Congenital Heart Disease (CHD) • Commonest congenital malformation • Approx 1% of live births • 10% of stillbirths have cardiac lesions • VSD and PDA are the commonest abnormalities Classification of CHD • Acyanotic: ASD, VSD, PDA, pulmonary stenosis, aortic stenosis, co-arctation • Cyanotic: Tetralogy of Fallot, transposition of the great arteries J Peterson: with permission Central cyanosis Blueness occurs when there is more than 5g/dl de-oxygenated haemoglobin If not anaemic, this will usually occur with an oxygen saturation of 85% or less Acyanotic congenital heart disease Three left-to-right shunts • VSD • ASD • PDA Ventricular Septal Defect (VSD) • Common: 30% of CHD • Sometimes diagnosed antenatally if a good four chamber view is obtained on ultrasound • Variable size • Loudness of murmur inversely related to size of shunt SVC Pulmonary veins IVC VSD Buzz words If large, a VSD may cause “a left to right shunt at ventricular level” Pulmonary artery Aorta Student report “My case was examination of a 3 year old with a VSD” © Dr R Clarke 2012-2013 www.askdoctorclarke.com 10 Ask Doctor Clarke in association with BMA Careers Small VSD • High velocity jet with loud “blowing” or “rasping” pansystolic murmur • May have a thrill, but no significant left to right shunt • Increased risk of endocarditis • Often close spontaneously before age 5 • Differential diagnosis: other pansystolic murmurs eg mitral and tricuspid regurgitation Large VSD • Typically presents with heart failure at 4-6 weeks • Breathless and sweaty on feeding or crying • May also be a cause of faltering growth or • Recurrent chest infections Large VSD: on examination • Left parasternal heave (due to right ventricular hypertrophy) • Quiet or absent pansystolic murmur • Pulmonary ejection murmur • In other words, signs of pulmonary hypertension Typical case: small VSD • Blowing pansystolic murmur at lower left sternal edge • With an associated thrill • But no right ventricular heave or signs of heart failure VSD investigations • ECG- right ventricular hypertrophy (dominant R wave in V1) • CXR- cardiomegaly, prominent pulmonary artery and plethoric lung fields • Echo- shows size of lesion and doppler flow may indicate size of shunt VSD treatment • None if small • Antibiotic prophylaxis controversial • NICE (2008) do not recommend it, but many paediatric cardiologists do! • Diuretics and ACEI for heart failure • Repair if large defect with risk of pulmonary hypertension • No need for antibiotic prophylaxis once repaired and “endothelialised” Atrial septal defect • May be asymptomatic • Recurrent chest infections or heart failure • Arrhythmias common in 30s and 40s (SVT and AF) • Flow across the defect itself does not create a murmur (as low pressures in atria) • Isolated ASD: low risk of endocarditis and antibiotic prophylaxis not needed (NICE 2008) Buzz words If large, an ASD may cause “a left to right shunt at atrial level” SVC Pulmonary veins IVC ASD Pulmonary artery © Dr R Clarke 2012-2013 www.askdoctorclarke.com Aorta 11 Ask Doctor Clarke in association with BMA Careers Wide fixed splitting of the second heart sound Delayed P2 Lub splat Lub Inspiration splat Expiration ASD treatment • Trans-catheter closure (via femoral vein and IVC to right atrium) or • Open heart surgery with patch repair • Before 5th birthday Patent ductus arteriosus (PDA) • 12% of CHD cases • Second commonest after VSD • Commoner in premature babies (kept open by hypoxia) • Normally closes within a day or two of birth • If persists, left to right shunt occurs as right sided pressures fall with lung expansion SVC Pulmonary veins IVC Patent ductus arteriosus Pulmonary artery Aorta PDA: on examination • Collapsing pulses: the shunting leads to extra blood flow through the lungs and hence extra blood returning to the left of the heart (volume overload) • Extra blood ejected from LV causes high systolic pulse pressure • Rapid “run-off” through the ductus leads to low diastolic pressure • Auscultation: continuous “machinery” murmur • Loudest below left clavicle and radiates to back BurrrrDurrr lub dub diastole PDA: treatments • Prostaglandin synthetase inhibitor (eg indometacin infusion) • Transcatheter occlusion • Surgical ligation © Dr R Clarke 2012-2013 www.askdoctorclarke.com 12 Ask Doctor Clarke in association with BMA Careers Cyanotic CHD SVC www.doctortipster.com Fallot’s tetralogy P pulmonary stenosis causing R right ventricular hypertrophy O over-riding aorta; R to L shunt across V VSD E ejection systolic murmur- pulmonary Pulmonary veins Aorta displaced to the right IVC LA Pulmonary stenosis VSD RA Right to left shunt through VSD due to pulmonary stenosis LV RV Pulmonary stenosis Aorta RV hypertrophy “Unfolded” “Folded” On examination • Clubbing and cyanosis • Right ventricular hypertrophy • Ejection systolic murmur Buzz words “Right ventricular outflow tract obstruction” “Infundibular pulmonary stenosis” Ie not just the valve that is narrow, the outflow tract just below the valve is affected Patent ductus in Fallot’s • Cyanotic spells often become apparent around day 2 or day 3 when the ductus closes • In 1944 Dr Helen Taussig noted that babies with a persistent patent ductus lived longer than those without • She thought an operation to create a similar shunt into the pulmonary artery would help • She persuaded Alfred Blalock to perform the first shunt operation Poem The aorta’s displaced to the right Squashing the PA so tight Where can the blood go? There’s right to left blood flow Across the septum- that’s right (Ventricular hypertrophy for you) SVC Pulmonary veins IVC Right to left shunt through VSD due to pulmonary stenosis Pulmonary stenosis Patent ductus bypasses obstruction Surgery • Two stage procedure • Shunt operation to increase pulmonary flow in order to help develop the pulmonary arteries, which have been “starved” of blood flow by the stenosis; improves oxygenation • Followed by definitive correction © Dr R Clarke 2012-2013 www.askdoctorclarke.com 13 Ask Doctor Clarke in association with BMA Careers Down’s syndrome and the heart Down’s syndrome: face R Round face O Occipital flattening (& nasal flattening) S Speckled iris (Brushfield spots) E Epicanthic folds O Open mouth with protruding tongue L Low set ears A Almond (oval) upward slanting eyes Hands: single transverse palmar crease, short fingers, curved little finger (clinodactyly) Strabismus (squint) Brushfield spots on iris Epicanthic fold Feet: sandal gap between big toe and other digits Flat bridge of nose Open mouth Protruding tongue Duodenal atresia “Double bubble” Down’s syndrome • Hands: single transverse palmar crease, short fingers, curved little finger (clinodactyly) • Feet: sandal gap between big toe and other digits • Increased risk of: duodenal atresia, squint, hypothyroidism, leukaemia, Hirschprung’s • 40-50% have a cardiac abnormality: all should have an echo at time of diagnosis Down’s syndrome associated with • ASD • VSD • Atrioventricular canal defect (low ASD and high VSD) • Mitral and tricuspid valve regurgitation Buzz words • “Endocardial cushion defect” • Leads to “failure of septation” of the heart • “AVSD” LA v RA RV LV Endocardial Cushions divide the heart into left and right; and into atria and ventricles Student report “Examine this child’s cardiovascular system. He was aged 2, with a systolic murmur. I was asked about Eisenmenger’s syndrome.” Question stop Eisenmenger’s syndrome refers to the process of shunt reversal- why does this happen? © Dr R Clarke 2012-2013 www.askdoctorclarke.com 14 Ask Doctor Clarke in association with BMA Careers Shunt reversal • Large shunt leads to pulmonary artery hypertension • As this develops, the degree of left to right shunting gets less which may lead to initial improvement in heart failure symptoms • Finally, the right sided pressures are so high that right to left shunting occurs causing cyanosis • This is called the “Eisenmenger syndrome”, causing acquired cyanotic heart disease • Only treatment option at this stage is heart-lung transplantation SVC Pulmonary veins IVC Reversed shunt Right ventricular hypertrophy Aorta Pulmonary artery hypertension Post Course Notes Post course notes on • Kawasaki’s disease • Heart failure • Rheumatic heart disease • Co-arctation • Transposition of the great arteries • Subacute bacterial endocarditis • Understanding splitting of the second sound in ASD • Making sense of Fallot’s • Prostaglandins and the ductus Case history This 3 year old has had a prolonged fever. She has developed a rash on her hands and feet which is now starting to peel. What is the likely diagnosis? What cardiac complication may occur? © Dr R Clarke 2012-2013 www.askdoctorclarke.com 15