Download Paediatric cardiology

Paediatric cardiology
A survival guide
Topics to cover
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Murmurs
Cardiac failure
Cyanosis
ECG – long QT
Chest pain
Pictures
Examination
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Growth – poor or too rapid?
Pulse – rate, character
RR
Is there a murmur?
Is there a liver?
Are femorals palpable?
– Radio-femoral delay cannot be detected < 10 years
• BP – cuff must cover > 2/3 upper arm
1. Murmurs
• 50% of kids have “innocent” murmurs,
usually with intercurrent illness
Innocent
• Mid-systolic
• Soft: “musical”
• Localised: no radiation
• Change with posture
Murmur
When to refer
• Child under 12
months
• Child is dysmorphic
• Additional heart
sounds
• Loud murmur
• Diastolic murmur
2. Cardiac failure
Congestive
Underlying pathology – congenital heart
disease or arrhythmia
Acute
Fortunately rare
< 3 months – duct-dependent lesion
> 3 months - myocarditis
Duct-dependent lesions
Coarct (TGA, critical AS, critical PS, pulm artery
stenosis with intact VSD)
PGE1 causes apnoea, hyperglycaemia, jitteriness so
intubate early
Myocarditis
Very easy to mistake for
bronchiolitis
• Respiratory viruses that attack
myocardium NB enterovirus 71 2013
• May have URTI prodrome – croup,
vomiting
• Look out for:
– Tachycardia
– +/- Tachypnoea +/- creps
– Liver may be normal
Acute cardiac failure
• Poor feeding,
lethargic
• Look grey
• Feel cold
• Tachypnoeic + creps
• Tachycardic
• Big liver +/- murmur
• Poor peripheral
pulses
Differential diagnosis
Sepsis
• BUT fluids will make
worse!
Management
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Oxygen
Intubate early
IO access
(Bolus)
CXR
Continuous ECG monitoring
(Troponins, EUC)
IV Frusemide 1mg/kg
Babies - consider
Prostaglandin E1
• Inotropes – Dopamine +
Dobutamine
Congestive cardiac failure
• Underlying congenital defect eg VSD
– + worsening condition
– + LRTI exacerbation
• O/e Growth, HR, cardiac size - ?P2, RR –
creps?, liver, peripheral oedema
Management
• Medical
– Feed – calories
– Diuretics – Frusemide +/- Spironolactone +/- ACEi
• Surgery - ideally at 10Kg
3. Cyanosis
• Clinically detectable at sats 85%
– Post-natal baby check at birth and 6 weeks
• Most cases diagnosed
– NB Pink Fallot
Fallot tetralogy
1. VSD
2. Stenosis of
pulmonary artery
3. RV hypertrophy
develops
4. Over-riding aorta
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As RV thickens
When to worry
Complications
• Growth – adequate if sats 85-95%
• Polycythaemia – CVA
• Gastroenteritis
• Worsening cyanosis
– Blocked BT shunt, Tet spell
Dehydration
• Be generous with fluids!
• Monitor for cardiac failure
• Monitor neurological signs
Worsening cyanosis
• Find out what are their “usual sats”
Treatment
• Give oxygen to maintain
• Treat any dehydration
• CXR, ECG
• Consult cardiologist
Tet spell
• Periodic cyanosis due to infundibular
spasm; progressing to cardiovascular
collapse
Treatment
• Give oxygen
• Give IV Morphine
• Discuss with cardiologist about IV betablockade
4. ECGs
• T waves inversion until 12 years
• Age-dependent values for axis, PR, QTc
QTc
• Under 6 months = <0.49s
• Over 6 months = < 0.44s
Perform an ECG
• First afebrile seizure
• Collapse with exercise, particularly
swimming
• Over 2 syncopal episodes in 2 years
SVT
• Commonest paediatric non-arrest
arrhythmia
Distinguish from sinus tachycardia
• Infants rate > 220
• If you can see P waves, they are negative
in II, III, AVF
• No beat to beat variability
• Abrupt termination of SVT
Management
• Go to Resus with trolley
• Vagal manouvres - dunk child in ice water,
carotid sinus massage, Valsalva
• Cannulate the biggest vein you can
• Draw up 3 doses of Adenosine in advance
with 10ml flushes
• Warn about side effects
• Start ECG recording as you push
Adenosine
5. Chest pain
• LOTS of parental anxiety
• Usually musculoskeletal – new sport or Wii
Other causes
• Pulmonary - pleuritic
• GI - dyspepsia
• Cardiac – pericarditis, ischaemia, ventricular
ectopics
• Psychosocial
When to worry
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Palpitations
Exercise intolerance
SOB at rest
(Could this possibly be post-Kawasaki??)
• Paediatric PE risk factors – indwelling
CVL; prothrombotic; FHx of thrombosis,
surgery or immobility > 3 days in last
month
Pericarditis
• URTI
• Pain radiating to shoulder
– Improves if lean forward
– Worse if deep breath in
• (Rub, cardiomegaly,
raised JVP)
• CXR, ECG, Troponins
• Treat with NSAIDS
Kawasaki
• Vasculitis, with coronary arteritis
• Kids aged 6 months – 5 years
Symptoms
• Unremitting fever: > 5 days, over 39ºC
• Eyes: non-exudative conjunctivitis with limbic sparing
• Oral mucosa: bright red lips with cracking, strawberry
tongue +/- pharyngitis
• Cervical LN: over 1.5cm bilaterally
• Rash
• Peripheral: hand or foot swelling with erythema
c/o sore throat
Treatment?
Rheumatic fever
Major
• Carditis – new
murmur, pericarditis
• Migratory polyarthritis
• Sydenhams chorea –
emotional lability
• Erythema marginatum
• Subcut nodules –
scalp, spine
Minor
• Polyarthralgia
• Fever
• Raised ESR or CRP
• Prolonged PR interval
• Positive throat swab,
or ASOT/DNase B
• History of RF or RHD
Summary
• Key features of examination
– Murmurs, liver, femorals, growth, ECG
• Life-threatening presentations
– Acute cardiac failure, Tet spells, SVT
• What to worry about
– Dehydration in congenital cardiac disease
– Myocarditis
– Kawasaki