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Transcript
Paediatric cardiology A survival guide Topics to cover • • • • • • Murmurs Cardiac failure Cyanosis ECG – long QT Chest pain Pictures Examination • • • • • • 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 • • • • • • • • • 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 • 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 • • • • 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