Peds Cardio

banannie's version from 2016-02-22 20:45


Question Answer
Fetal alcohol syndromeVSD, ASD, tetralogy of fallot
- Persistent truncus arteriosus
- Tetralogy of fallot
Pregestational maternal diabetesTransposition of the Great Vessels
Congenital rubellaPDA
Down's syndromeASD > VSD
Turner'sCoarctation of the aorta (infantile)
L → R ShuntsAcyanotic LateR: VSD > ASD > PDA
MC congenital heart defectVSD [fetal alcohol syndrome]
How do you close a PDA?Indamethacin
Ostium secundum defectsASD
Wide fixed split S2ASD
Cause of paradoxical embolusUsually ASD
PDADuctus arteriosus fails to close [congenital rubella]
Continuous machine-like murmur
- Inspiratory split S2
Coarctation of the aortanarrowed aorta: infantile comes before the arch, adult comes after the arch
Rib notchingCoarctation of teh aorta:
R → L ShuntsBlue babies:
1. Persistant truncus arteriosus
2. Transposition of the great vessels
3. Tricuspid atresia
4. Tetralogy of Fallot
5. Total anomalous pulmonary venous return
Blood from the RV → Pulmonary artery and aortaTruncus arteriosus fails to divide
Separate pulmonary and systemic systemsTransposition of the great vessels [pre-gestational diabetes]
Rx for transposition of great vesselsPGE to kEEp the ductus arteriosus open until surgery
Tetralogy of FallotPulmonary stenosis
Right ventricle hypertrophy
Overriding aorta
SquattingTetralogy of Fallot: ↑ PVR: ↑afterload ↓ cyanotic R→L shunt
Cause of Tetralogy of FallotAnteriosuperior displacement of the infundibular septum
- Abnormal neural crest cell migration
Tricuspid atresiaAbsent tricuspid valve + hypoplastic RV
- Requires ASD and VSD
MC cause of childhood cyanosisTetralogy of Fallot
Total anomalous pulmonary venous returnPulmonary veins drain into right heart
Boot shaped heartTetralogy of fallot
What congenital heart defects are caused by abnormal migration of neural crest cells?Truncus arteriosus
Transposition of Great Vessels
Tetralogy of Fallot
Severity of Tetralogy of Fallot is determined byDegree of pulmonic stenosis
Degree of RV outflow obstruction affects pressure and therefore direction of shunt
Lower extremity CyanosisPDA
Abnormal Neural Crest migration can causeToF
Transposition of the Vessels
Truncus arteriosus
What embryologic event results in ToF?Abnormal neural crest migration

Cardio principles

Question Answer
Increase PreloadExercise, Transfusion, Pregnancy
What decreases preload?nitroglycerin (dilate veins)
What decreases afterload?vasodilators (dilate arteries ↓ TPR)
What increases contractility?Catecholamines (Beta 1 receptors NE, epi)
What decreases contractility?Heart failure, Beta blockers, Acidosis, Hypoxia, Hypercapnia, Non-dihydropyridine CCB's
What effect do non-dihydropyridine CCB's have on the heart?Decrease contractility [verapamil, diltiazam]
How do you increase COIncrease contractility, Increase preload, Decrease afterload
Ejection fractionNormal >50%
Decreased ejection fractionSystolic HF (normal in diastolic HF)

Heart sounds

Question Answer
opening snapMS
mid systolic clickMVP
Mitral stenosisopening snap with low diastolic rumble
opening snap and low diastolic rumbleMS
crescendo-decrescendo systolic ejection murmurAS
aortic stenosiscrescendo-decrescendo systolic ejection murmur loudest at heart base (R sternal border)
holosystolic high-pitched blowing murmurMR and TR
mitral regurgholosystolic high-pitched blowing murmur radiates toward axilla
tricuspid regurgitationholosystolic high-pitched blowing murmur radiates to R sternal border
mid systolic click followed by systolic murmurMVP
mitral valve prolapsemid systolic click followed by systolic murmur
VSDholosystolic, harsh-sounding murmur
holosystolic low-pitched loud murmurVSD
high-pitched blowing early diastolic decrescendo murmurAortic regurgitation
patent ductus arteriosuscontinuous machine-like murmur loudest at S2 (pulmonic area)
ASDloud S1 with wide, fixed split S2
loud S1 with wide, fixed split S2ASD
machine like murmurPDA
paradoxical splitSplit decreases with inspiration: delayed Aortic valve closure
- AS
wide splitDelayed RV emptying:
- PS
which murmurs are benign?split S1, split S2 with inspiration, S3 < 40 y.o, Early quiet systolic
water hammer or head bobbingAortic regurg
- due to wide pulse pressure aka hyperdynamic circulation
which murmurs are heard best with inspiration?Right sided
- Increase venous return with inspiration
[I in RIGHT for Inspiration]
which murmurs are heard best with expiration?Left sided
- Decrease intrathoracic pressure, Decrease preload
[ E in LEFT for Expiration ]
which murmurs are increased with hand grip?AR and MR (increase SVR increase afterload)
which murmurs are increased with valsalva?hypertrophic cardiomyopathy!!
(increase intrathoracic pressure, decrease afterload)
which murmurs are decreased with valsalva?AS, AR, MS, MR
what murmurs are heard best in left lateral decubitus?mitral (regurg and stenosis), left S3 and left S4
S3Normal in young patients
LV failure in old patients
S4Atria contracting against a stiff ventricle due to ventricular hypertrophy
- AS
- fibrosis post-MI
Which auscultatory finding indicates worse severity of mitral regurgitation?S3 gallop
S3 gallopBad mitral regurg
- Lots of regurged blood in the ventricle

More on Valvular Disorders

Question Answer
loudest at heart baseAS
radiates to carotidsAS
pulses parvus et tardusAS (pulses are weak with delayed peak).
where does aortic stenosis radiate to?carotids
which valvular defect is associated with pulsus parvus et tardus ?aortic stenosis
loudest at apex and radiates toward axillaMR
Often due to ischemic heart diseaseMR (post MI, MVP, LV dilatation)
can be caused by RF and infective endocarditisfavors mitral (stenosis and regurg) but all valves are susceptible
which murmur radiates to axilla?mitral regurg
what commonly causes tricuspid regurg?RV dilatation
which murmur radiates to R sternal border?tricuspid regurg, aortic stenosis
which murmurs can be caused by Rheumatic fever and infective endocarditismostly mitral but all valves can be involved
due to sudden tensing of chord tendineaeMVP midsystolic click
best heard over apexMVP
loudest just before S2MVP
associated with chord ruptureMVP
most common valvular lesion?MVP
associated with marfan or Ehlers-danlos?MVP
due to aortic root dilation, bicuspid aortic valve, endocarditis, RFAR
progresses to L Heart failureAR
severe chronic aortic regurgitationlong diastolic murmur and hyper-dynamic pulse (widening PP, head bobbing, pulsatile nail beds)
decreased interval between S2 and OS is a worse prognosismitral stenosis
what can chronic MS cause?LA dilatation
best heard at L infraclavicular areaPDA
what does inspiration do to heart sounds?increases venous return to RA so increases intensity of R heart sounds (Pulmonic and Tricuspid)
what does handgrip/rapid squat/passive leg raise/ alpha agonists do to heart sounds?increases afterload/preload. Increased intensity of MR, AR, AS, VSD murmurs, Decreased HCM, Later onset MVP click
what does valsalva/ sudden standing/ nitroglycerine admin do to heart sounds?decrease preload/afterload, decrease intensity of most murmurs (including AS), increase HCM intensity, MVP earlier onset of click
asymmetric hypertrophy of the septum compared to the free wallHCM
symptoms of ASweak delayed peripheral pulse, syncope, angina, SOB
causes of ASbicuspid aortic valve, senile calcification, ARF with MS, tertiary syphilis
symptoms of MSpulmonary congestion, a-fib, cough
causes of MSARF, infective endocarditis, mitral annular calcification, congenital
causes of MRARF, infective endocarditis, ischemic heart disease, LV dilation, MVP
MVPlarge floppy billowing MV
causes of MVPidiopathic, inherited
which patients are most likely to have tricuspid endocarditisIV drug users

Where Do You Hear Me

Question Answer
Aortic stenosisupper right sternal border
flow murmurupper right sternal border
aortic valve sclerosisright upper sternal boarder
pulmonic stenosisupper left sternal border
flow murmur (ASD)upper left sternal border
tricuspid regurglower left sternal border
tricuspid stenosislower left sternal border
apexmitral regurg
apexmitral stenosis
PDAleft intraclavicular area (upper left sternal border)
VSDlower left sternal border

General Heart Murmurs

Question Answer
crescendo-decrescendo systolic ejection murmuraortic stenosis
holosystolic, blowing murmurmitral/tricuspid regurgitation
midsystolic click with late systolic crescendo murmurMVP
holosystolic, harsh sounding murmurVSD
high pitched blowing early diastolic decrescendo murmurAR
follows opening snap with delayed rumbling late diastolic murmurMS
continuous machine like murmurPDA
innocent murmurnever diastolic,
wide fixed splitting of S2ASD and endocardial cushion defect

Pediatric Heart Conditions and their disease associations

Question Answer
ASD and endocardial cushion defectsDown syndrome
PDAcongenital rubella
coarctation of the aortaTurner
coronary artery aneyursmsKawasaki
congenital heart blockneonatal lupus
supravalvular aortic stenosiswilliams
ebsteinsmaternal lithium use during pregnancy
transposition of the great vesselsmaternal diabetes
bicuspid aortic valveTurners

Cyanotic heart disease in newborns

Question Answer
single S2 and VSD murmurtransposition of the great vessels
egg on a string x raytransposition
treatment of TGAstart IV PGE to maintain the PDA and balloon atrial septostomy to create an ASD
boot shaped heartTOF
harsh pulmonic stenosis murmur/VSD/crescendo decrecendo systoluc murmur over L upper sternal borderTOF
single S2 and VSDtricsupid atresia
to be compatible w life need ---- in TGAseptal defect and a PDA
single S2 and systolic ejection murmurtruncus arteriosus
total anomalous pulmonary venous returnsevere cyanosis and respiratory distress
snowman sign (enlarged supracardiac veins and SVC)total anomalous pulmonary venous return with obstruction
why will child squat in TOFincrease SVR and decrease right to left shunt
severe cyanosis in newborn, decreased pulmonary blood, left axis deviation and LVHtricuspid atresia
pulmonary blood flow depends on prescence and size of VSDtricuspid atresia
holosystolic murmor of tricuspid insuffiencyebstein anomaly
egg on the string appearanceTGA
single S2TGA
snowman appearance on X-rayTAPVR
enlarged right atrium, right ventricle and pulmonary artery, and small left atriumTAPVR
central cyanosis and HF in first few weeks of life, no murmurshypoplastic left heart syndrome
CXR findings in coarctation of the aorta3 sign and ribnotching

acyanotic heart disease

Question Answer
when to repair VSDsymptomatic patients who fail medical management, children less than ` year of age with signs of pulmonary hypertension, and older children with large VSDS
fixed, widely spilt S2ASD
bounding peripheral pulsesPDA

Other Cardiac Pathology

Question Answer
staph endocarditismore common in those without underlying heart disease
strep endocaridtismore common in patients with underlying heart disease or after dental procedures
clinical presentation of IEprolonged fever; new or changing heart murmur
ARFrelated to GAS infection within several weeks
prescence of Sydenham's choreasufficient for diagnosis of ARF
if chorea isolated in ARF treat withphenobarbital
low voltage QRSpericarditis
pulsus paradoxusa drop in BP greater than 20mnHg during inspiration in a child w pericarditis indicates cardiac tamponade
when a child presents with hypertension thinkrenal causes