Cardiac

Question 1

Janeway lesions and Oslers nodes are characteristic lesions of infectious endocarditis.
True or False

Answer 1

True

Question 2

Hypertension-prevalence 2-5%

Answer 2

Diagnosis: Blood pressure consistently above 95th% for age,
gender, height, measured on 3 separate occasions
1. Primary: Now leading type. Multifactorial: low birth weight,
genetic, familial, environmental stress, dietary factors
2. Secondary: Usually renal vascular in origin (60%), can be
systemic vascular, genetic/metabolic disorder or endocrine
disorder.
3. Other: adrenal gland, OSA, stress, anxiety, coarctation of
the aorta, endocrine disorders, pregnancy, metabolic
syndrome.

Question 3

Hypertension: Diagnosis/Diagnostics

Answer 3

Labs: CBC, Urinalysis, Culture, Uric acid, Electrolytes (BUN,
creatinine), Fasting Lipid panel and Hepatic profile. Pheochromocytoma labs(urine/plasma metanephrines).
Renal ultrasound, Echo (assess for LVH), 12 Lead EKG(LVH, strain patterns), Eye/retinal exam
Pearls- Correct cuff size, 4 extremity BP with pulse checks. 30% of children evidence of vascular injury/stiffening and LVH.

Question 4

Hypertension Management

Answer 4

Pre-hypertensive: Counsel, follow-up
Stage 1: diet, exercise, weight loss, DASH diet
Stage 2: First Line-Diuretics.

ACE inhibitors-dilates vessels, decreases resistance, Good with CKD, diabetes, watch for hyperkalemia, cough. “Prils”.

-ARB-Angiotensin 2 Receptor blockers or “Artans” act by
-Ca channel blocker-dilate, reduce resistance, arrhythmogenic, may get dizzy, fatigue, edema. Good in asthma. “Pines”
-Beta blockers(Not first Choice)-Blocks SNS, careful in diabetes, asthma, heart block, may get orthostatic hypotension, nightmares, tiredness, “Ols”.

Question 5

Hypertensive Emergencies

Answer 5

Management: IV anti-hypertensives:
esmolol, labetolol, nicardipine and or
hydralazine.
* Clear goals! No more than 25%-33%
goal reduction over first 12hrs, total
correction over 48-72hrs
* Not trying for normotensive
* Monitor for hypertensive
encephalopathy
* Treat underlying disease!

Question 6

A child is being admitted for hypertension. What is a safe
strategy for blood pressure reduction?
A Return to normal B/P in 12hrs
B Reduction of B/P by 25% in 12hrs
C Return to normal B/P in 24hrs
D Reduction of B/P by 40% in 12hrs

Answer 6

B. Reduction of B/P by 25% in 12hrs.

Question 7

An adolescent with headaches has been followed for Stage 1
primary hypertension by PCP and now has progression to
Stage 2 despite lifestyle modifications. What is the next medical
intervention?
A DASH diet
B Repeat BP in 1 month
C Pharmacological
D Endocrine referral

Question 8

A diabetic teen is initiated on an anti-hypertensive agent, which
medication should be avoided?
A Amlodipine
B Atenolol
C Enalapril
D Lasix

Answer 8

B. Atenolol
Beta blockers can affect glucose levels resulting in hypoglycemia.

Question 9

Grade I murmur

Answer 9

Faintest murmur
auscultated

Question 10

Grade II murmur

Answer 10

Murmur is faint but easily identified.

Question 11

Grade III murmur

Answer 11

Moderately loud.

Question 12

Grade IV murmur

Answer 12

Loud murmur with a thrill

Question 13

Grade VI murmur

Answer 13

Loud-can be heard without stethoscope.

Question 14

Grade V murmur

Answer 14

Loud murmur but need stethoscope to hear.

Question 15

Innocent Murmurs

Answer 15

7 S’s of Innocent murmurs
* Small
* Single
* Short
* Sensitive
* Soft
* Sweet (not harsh)
* Systolic

Question 16

A mother of a 1-year old brings her child in for concern of a
murmur heard at a well child check up. Which ausculatory
finding would be most concerning?
A. Twangy, mid-systolic murmur at the mid-LSB
B. Continuous murmur in infra/supra-clavicular region that
disappears when supine
C. Early systolic murmur heard over the supraclavicular fossa
D. Harsh, diastolic murmur heard best at apex

Answer 16

D. Harsh, diastolic murmur heard best at apex.

A is the very commonly heard Still’s murmur.
B. Venous hum-heard only in the upright position, disappears in the supine position & can completely obliterated by rotating the head to the side or occluding the neck veins.
C. Carotid bruit-early systolic murmur heard over the supraclavicular fossa.

Question 17

Still’s Murmur

Answer 17

Most common, Low
frequency (use bell side),
* Pulmonary Ejection-Commonly seen in 8-14 y/o children. Heard
heard best at mid-left
at left upper sternal border,
sternal border when the
midsystolic and has a grating
patient is supine. Mid-
systolic, grade 2-3-no thrill
sound without radiation. Usually grade 1-3/6. Exaggerated by
or click. Vibratory or
pectus excavatum,
twangy in sound. Becomes
kyphoscoliosis, or straight back
quieter or disappears with
upright positioning and when
bell pressed firmly down or
with valsalva

Question 18

Pulmonary EJection Murmur

Answer 18

Commonly seen in 8-14 y/o children. Heard
heard best at mid-left
at left upper sternal border,
midsystolic and has a grating
sound without radiation. Usually grade 1-3/6. Exaggerated by
pectus excavatum,
kyphoscoliosis, or straight back

Question 19

A one month old former 34 week gestation neonate is being
examined and a high pitched grade II/VI murmur is heard at the LUSB that transmits to the axillae and back. What is
suspected?
A. Still’s murmur
B. Ventricular Septal Defect
C. Patent Ductus Arteriosus
D. Peripheral Pulmonic Stenosis

Question 20

Acute Rheumatic Fever

Answer 20

Collagen vascular disease of connective tissue that results in vasculitis that occurs 1-5 weeks following Group A Strep pharyngitis
Symptoms: Arthritis, carditis, subcutaneous nodule, chorea,
and erythema marginatum. Valve damage can be progressive and chronic.
Who? Children from 5-15 y/o, can be as young as 3.
Leading cause of acquired heart disease worldwide.

Question 21

Rheumatic Fever Jones criteria Major

Answer 21

New apical systolic murmur,Carditis and valvulitis.
Polyarthritis: lg joints with pain, swelling, tenderness
Erythema marginatum: transient, nonpuritic, nonpainful rash on trunk, & extremities.
Subcutaneous Nodules: painless over joints.
Chorea: purposeless, involuntary, rapid movement of trunk & extremities.
* Antistreptolysin O titer (ASO) rises within 1 wk & then for 3-6 wks after GAS infection

Question 22

Rheumatic Fever Jones criteria Minor

Answer 22

Arthralgia
* Fever
* Elevated acute phase
reactants (ESR, CRP)
* Prolonged PR interval(EKG)

Question 23

Rheumatic Fever Management

Answer 23

Acute Phase: penicillin
* Aspirin therapy, bed rest until fever and symptoms resolve
* Cardiology and ID Consults
* Prevention! Children should
take SBE/PCN prophylaxis at
time of predicted risk.

Question 24

Long QT Syndrome

Answer 24

Usually not diagnosed until child/adolescent has a cardiac event, including syncope or cardiac arrest. Relatives of patients who have died of sudden death requires genetic evaluation.
* Treatment is with beta blockers.
* Implantable cardioverter/defibrillator/Ablation can provide cure.
* Avoid medications that will prolong QT

Question 25

Cardiomyopathy

Answer 25

Dilated, hypertrophic & restrictive.

Question 26

Cardiomyopathy S/S

Answer 26

SOB, CHF, fatigue, lethargy, exercise intolerance, decreased appetite. ECHO: Decreased CO and global function, most important tool for dx and follow up. EKG-sinus tachy, Prolonged PR, ST-T wave changes, hypertrophy.

Question 27

Cardiomyopathy Evaluation

Answer 27

Cardiomyopathy panel, genetics, trend BNP. CXR: cardiomegaly, enlarged L atrial shadow, pulmonary edema.

Question 28

Dilated cardiomyopathy

Answer 28

Systolic dysfunction * Often asymptomatic * LA/LV affected, chambers dilated with decreased contractility, very poor function * Beta blockers usefu

Question 29

Restrictive cardiomyopathy

Answer 29

Most deadly, least common * Atrial dysfunction as large amount of blood is not able to leave ventricle * Diastolic dysfunction-not able to fill adequately * Walls are stiff but may not be hypertrophied.

Question 30

Hypertrophic Obstructive Cardiomyopathy

Answer 30

50% familial, autosomal dominance * Acute decompensation, usually with sports or activities * Syncope rare but malignant * Goal: Improve diastolic dysfunction * Use: Beta blockers, avoid catecholimines * Dual chamber pacing * Surgery: Myotomy or myomectomy

Question 31

Cardiomyopathy Management

Answer 31

Stable: Ace inhibitors/beta blockers to decrease LV stress Acute: Increase CO with ino/lusitropes, vasodilators, with careful use of diuretics * Pre-load dependent volume restriction * IVIG, antivirals, VAD, ECMO, and heart transplant. * Treat arrhythmias- Amiodarone is the treatment of choice

Question 32

Myocarditis

Answer 32

Serious, acute infection/ inflammation of the myocardium usually from viral infection-appear ill. * Sudden cardiac failure with murmur, gallop or arrhythmia with resting sinus tachycardia as primary symptom. * Diagnosis: Troponin leak, elevated BNP * EKG: low voltage, ST-T wave abnormalities, prolonged QTc, AV conduction delays. Premature contractions, heart block Dx: gold standard is biopsy(EMB), MRI gaining popularity with criteria in place for diagnosis and follow up. -supportive care: digoxin, ace inhibitors, diuretics, IVIG Fulminant Heart Failure-ECMO,VAD for transition to transplant.

Question 33

Pericarditis

Answer 33

Pericarditis: Inflammation of the pericardium of the heart. Symptoms: fever, tachypnea, tachycardia, friction rub-may present with tamponade sx. Diagnosis: CXR-cardiomegaly. EKG-Diffuse ST elevation, PR depression Treatment: Emergent pericardiocentesis for tamponade and antibiotics for 3-4 weeks for presumed Staph and Hflu until sample can be obtained. Colchicine and NSAID’s have been shown to have beneficial effects on recurrent/recalcitrant cases

Question 34

Endocarditis

Answer 34

Endocarditis: Infection inside heart. Can have acute septic presentation. CVL or foreign material in the heart is risk factor or disruption of the endothelium can be the etiology. * Symptoms: Fever, murmur, embolic phenomenon, myalgias, malaise, petechiae, vasculitis, Osler nodes, mitral valve vegetation * Diagnosis: Duke Criteria: 2 major or 1major + 2minor or 5minor. * Need Echo/TEE, PICC placement. ID consult. * Treatment:4-6 weeks antibiotics-most common staph and strep. * Strep- PCN, rocephin or vanco, Enterococci-ampicillin, Staph aureus- nafcillin * Need Surgery: abcess formation, significant emboli, new heart block, CHF * Need to ensure following AHA guidelines for SBE prophylaxis for indicated contaminated procedures.

Question 35

What would be an important referral for a toddler with no past medical history of illness who has suffered a sudden cardiac arrest? A Genetic B Rheumatology C Endocrine D Orthopedics

Answer 35

A. Genetic. Any child with sudden unexplained cardiac arrest or syncope should be evaluated for long QTC. The parents & siblings should be considered for evaluation of this disorder.

Question 36

A 15 year old is brought emergently to the ED after collapsing at a basketball game. He was quickly revived, but is still complaining of fatigue, weakness, and mild chest pain. What diagnostic testing should be done first? a. MRI and CBC b. Electrolytes and EKG c. CBC and echocardiogram d. Electrolytes and chest x-ray

Answer 36

B. Electrolytes and EKG Is he having a dysrhythmia or electrolyte abnormality? Would need CXR & echo for follow up evaluation to determine cardiomegaly & presence of defect.

Question 37

An echocardiogram is being completed for suspected cardiomyopathy. What is the expected finding? A Mitral valve vegetation B Valvular dysfunction C Dilated coronary arteries D Decreased function

Answer 37

D. Decreased function Echo will reveal decreased CO & global function. Sx's include: SOB, CHF, fatigue, lethargy, exercise intolerance, depressed appetite. Ekg may reveal sinus tachycardia, prolonged PR, ST-T wave changes, hypertrophy.

Question 38

A child admitted with fever and a viral illness suddenly complains of severe chest pain. The following EKG is resulted. What does the provider suspect? A Endocarditis B Pericarditis C Myocarditis D STEMI

Answer 38

B. Pericarditis Children with pericarditis present with fever, tachypnea, chest pain, tachycardia, & friction rub. Can progress to tamponade.

Question 39

Acyanotic VSD

Answer 39

Most common of all congenital heart defects Accounts for 15-20% of all defects. Hallmark-Regurgitant systolic murmur at the LLSB-depends on the severity of defect Usually holosystolic or less than holosystolic A thrill may be palpable at lower left sternal border CHF and pulmonary HTN with large defects.

Question 40

ASD-acyanotic

Answer 40

Compromises 5-10% of all defects but often exists as part of other defects Typically female and slender Hallmark-widely split fixed S2 grade 2-3/6 at LUSB. murmur at the LLSB-depends on the severity of defect SEM across Pulmonary valve May have mid-diastolic rumble r/t tricuspid stenosis. Often asymptomatic and have spontaneous closure (40%) May qualify for a device closure. Routine monitoring via ECHO, RVH noted.

Question 41

AV Canal

Answer 41

2% of all defects, associated with Trisomy 21 Failure of the endocardial cushion to develop normally 3 components: ASD, inlet VSD, abnormal formation of the AV valves with L-R shunting. Symptoms depend on type and configuration. Common: Tachypnea, poor weight gain, signs of CHF. Systolic regurgitant murmur 3-4/6 at LLSB. Control CHF, encourage weight gain: surgical correction by 6 months of age Post-op arrhymias, mitral valve regurgitation

Question 42

PDA

Answer 42

Occurs in 5-10% of all CHD Common in pre-term infants CHF-Tachycardia and tachypnea noted. Grade 1-4/6 continuous machinery like murmur audible at the left infraclavicular area or upper left sternal border. Systolic thrill at the upper left sternal border with hyperactive precordium, bounding pulses, and wide pulse pressure Unrepaired, can result in pulmonary vascular obstructive disease, Cor pulmonale or parenchymal lung injury disease Surgically ligated or coil occlusion

Question 43

Coarctation of the Aorta

Answer 43

8-10% of all CHD * Narrowing of the aortic arch causing decreased flow * Symptoms: upper extremity hypertension, absent or weak pulses in LE, Pulmonary edema in neonate with LV failure, cardiogenic shock, risk for intracranial hemorrhage(10% untreated adults), Brachial femoral pulse lag. 4 extremity B/P with gradient. * Systemic hypertension/asymptomatic murmur in older child, any child with repaired PDA at risk later in life * May hear ejection click from bicuspid aortic valve * CXR with 3 sign, rib notching, 4 extremity blood pressure * Echo/EKG - MRI definitive * Surgical repair with re-anastomosis or balloon stent placement

Question 44

Congestive Heart Failure

Answer 44

Volume or pressure overload leading to poor cardiac output

Question 45

Congestive Heart Failure S/S

Answer 45

crackles, respiratory distress, tachycardia, diaphoresis, hepatomegaly, FTT, cardiomegaly, exercise intolerance, decreased urine output with edema.

Question 46

Congestive Heart Failure Evaluation

Answer 46

CXR, echo, MRI, CT, cardiac cath

Question 47

Congestive Heart Failure Management

Answer 47

-Optimize volume status: Diuretics (lasix, chlorothiazide), Aldactone for remodeling, fluid restrictions. -Cardiac contractility: digoxin, afterload reduction (enalapril, milrinone), vasodilators. * When Inotropic support needed-stop beta blockers! * Maximize nutrition

Question 48

Question 10 A slender 5 year old female presents for school check up with a widely split fixed S2. What CHD does the provider suspect? A Atrial Septal Defect B Ventricular Septal Defect C Coarcation of the Aorta D Patent Ductus Arteriosis

Answer 48

A.Atrial Septal Defect ASD grade 2-3/6 SEM across pulmonary valve

Question 49

An infant in the newborn nursery is found to be hypotensive with cool feet and feeble pedal pulses. As he is being transferred to the NICU, what other bedside maneuver or evaluation should be performed? A Knee to chest maneuver B Ice to the face C 4 extremity blood pressures D Hyperoxia test

Answer 49

C. 4 extremity blood pressures Coarc should be suspected in a newborn with upper/lower extremity pulse lag & gradient, UE hypertension, & LE weaker pulses. Completing 4 ext BP check with coarc should reveal an upper and lower extremity BP gradient.

Question 50

Tetralogy of Fallot Cyanotic

Answer 50

6-10% of all CHD Typical 4 findings. where degree of cyanosis depends on degree of RVOT obstruction/pulmonary stenosis 1. VSD 2. RVOT obstruction 3. Overriding Aorta 4. RVH CXR-Boot shaped heart Holosystolic murmur at LSB-

Question 51

Hypercyanotic Event (TEF spell)

Answer 51

Hypercyanotic event-hyperpnea and agitation-medical emergency, Causes extreme right to left shunting-no blood to the lungs. S/S: tachypnea, irritability. Treat by increasing SVR, decreasing impedence to pulmonary Degree of cyanosis depends on presence/degree of blood flow and reversing acidosis: 1. Oxygen-pulmonary vasodilator 2. Morphine-sedation 3. Bicarb-alkalosis-pulm vasodilator 4. Phenylephrine-selectively increases SVR, knee to chest

Question 52

Pulmonary Atresia

Answer 52

Rare only 1-3% of all defects Degree of cyanosis depends on presence/degree of tricuspid regurgitation Cyanosis with tachypnea at birth, needs PGE, BT shunt Hyperdynamic apical impulse with single S1, S2

Question 53

Tricuspid Atresia

Answer 53

Complete lack of tricuspid valve leads to NO communication between the RA and RV * 3 types based on relationship of great vessels * Restrictive ASD-needs atrial septostomy-will be ductal dependent. * Elevated PVR and varying degrees of pulmonary blood flow will guide surgical interventions * 3 staged surgical repair

Question 54

Blalock-Thomas-Taussig Shunt (BTT)

Answer 54

To increase pulmonary blood flow in ductal dependent lesions. Basically an artificial PDA * Usually kept small-3.5mm * Placed to connect the subclavian or carotid artery to the PA to allow blood flow to the branch pulmonary arteries and lungs. * Anticoagulants and good hydration for patency, shunt murmur should be able to be auscultated.

Question 55

Pulmonary Artery Band (PA Band).

Answer 55

Used: When unrestrictive pulmonary blood flow is present, limits the flow by cinching down the PA * Prevents pulmonary over- circulation, helps promote systemic blood flow. Balance the Qp to Qs ratio

Question 56

Transposition of the Great Vessels(TGA)

Answer 56

Most common Cyanotic defect in newborns * If no intra-atrial or restrictive or ventricular * Aorta arises from the RV and the PA arises from the LV. Desaturated blood returns from the body to the RA and goes out to the body while well oxygenated blood returns from the LA/LV to the PA Creates a parallel circulation that is incompatible with life * Vital organs have low perfusion * No murmur, single S2, unless +VSD * Emergent balloon septostomy and prostaglandins as child is ductal dependent *If no intra-atrial or restrictive or ventricular opening, need to create an ASD, PFO likely not large enough. Treatment is an arterial switch procedure that involves moving the coronary arteries. Need LV support post-op.

Question 57

Total anomalous pulmonary venous return (TAPVR).

Answer 57

Obstructive type is emergency surgery for atrial septostomy * Drainage of pulmonary veins into systemic venous structure or RA * Snowman sign on CXR * Frequent pulmonary infections with mild cyanosis, could have pulmonary edema, poor growth * Surgical repair in infancy.

Question 58

Hypoplastic Left Heart Syndrome(HLHS)

Answer 58

7-9% of all CHD * Variable murmur, but accounts for 25% of all cardiac deaths before 7 days of life if not diagnosed in utero * Presents with: shock, respiratory distress, may have early heart failure. * single S2 at LSB

Question 59

Ductal dependent lesion

Answer 59

When the systemic or pulmonary circulation is dependent on the PDA to provide mixed blood for circulation. (HLHS, TGA, Pulm atresia, Coarc, critical AS, IAA) The ductus closes get immediate decompensation, death if undiagnosed and ductus not opened. * Open ductus with prostaglandin (PGE1) infusion: pulmonary blood flow. side effects-apnea, hypotension, decreased platelet aggregation activity * Staged Palliative Surgery may be needed 1. Norwood/Sano aorta. 2. Bidirectional Glenn 3. Fontan

Question 60

Stage 1: Norwood Procedure

Answer 60

BT shunt created from subclavian or carotid artery to the PA to allow blood flow to the branch pulmonary arteries and lungs for better pulmonary blood flow. Neo-Aorta is constructed from the root of the PA and the ascending aorta.

Question 61

Stage 1: Sano Modification

Answer 61

Create systemic perfusion via shunt from RV to systemic circulation via a PA conduit (instead of the BT shunt). * Neo-Aorta construction is the same as Norwood * Goal: prevent diastolic runoff of systemic blood into PA-better coronary perfusion

Question 62

Stage 2: Bidirectional Glenn

Answer 62

Decrease volume load on RV by performing anastomosis between SVC and the PA. * Creates passive, parallel blood flow * Goal: off load the ventricle.

Question 63

Stage 3: Fontan

Answer 63

Definitive repair-Separate the pulmonary and systemic systems by baffling the IVC to the PA and providing a extracardiac conduit with a fenestration or pop-off for the RA * Transition from parallel blood flow to series

Question 64

Mitral Stenosis

Answer 64

Most commonly caused by Rheumatic Fever Fatigue, SOB, LA enlargement, hemoptysis * May get atrial fib, pulmonary, pulm edema, blood clots, pulm HTN, Presents with frequent pulmonary infections Grade 1-4 Apical murmur

Question 65

Aortic Stenosis

Answer 65

Sub-valvular or above Symptoms depend on severity of obstruction Mild-well tolerated Moderate-LVH/failure Severe- not enough CO to support life CHF, harsh loud mid-systolic ejection murmur at LSB that radiates

Question 66

Cardiac Transplant

Answer 66

Donor heart is transplanted into similar aged recipient in end stage heart failure All medical/surgical options have failed. < 1 yr of age due to congenital defects. Comprises One-third of all transplants. In older children, over half of transplants occur secondary to cardiomyopathy. Many need inotropic or pulmonary support. Malignant arrhythymais and complete deterioration of ventricular function may be present.

Question 67

Cardiac Transplant

Answer 67

Cardiac catherization is done to assess hemodynamics, anatomy & PVR. Additional evaluations: ECHO, EKG, MRI/MRA, & exercise stress testing. End organ functions are assessed. Kidney, liver & pulmonary function & lipid profile Immunologic & infectious labs must be sent.

Question 68

Cardiac Transplant

Answer 68

Families also endure psychosocial and financial evaluation and able to withstand the rigors of post- transplant life Post-op Management: The first 72 hours post-transplant remain the most critical. The primary goals are to maintain coronary perfusion, systemic blood pressure, and adequate cardiac output while initiating immunosuppression. * The early reasons for failure: primary graft failure & right heart failure that is associated with elevated PVR.

Question 69

Cardiogenic Shock

Answer 69

Heart is unable to meet demands of the body, leads to low cardiac output state. Poor systolic function leads to poor CO and diminished blood flow. Heart rate and stroke volume will compensate to increase CO but eventually compensation fails leads to hypotension. Types: Ingestion/toxidromes, CHD, arrhythmias, trauma, metabolic derangements. PE findings: cool extremities, poor to absent pulses, pallor, hepatomegaly, AMS, lactic acidosis, oliguria, tachycardia, tachypnea. Management: ABC’s, cautious fluid administration, Inotropic support with vasopressors. Correct derangements as able.

Question 70

ECMO

Answer 70

Short term severe respiratory and/or cardiac support in a reversible condition after maximal medical management has failed. Can be venoarterial (biventricular and respiratory support) or venovenous (respiratory only). Deoxygenated anti-coagulated blood from venous catheter drains out to oxygenator and returns oxygenated blood to the child. Pumps, oxygenates and removes CO2. Can add renal circuit on in AKI.

Question 71

What is the most likely diagnosis of a child who presents in atrial fibrillation with SOB, lethargy and an apical murmur grade 2/6 at the left upper heart border? A VSD B Aortic Stenosis C TAPVR D Mitral Stenosis

Answer 71

D. Mitral Stenosis Most common from rheumatic fever. Fatigue, SOB, LA enlargement, hemoptysis, may get Afib, pulm edema, blood clots, pulm HTN, grade 1-4 apical murmur

Question 72

A full term newborn infant has cyanosis without respiratory disease. What cardiac lesion is suspected? A. Atrial Septal Defect B. Coarctation of the Aorta C. Complete AV Canal D. Transposition of the Great Vessels

Answer 72

D. Transposition of the Great Vessels Blood flow L-R None of the other lesions are cyanotic

Question 73

A toddler in the ED is found squatting on the floor with severe agitation and cyanosis. What treatment should be provided? A Increase activity B Diuretics C Oxygen D Move upright

Answer 73

C. Oxygen For hypercyanotic episode caused by infindibular muscle spasms resulting in R-L shunting through the VSD that is associated with TOF. Treat with O2, sedation, knee chest positioning, volume expansion, may need phenylephrine, esmolol or ecmo.

Question 74

Diagnsotics: EKG

Answer 74

Limb leads provide frontal direction * Precordial leads provide

Question 75

Arterial Blood Pressure Monitoring

Answer 75

Normal for age Waveform can be dampened or peaked Wide Pulse Pressure: PDA, vasodilation, anemia * Narrow Pulse Pressure: cardiac tamponade, dehydration, status asthmaticus. * Pulsus Paradoxus- Exaggerated fall > 10mmHg in BP during inspiration. Seen in asthma, COPD & cardiac tamponade.

Question 76

.Post Operative Emergencies: Cardiac Tamponade

Answer 76

Cardiac Tamponade: cardiac compression occurring when blood or fluid builds up in the space between the myocardium & pericardium.

Question 77

Cardiac Tamponade S/S

Answer 77

Friction rub, narrow pulse pressure, obstructive shock with low CO and high SVR. Cold extremities & poor perfusion. -Beck’s Triad-JVD, muffled heart sounds, hypotension

Question 78

Cardiac Tamponade Management

Answer 78

Pericardial thoracentesis with ultrasound guidance under sedation.

Question 79

Post Operative Emergencies: Dysrhythmias-SVT

Answer 79

SVT: Narrow complex tachycardia with abnormal P-wave morphology that occurs above bundle of His -Infant with pallor, diaphoresis, poor feeding and irritability. -Older kids with chest pain, palpitations, SOB and dizziness. Can tolerate for some period of time. Stable: Valsalva, vagal maneuvers Unstable: Synchronized cardioversion 0.5-1j/kg Adenosine 0.1mg/kg/dose Long-term management-Digoxin, propranolol, amiodarone, possible ablation

Question 80

Post Operative Emergencies: Dysrhythmias-JET

Answer 80

Fast narrow complex tachycardia with variable heart rates from enhanced automaticity. * Loss of atrial filling in diastole can cause drop in CO * Management: Control temperature, normalize electrolytes, reduce catecholamines as able. * Dual chamber pacing at higher rate to restore synchrony, amiodarone is first line med

Question 81

Post Operative Emergencies: Dysrhythmias-Bradycardia

Answer 81

Common causes -High ICP -Hypoxia -Hypothyroidism -Hyperkalemia -Hypothermia -Sedation, Seizures -Sleep -Infection -Drugs-Digoxin, beta-blockers, precedex Fix Problem! Follow PALS algorithms,

Question 82

Post Operative Emergencies: Bradycardia Pacemakers

Answer 82

Uses-Provides electrical stimulus to the heart when no or low intrinsic activity present. Can be single or dual chamber. * Temporary-esophageal, epicardial, transvenous or transcutaneous. * Permanent-Implanted, battery powered device * Mode is dependent on intrinsic rhythm and is set to support function * Complications-Failure to capture, sense or pace or over-sensing. Infection, lead fractures, battery failure. * Can be with or without ICD or Implantable Cardioverter Defibrillator. Used with Sustained V-Tach or fibrillation, prevent sudden cardiac death from arrhythmias.

Question 83

Pulmonary Hypertension S/S

Answer 83

poor feeding, tachypnea, cyanotic spells, failure to thrive, syncope, irritability, gallop rhythm, loud second heart sound, murmurs, JVD, hepatosplenomegaly, peripheral edema. Worsened by: acidosis, hypoxia, pain, noxious stimulus, fever Acute crisis: Right sided heart failure.

Question 84

Pulmonary Hypertension Evaluation & Management

Answer 84

Diagnostics: Cardiac catheterization is the gold standard. Echo to screen. Management: symptom dependent: oxygen, diuretics, calcium channel blockers, oxide(vasodilator), prostacyclin (vasodilator) and endothelin (vasoconstricts) pathways. prostaglandins (Epoprostenol, Treprostinil), anticoagulation, endothelin antagonists (Bosentan,Ambrise

Question 85

Post-op Complications Low cardiac output syndrome & Postcardiotomy syndrome

Answer 85

Low cardiac Output Syndrome- Predictable fall in CO after bypass at 6-18hrs. Must balance B/P and SVR. HR X SV =CO 2. Postcardiotomy syndrome: febrile illness secondary to a cell mediated immune inflammatory reaction involving the pleura and pericardium 1-2 weeks after tissue injury to myocardium. Symptoms: fever, pericardial effusion, fatigue, chest pain, irritability, poor PO intake. Could lead to cardiac tamponade. Diagnostics: CXR, EKG and echo Treatment: NSAIDs-5-7days or systemic steroids for recurrent or cases.

Question 86

Post-op Complications-chylothorax

Answer 86

Dispruption of the lymphatic system from trauma or damage. Accumulation of chylus fluid in the pleural space leading to effusion and resp distress. Diagnosis: Milky pleural fluid tests +for chylomicrons with TG level >110mg/dl. Can get US or lateral CXR for effusions. Treatment: Placement of thoracostomy tube to alleviate respiratory distress. Dietary restriction of fat. May take MCT formula or IL for fat source. Diuretics and octreotide used with mixed results. Pleurodesis uncommonly done-only for refractory

Question 87

A 30 month old child has surgery for total anomalous pulmonary venous return and develops fever, pallor and bradycardia. What is the most likely complication? A Pulmonary hypertension B Postcardiotomy syndrome C Low Cardiac output syndrome D Sick Sinus Syndrome

Answer 87

B. Postcardiotomy syndrome Febrile illness secondary to a cell mediated immune inflammatory reaction involving the pleura & pericardium.

Question 88

A 10 year old arrives to the emergency department with low grade fever, lethargy, hypotension with ectopy and elevated cardiac enzymes. Which cardiac test should be obtained urgently? A. MRI B. Stress test C. CT D. Echo

Answer 88

D. Echo Concern for myocarditis.

Question 89

An infant is post-op 8 hrs from TOF repair and has developed muffled heart tones, narrow pulse pressure and cool extremities. What is the best course of action? A Synchronized cardioversion B Increase epinephrine drip C Initiate antibiotics D Pericardial thoracentesis

Answer 89

D Pericardial thoracentesis

Question 90

A newborn with AV canal and trisomy 21 has bradycardia and poor feeding. Which of the following is a likely etiology? A Hyperthermia B Hypothyroidism C Hypertonicity D Hypokalemia

Answer 90

B. Hypothyroidism

Question 91

A toddler is undergoing an echocardiogram due to suspicion for Kawasaki disease. What should the provider anticipate will be needed for this study? A Transesophageal approach B Sedation C Contrast D Bubble study

Answer 91

B. Sedation Kawasaki disease needs echo to look at coronary arteries which are hard to see, so need child still and sedated.