1
Q
Ventricular septal defect- symptoms
A
- Small- asymptomatic, normal growth
- Moderate- poor feeding, failure to thrive (FTT), short of breath (SOB)
- Large- poor feeding, FTT (falls down centiles), SOB, sweaty and pale with feeds
- Most common congenital heart defect, associated with downs syndrome, all require echo
2
Q
VSD- time of presentation
A
- Antenatal diagnosis at 16-18 weeks
- Presentation at 6-8 weeks
- Defect in the membranous portion of the ventricular septum is more common than the muscular portion
- Congestive heart failure typically presents after 4-6 weeks
- Persistent pulmonary hypertension of the newborn (PPHN) may become established by 6-12 months
3
Q
VSD- clinical findings
A
Auscultate: Pan-systolic murmur heard loudest at the lower left sternal border. Loud P2 suggests the presence of pulmonary hypertension
4
Q
VSD- investigations
A
- Basic obs
- Echocardiography
- CXR – cardiomegaly and pulmonary oedema (increased pulmonary vascular markings) if severe VSD (presence of heart failure), enlarged pulmonary artery
- ECG: In patients with moderate or large VSD, the ECG may demonstrate LV hypertrophy. May have Right ventricular hypertrophy as well
5
Q
VSD- management
A
- Small lesion: < 5mm usually close spontaneously, no repair required (30-40%)
- Moderate lesion: Diuretic therapy (furosemide and spironolactone). Feeding with high caloric feeds (Infantrini)
- Large lesion: Manage as per moderate lesion. Optimise weight gain for surgery. Schedule for surgery before 12 months to prevent persistent pulmonary hypertension of the newborn (PPHN). Either transvenous catheter closure or open heart surgery
6
Q
ASD symptoms and time of presentation
A
- Typically asymptomatic, some children will have recurrent chest infections
- The mean age of diagnosis is 4.5 years from an incidental finding of a murmur. Symptomatic presentation is usually before the age of 40 with arrhythmias, dyspnoea
7
Q
ASD- ascultate
A
- Ejection systolic murmur heard loudest at the upper-left sternal border (ULSB)
- Widely fixed splitting of the second heart sound
8
Q
ASD investigations
A
- Pulse oximetry
- ECHO – shows dilated RV and increased RV filling and ejection time
- CXR – usually no findings
- ECG – incomplete RBBB
9
Q
ASD management
A
- Most children are asymptomatic and rarely require congestive heart failure (CHF) therapy
- Spontaneous closure in lesions smaller than 7-8mm
- Large defects require repair – percutaneous (catheter closure) or open surgery
10
Q
Patent ductus arteriosus (PDA) symptoms
A
Symptoms
- Small – asymptomatic
- Moderate – congestive heart failure with failure to thrive (poor feeding)
- Large – poor feeding, severe failure to thrive, recurrent lower respiratory tract infections (preterm infants may experience failure to wean from ventilation)
- More common in preterm infants
- Symptoms usually present 3-5 days after birth when the duct begins to close
11
Q
PDA clinical features
A
- Bounding pulses and wide pulse pressure
- Auscultate: Continuous machinery murmur typically heard at the upper-left sternal border (best heard below left the clavicle). Check for the presence of a thrill at the upper left sternal border
12
Q
PDA investigations
A
- 2D echocardiography and Doppler
- CXR and ECG are less useful in diagnosing PDA
13
Q
PDA management
A
- If preterm – good probability of spontaneous closure
- If term – less likely to close spontaneously
- Medical – indomethacin/ibuprofen (not effective in term infants)
- Surgical – catheter closure or PDA ligation (left lateral thoracotomy incision) when weight is at least 5kg
14
Q
Coarctation of the aorta pathophysiology
A
- Obstruction to the left ventricles outflow tract leads to an increase in left ventricular afterload which causes left ventricular hypertrophy
- Associated with Turners syndrome, can develop heart failure
- Symptoms present 3-5 days after birth when the duct begins to close as the PDA and foramen ovale allows blood to bypass the outflow obstruction
15
Q
Coarctation of the aorta clinical features
A
- Palpate: Systolic blood pressure is high when measured with BP cuff. Absent femoral pulses or radio-femoral delay. Cold extremities (especially feet). Hepatomegaly in heart failure due to severe coarctation
- Auscultate: Murmur heard at the back between the scapulae
16
Q
Co-arctation of the aorta investigations
A
- 2D echocardiogram and Doppler – direct visualisation of defect
- CXR and ECG are less useful in the diagnosis
17
Q
Co-arctation of the aorta management
A
- Medical therapy: Continuous intravenous infusion of prostaglandin E1 to keep the ductus arteriosus open. Dopamine or Dobutamine to improve contractility in those with heart failure.
- Supportive care for metabolic acidosis, hypoglycemia, respiratory failure, and anaemia
- Surgical repair: Balloon angioplasty. Resection with end-to-end angioplasty. Bypass graft. Subclavian flap
18
Q
Different shunts in the infants heart
A
- Ductus arteriosus: this shunt moves blood from the pulmonary artery to the aorta
- Foramen ovale: bypasses the lungs and moves blood from the right to left atrium
- Ductus venosus: shunts a portion of umbilical blood flow directly to the inferior vena cava. Allows oxygenated blood from the placenta to bypass the liver
19
Q
Cyanotic heart disease
A
- Decreased pulmonary flow: Tatralogy of fallot, Tricuspid atresia, other univentricular heart conditions with pulmonary stenosis
- Increased pulmonary flow: Transposition of the great arteries, Total anomalous pulmonary venous return
- Cyanotic heart conditions have a right to left shunt which causes low levels of oxygen in the systemic circulation. Acyanotic heart conditions can become cyanotic over time
20
Q
Acyanotic heart disease
A
- Left-right shunt lesions: Ventricular septal defect, Atrial septal defect, Atrio-ventricular septal defect, Patent ductus arteriosus
- Obstructive lesions: Aortic stenosis, Pulmonary valve stenosis, Coarction of the Aorta
Louder murmurs are caused by smaller defects. The cardiothoracic angle is often larger in children/neonates.
21
Q
CXR- heart failure neonates
A
- Increased pulmonary vascular markings (alveolar oedema)
- Left atrial/ left ventricular enlargement
- Upper-lobe diversion/ enlarged pulmonary arteries
Patients with congenital heart disease get vaccines against the flu and RSV (Palivizumab)
22
Q
What does tetralogy of fallot contain
A
- Ventricular septal defect
- Overriding aorta
- Pulmonary stenosis
- Right ventricular hypertrophy
23
Q
Tetralogy of fallot symptoms and presentation
A
Symptoms: Cyanosis, poor feeding, sweating during feeds. Most common cyanotic congenital heart disease
Time of presentation: during the neonatal period when the patent ductus arteriosus begins to close (day 3-5).
Can be associated with Di-George syndrome
24
Q
Tetralogy of Fallot clinical findings
A
- Cyanotic “tet” spells: Causes crying, pain, agitation and dehydration
- The murmur is crescendo-decrescendo with a harsh ejection systolic quality, heard loudest over the upper-left sternal angle with posterior radiation.
25
Tetralogy of fallot investigations
- 2D echocardiogram and Doppler – to assess location and number of VSDs and severity of RVOTO
- ECG – right atrial enlargement and right ventricular hypertrophy (right axis deviation, prominent R waves anteriorly and S waves posteriorly)
- CXR – classic “boot-shaped heart”, with a right aortic arch
- Cardiac catheterisation can help further delineate cardiac lesion, particularly helpful for assessing levels of right ventricular outflow obstruction
26
Tetralogy of fallot- management
- Neonates with severe cyanosis: prostaglandin infusion
- Tet spells: knee to chest position. Oxygen, calm the child, morphine, sedation.
- Medication: Oxygen, morphine, B-blockers. Prostaglandins are used to maintain patent ductus arteriosus
- Heart failure: digoxin and loop diuretics (furosemide)
- Prophylaxis for endocarditis: antibiotics
- Surgical repair: Ballock-Taussig shunt
27
Transposition of the great arteries pathophysiology
Pathophysiology: the aorta arises from the RV and pulmonary artery from the LV, resulting in deoxygenated blood from the RV being circulated around the body. The ductus arteriosus stays open to allow some mixing of blood. Most common CHD presenting during the neonatal period
28
Transposition of the great arteries key features
- Symptoms: cyanosis, poor feeding, sweating during feeds
- Without treatment: 90% die within the first year
- Time of presentation: day 3-5
- Clinical findings: cyanosis, tachypnoea, murmur
29
Transposition of the great arteries investigations
- Fetal ultrasound
- Echocardiogram
- CXR – classic “egg on a string” appearance
- ECG and cardiac catheterisation is typically not used in the diagnosis of TGA
30
Transposition of the great arteries management
- Prostaglandin E prior to surgery to maintain the ductus arteriosus
- Balloon atrial septostomy to increase mixing of the two circulatory systems
- Arterial switch procedure
31
Innocent murmur
- Easier to hear normal blood-flow as less soft tissue/bone between stethoscope and heart
- Innocent murmurs are louder during high cardiac-output i.e. fever and often vary with posture/manoeuvres
- “Seven S’s” of Innocent Murmurs: sensitive, short, single, small, soft, sweet, and systolic.
- Murmurs that should be referred are: Loud, Pansystolic, Diastolic.
- Other warning signs include: Family history, failure to thrives, symptoms of heart failure.
32
Conjunctivitis
- Can either be allergic, viral or bacteria
- Viral causes: adenovirus or herpes simplex
- Bacterial: S.aureus, S.pneumoniae. Can also be caused by STI’s. Can cause eye lids to stick together with purulent discharge
- Symptoms from the eye: redness, pain, itching, gritty sensation and discharge
- Clinical diagnosis but can take cultures
- Neonatal conjunctivitis can be caused by gonococcal infection
33
Treatment of conjunctivits
- Allergic: avoid allergen, are given artificial tears, topical antihistamine and mast cell stabilisers like topical sodium cromoglycate
- Viral: self limiting, treatment focused on symptom relief and prevention through good hygiene
- Bacterial: self limiting or topical antibiotics like chloramphenicol or fusidic acid
33
Paediatrics: normal bowel opening amount
Children open their bowel from a mean of 3 times per day for infants under 6 months old to once a day after 3 years of age.
34
Constipation: Child <1 year
- Stool pattern: fewer than 3 complete stools per week (does not apply to exclusively breastfed babies after 6 weeks of age). Hard large stool. Rabit droppings (type 1)
- Associated symptoms: distress on passing stool, bleeding associated with hard stool, straining
- History: previous episodes of constipation, previous or current anal fissure
35
Constipation: child >1 year
- Stool pattern: Fewer than 3 complete stools per week (type 3 or 4). Overflow soiling (very loose, very smelly, stool passed without sensation). Rabbit droppings (type 1). Large, infrequent stools that can block the toilet
- Associated symptoms: Poor appetite that improves with passage of large stool. Waxing and waning of abdominal pain with passage of stool. Evidence of retentive posturing (typical straight legged, tiptoed, back arching posture), Straining, Anal pain
- History: Previous episodes of constipation, previous or current anal fissure, Painful bowel movements and bleeding associated with hard stools
36
Causes of constipation
- Idiopathic
- Dehydration, low fibre diet
- Medication i.e. opioids
- Anal fissure
- Over enthusiastic potty training
- Hypothyroidism, Hypercalcaemia
- Hirschsprungs disease
- Learning disability
37
Constipation: red flags suggesting underlying disorder
- Constipation is reported from birth or the first few weeks of life
- Passage of Meconium >48 hours
- Ribbon stools
- Faltering growth is an amber flag
- Previously unknown or undiagnosed weakness in legs, locomotor delay
- Abdominal distension
- Amber flag: disclosure of evidence that raises concerns over possibility of maltreatment
38
Constipation: if faecal impaction is present
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- disimpaction treatment can initially increase symptoms of soiling and abdominal pain
- Movicol disimpaction regimen is followed by maintenance Movicol with a high fibre diet
39
Constipation: maintenance therapy
- first-line: Movicol Paediatric Plain
- add a stimulant laxative if no response
- substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
- Don’t use dietary intervention alone, though ensure the child has adequate fibre and fluid
40
Constipation: advice for infants
- Infants not yet weaned (<6 months): for bottle fed infants give extra water in between feeds, try a gentle abdominal massage and bicycling the infants legs. For breast fed infants, constipation is unusual and organic causes should be considered
- Infants who have or are being weaned: offer extra water, diluted fruit juice and fruits. If not effective consider adding lactulose
41
Hirschsprung's disease
- The distal colon is not innervated correctly, the resulting aganglionic colon is shrunken and cant distend properly, causes a back pressure of stool in the more proximal colon
- Symptoms: delay in passing meconium (>48h), distended abdomen, forceful evacuation of meconium after digital rectal examination
- Diagnosis: rectal suction biopsy
- Management: removal of section of aganglionic colon and healthy bowel is pulled through
42
Croup: key features
- Viral in origin
- Parainfluenza, rhinovirus, RSV, influenza
- Symptoms: Hoarseness, ‘barking cough’, stridor, worse at night, fever, coryzal symptoms, head bobbing, nasal flaring
- Symptoms resolve 2-7 days
- Peak incidence 6 months- 3 years, more common in autumn
- Complications: airway obstruction and respiratory distress
43
Croup: red flags for respiratory failure
- Signs of respiratory distress e.g. intercostal recessions, accessory muscle usage, tachypnoea
- Cyanosis
- Decreased level of consciousness
- Stridor may decrease due to worsening airway obstruction
- Decreased air entry on auscultation of the chest
- Tachycardia
44
Croup management
- ABCDE: oxygen
- Conservative: sit patient up, fluids and rest
- Oral Dexamethasone/prednisolone or if severe, nebulised adrenaline
- If unable to swallow oral steroids use inhaled budesonide (2 mg nebulised as a single dose) or intramuscular dexamethasome (0.6 mg/kg as a single dose)
- Anaesthetic +/- ENT if airway concerns
45
Mild croup
- Occasional barking cough
- No audible stridor at rest
- No or mild suprasternal and/or intercostal recession
- The child is happy and is prepared to eat, drink, and play
- Can be treated at home with a single dose of oral dexamethasone. Use paracetamol or ibuprofen for fever and pain
46
Moderate croup
- Frequent barking cough
- Easily audible stridor at rest
- Suprasternal and sternal wall retraction at rest
- No or little distress or agitation
- The child can be placated and is interested in its surroundings
47
Severe croup
- Frequent barking cough
- Prominent inspiratory (and occasionally, expiratory) stridor at rest
- Marked sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
- Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
48
Croup: when to admit to hospital
- Moderate or severe croup
- <3 months of age
- Known upper airway abnormalities i.e. Laryngomalacia, Down’s syndrome
- Uncertainty about diagnosis
- At rest stridor or sternal recession
- RR >60, cyanosis, high fever, fluid intake <75% of normal or no wet nappies in 12 hours
49
Croup investigations
- the vast majority of children are diagnosed clinically
- however, if a chest x-ray is done: a posterior-anterior view will show subglottic narrowing, called the 'steeple sign'. In contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the 'thumb sign'
Year 5
flashcards
Decks in class (24)
# Cards
-
Paediatrics 150
-
Paediatrics 250
-
Paediatrics 350
-
Paediatrics 450
-
Paediatrics 551
-
Paediatrics 659
-
Paediatrics 751
-
Paediatrics 850
-
Paediatrics 950
-
Paediatrics 1038
-
Repro 150
-
Repro 249
-
Repro 349
-
Repro 452
-
Repro 552
-
Repro 649
-
Repro 750
-
repro 850
-
Repro 952
-
Psych 150
-
Psych 250
-
Psych 350
-
Psych 450
-
Psych 545
