Gavin Burgess R5, PEM. General Review common presentations Uncommon Paediatric ECG Congenital...
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Transcript of Gavin Burgess R5, PEM. General Review common presentations Uncommon Paediatric ECG Congenital...
Gavin Burgess R5, PEM
General
Review common presentations Uncommon Paediatric ECG Congenital heart disease Rhythm disturbances Long QT HOCM Rheumatic fever Carditis – myo, endo, peri
General
Innocent murmurs Kawasaki disease
Fetal circulation
“Normal”
Age Respiratory rate
Pulse rate Systolic BP
O-1mo 30-60 120-160 50-70
1-12mo 20-40 80-140 70-100
1-5y 20-30 80-130 80-110
6-12y 20-30 70-110 80-120
adolescents 12-20 60-100 110-120
“Normal”
Ball-park BP? Neonate? Older?
“Normal”
Gestational age should equal MAP Systolic BP = 70 + (2 x age)
“Normal” ECG
Typically have shorter PR, QRS, QT RV dominance, RAD
RVH
Causes Tetralogy of Fallot PS Coarct ASD TAPVD Large VSD with Pulm HT
LVH
Causes AS VSD PDA Complete AV block Cardiomyopathy
Diagnosis?
Superior or “north west” axis Endocardial cushion defect
2% of congenital heart disease Down syndrome account for 70% Fatal due to pulm HT Banding in infancy
Myocardial infarction
AT III Cardiomyopathy Congenital heart disease CAD (ALCAPA) Drugs (cocaine) Homocystinuria Hyperlipidaemia and cholesterolaemia Kawasaki Leukaemia Marfans Haemoglobinopathies Tumours (myxoma) Rheumatic fever SLE
Diagnosis?
Diagnosis?
Diagnosis?
Which lesions give cyanosis? Tetralogy of Fallot Tricuspid atresia Transposition of the great arteries (IDM) Truncus arteriosus Total anomalous pulmonary venous
drainage Hypoplastic left heart Ebstein’s anomaly (lithium) Pulmonary atresia/severe stenosis
Pulmonary markings
Decreased: Pulmonary atresia/stenosis Tetralogy Tricuspid atresia Ebstein’s anomaly
Increased: TGA TAPVD Truncus
What’s the hyperoxia test? ABG Give 100% O2 Repeat ABG after 10 min If rises by >10%, likely pulmonary
lesion
When does the ductus close? 10-14 days after birth, it is
physiologically closed
Neonatal and infant presentations to ED What are the 4 presentations in and
infants neonates? 1) shock 2) cyanosis 3) cardiac failure 4) murmur
What are the ductal-dependent lesions? Systemic
Coarct/interrupted arch Aortic stenosis HLH
Pulmonary PS/atresia Tricuspid atresia
Shock
L ventricular outflow obstruction Coarct AS HLH
Shock
Management: ABC’s Start prostin CXR ECG
What’s prostin?
Prostaglandin E1 Rate 0.05-0.2 mcg/kg/min Side effects?
Apnoea Fever Flushing Hypotension
Prostin has an “all or nothing” action Should work in 15min
Time to presentation of cyanotic lesions
Age ECG X-ray
0-1 week TGA RVH Increased
1st week TAPVD RVH Increased
1-4weeks Tricuspid Atresia
LVH Decreased
Severe PS RVH Decreased
1-12weeks TOF RVH Decreased
Anytime in infancy
Truncus arteriosus
BVH Increased
Cyanosis
What is a tetralogy of Fallot? RVH Overriding aorta VSD RV outflow obstruction
What’s a “tet spell”?
Change in the balance of pulmonary and systemic flow
Hypoxic and cyanotic event Decreased system vascular
resistance or increased RV outflow obstruction
Increasing hypoxia
How do I treat it?
O2 Chest-knee (why?) Analgesia B-blocker (why?)
Cardiac failure
History: Fussy Sweating FTT Short frequent meals
Physical: HSM Murmur FTT You will NOT see a JVP AVM – auscultate the head
Murmurs
Features of an innocent murmur 80% of children will have a murmur at
some time in their lives All have normal ECG and X-rays Never diastolic
Common innocent murmurs
Type Description Age
Still’s LLSB, 2/6, “twang” 3-6y
Pulmonary flow ULSB, blowing, transmits
Gone in 3-6mo
Venous hum Supra clavicular, rotate head, supine goes
3-6y
Carotid bruit Over carotid Any age
Arrhythmia
SVT Very common Tolerated well, occasional LOC change Child is fussy Newborn >220 bpm <12y often accessory pathway
Arrhythmia
SVT treatment In shock vs stable Vagal stim Adenosine Amiodarone ,verapamil use extreme
caution. Frequently develop profound hypotension and die
Arrhythmia Long QT
History Deafness Single person MVC Swimming syncope Exercise syncope Family history of sudden death Seizure of unknown etiology Recurrent syncope/lightheadedness Sibling with SIDS
Physical Infant with bradycardia
Arrhythmia
All first degree family members should be screened with ECG
HOCM
2% under 2 y, 7% under 10y Variable history
CP Palpitations SOB Syncope Sudden death High risk if syncope Sudden death with strenuous exercise
HOCM
Physical S4 gallop, mid systolic murmur Increased PVR decreases murmurs
Rheumatic fever
Who was Jones? What where his criteria? What do you need to make a
diagnosis? Which valve? Then?
Rheumatic fever
What about Sydenham’s chorea? And the rash?
Rheumatic fever
Treatment ASA 75-100mg/kg Prednisone 1-2mg/kg Benzathine (Pen G) 600 000U (27kg), 1.2
million U (27kg) Prophylaxis Age questioned
Myocarditis
Various causes, most notably viral Coxsackie A,B, ECHO, flu’ Non-specific viral prodrome Non-specifc fussiness, lethargy etc Heart failure IVIG may be indicated
Infective endocarditis
Rheumatic fever, congenital heart defects, catheters, IVD
S. aureus, viridans are the usual suspects
Fungi in neonates, usually in the NICU
Infective endocarditis
Major 2 + BC, (viridans, s. bovis, HACEK, S. aureus,
enterococci Persistently + BC (1 hr between multiple, or
12h or 3h +) + echo mass at typical sites Intracardiac abscess Prosthesis failure New regurgitant murmur
Infective endocarditis
Minor Fever (38C) Predisposing condition/IVD Vascular phenomena Non-specific echo findings
Prophylaxis -1997
Prophylaxis
High risk Prosthesis Previous IE Transplants Complex CHD
Dropped from the list……. Moderate risk
(PDA,VSD,primumASD,coarct,bicuspidAV) Calcified AS,RF,HOCM,MVP
Pericarditis
Classic chest pain worse when lying flat
Radiation to L shoulder Friction rub Most often viral causes Diffuse ST changes, “saddle”shaped CXR important Cefotaxime, ASA, prednisone,
colchicine
Kawasaki disease
Etiology unkown, presumed infectious
More common in Asian and Pacific islanders
Peaks around 1-2years, 80% under 4y, 50% under 2y
Slight male preponderance 3mo-8y is typical range
Kawasaki disease
3 phases Acute phase (10 days)
High fever for 5 days 4 of
rash (ANY rash, no bullae/vesicles), oedema of extremities/ peeling of extremities Non-exudative bulbar conjuctivitis Mucosal changes (cracked lips, strawberry
tongue – even on HISTORY) Cervical LN (1.5cm)
Carditis, other organs (arthritis, pyuria, gallbladder/liver, menigitis, irritable
Kawasaki disease
Acute ESR, CRP WCC, plt Lipids, LFTs Echo coronary artery aneurysms unusual
before 10d
Subacute phase Desquamation Coronary disease Rash, fever, LN disappear plt
Kawasaki disease
Convalescent phase ESR, plt normalise Beau’s lines
Kawasaki disease
Rx IVIG ASA Vaccinations Steroid of no benefit Reduces CAD from 25% to 5% Untreated mortality 1-5%