Pedi Cardiovascular Disorders

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Pedi Cardiovascular Disorders
2013-03-04 20:20:21
Pediatrics cardiovascular disorders

South plains college pediatrics (nursing school)
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  1. S/S of pedi hypovolemic shock
    • -Dry mucous membranes
    • -Depressed fontanel
    • -Cold clammy skin
    • -oliguria
    • -Poor skin tugor
    • Delayed capillary refill.
  2. S/s of Distributive Shock (Early Septic shock)
    • -Vasodialation
    • -Extremities that are warm to the touch
    • -Tachycardia, tachypnea
  3. S/s of cardigenic shock
    • -Hepatomegaly
    • -cardiomegaly
    • -Increased central venous pressure
    • -Periorbital edema
    • -crackles
    • -Diaphoresis
    • -Oliguria
    • -Reduced capilary refill
    • -Diffrences in proximal and distal pulses
  4. General symptoms of Shock
    • -Hypotension is a LATE sign of shock
    • -Watch for change in loc (condition is worsening) 
    • -Tachycardia
  5. What is the most common cause of shock in children?
    Hypovolemia, characterized by an overall decrease in circulating blood or fluid volume.
  6. What are common causes of hypovolemic shock?
    • Hemmorage
    • burns 
    • dehydration
    • Surgery
    • blood loss by trauma
    • (Plasma losses)
    • Vomiting
    • diarrhea
    • burns
    • diabetic keto acidosis
  7. What is the cause of distrbutive shock?
    It is a result of an abnormality in the distribution of blood flow or inability of the body to maintain vacular tone through vasconstriction.
  8. What is the most common form of distributive shock?
    Septic Shock, and occurs when microbial toxins (form bacteria, viruses, fungi or rickettsiae are presnet in the blood.
  9. What do the toxins in the blood do during septic shock?
    Cause a cascade of meabolic hemodynamin and clinical changes resulting in impaired organ perfuison and hypotension.
  10. Which children are at greater risk or septic shock?
    • ones with debilitating illnesses and prolonged hospitalization in the ICU with many invasive lines 
    • Immunosuppressed children
  11. Give other forms of Distributive shock
    • Anaphylaxis 
    • central nervous injury
    • spinal injury
    • drug intoxication
  12. When does cardiogenic shock occur?
    When myocardial function is impaired and cardiac output is not sufficient to meet the bodies metabolic demands.
  13. What do you look for in cardiogenic shock?
    • Low cardiac output
    • cyanosis
    • resp distress
    • diffrerent extremity B/P
    • poor tissue perfusion
    • poor response to fluid resuscitation
  14. What causes cardiogenic shock?
    • Structual congenital abnormalities 
    • heart disease
    • infectious and noninfetious cardiomyopatheis 
    • intactable arrhythmias 
    • trauma
    • ischemia
    • metabolic abnormalites
    • drug intoxication
    • impaired cardiac function after heart surgery
  15. How is cardigenic shock diffrent from hypovolemic shock
    the compensatory mecehanism that occur in a child with CS my cause more heart damage. they take blood away from teh paeripheral splenci and mesnteric ciruclation to help maintain the vital organs.
  16. General appearance Color
    Looks good-Pink mucus membranes consistent color over the trunk and extremites

    Looks bad- Mottled color gray or pale.
  17. How do you diagnose Shock?
    • Chiefly on the basis of clinical manifestatons and medical history
    • Chest radiograph.
  18. What will the chest radiograph show in cardiogenic shock
    • Enlarged heart
    • pulmonary edema
  19. Why is hypotension a late sign of shock?
    Children can compensate for 25% blood loss with an increased heart rate.and peripheral vascular resistance.
  20. How do you treat hypovolemic shock?
    • Airway 
    • breathing 
    • Circulation- infuse NS or LR
    • crystalloid bolusus 
    • blood transfusions
  21. How do you treat Ditributive shock?
    • Restor hemodynamic status with fluid restriction
    • treat undelying cause
  22. How do you treat for septic shock
    Parenteral antibiotics
  23. Which side of the heart has less pressure?
    The RIGHT side!!

    18 to 30/0 to 5mm
  24. Which blood has less oxygen content??
    Venous (return blood)
  25. What is the pressure in the left ventricle?
    90 to 140/5 mm hg
  26. What are the o2 sats in the left ventricle?
  27. How does fetal circulation differ from neonatal circulation? (3 Ways)
    THe process of gase exchange

    the pressures within the systemic and pulmonary circulations

    and the existaence of anatomic structures that assist in the delver of oxygent rich blood to vital organs.
  28. For a fetus where does gas exchange?
    In the placenta
  29. In fetal circulation where is pressure higher right or left ventrical?
    In fetal circulation they are Equal pressure.
  30. What are the three fetel shunts?
    • Ductus venosus 
    • foramen ovale
    • Ductus arteriosus
  31. What switches gas exchange from placenta to lungs?
    Teh baby's first breath.
  32. Why do the shunts close?
    They close due to pressure change and increased O2 content of the blood.
  33. How long does it take for fetal shunts to close?
    May take several days.
  34. Cardivacular alteration is childresn are either?
    • Congential or
    • acquired
  35. where is the usual site for Cardiac Catheterization?
    The femoral
  36. What is the etiology of Congenital Heart Disease?
    • but may be linked to 
    • DMII
    • Maternal infection
    • smoking during pregnancy
    • obesity
    • exposure to chemicals
  37. What genitec conditions increase risk for CHD?
    • Trisomy 21
    • Turner syndrome (Girls)
    • Klinefelter (boys)
    • Marfan syndrome 
    • velocardiocafacial syndrome
    • family history
  38. What is Shunt?
    Abnormal blood flow form one part of the circulatory system to another.
  39. What is heart failure?
    The hearts inability to circulate blood to maintain sufficeient cardiac output to meet the metabolic demands of the body.
  40. How the does the heart intialy responed in Heart failure?
    Increases heart rate. over time the heart may become enlarged (cardiomegaly) causing the wall muscles to grow weak and inefficient.
  41. What happens when the heart muscles become weak?
    can reduce blood volume in the body which causes the body's arteries to constict and for the heart to work even harder. and can lead to pulmonary edema.
  42. What are the subtle symptoms in early CHF?
    • Tachypnea (70-80 breaths)
    • poor feeding 
    • diaphoresis during feeding
    • dyspnea during feeding
    • lethargic
    • abnormal cardic rythm gallop
    • periorbital and facial edema n
    • neck vein distention 
    • hepatomegaly 
    • splenomegaly 
    • decreased peripheral perfusion
    • decreased urine output
    • mottling and cynosis, pallor
  43. If a Hf baby exhibits diaphoresis and complain of decreased appetite what can cause this?
    Chornic abd pain usually related to poor circulation and decreased perfusion to abd organs.
  44. Why should you use O2 with caution in children with left to right shunts?
    Because oxygen is a vasodilator it may increase pulmonary blood flow.
  45. If the child has not been able to decrease symptoms and achieve weight gain what would you do?
    Sugical intervention.
  46. What can increase the risk for digoxin toxicity?
    • Hypokalemia
    • hypomagnesium
  47. What is pulmonary hypertension?
    • Elevated blood pressure in the blood vessels of the lungs
    • Diagnosesd when pressure is>25 mmhg
  48. What is the most common cause PAH
  49. How long does it take for PAH to occur?
    Over time when vascular changes eventually lead to vessle wall thickening severe irreversible vasoconstriction and vascular obstruciotn. causes a reversal of cardiac shunting and become right to left. (Eisenmenger syndrome)
  50. What is used to treat PAH in newborns?
    Inhaled nitric oxide because it is an effective pulmonary vasodialator.
  51. Give types of Congenital Heart Disease? CHD
    Acyanotic (L to R shunt)

    • atreial septal defect
    • –Ventricular
    • Septal
    • Defect (VSD)

    • –Patent
    • Ductus Arteriosus
    • (PDA)

    • –Atrioventricular Septal
    • Defect (AVSD)

    • –Stenotic
    • Lesions including pulmonary stenosis, aortic stenosis, coarctation of
    • the aorta, and interrupted aortic arch
  52. Types of CHD (cont)
    •Cyanotic Lesions (R to L shunt)

    • –Tetralogy
    • of Fallot

    • –Tricuspid
    • valve abnormalities

    • –Pulmonary
    • atresia

    • –Pulmonary
    • stenosis

    • –Hypoplastic L.
    • heart

    • –Transposition
    • of the great arteries

    • –Single
    • ventricle
  53. What is the gold standard for cardiac therapeutic modalities
    Cardiac Catherterizaton it usually constitutes teh final definitive diagnostic test for many patients.
  54. Complications to be aware of in cardiac cathererization?
    • Dysrhiythmias
    • hemmorrhage
    • vascular damage 
    • vasospasm
    • thrombus 
    • emboules 
    • infectio 
    • reaction to the dye
    • catheter perforation
  55. How can you tell if there is a thrombus in the venous system?
    swelling and inflamation to the affected limb
  56. How can you tell there is a thrombus in the arterial system?
    Coolness or dicoloration of the extremity and loss of pulses distal to the thrombus.
  57. How is the patient positoned after cardiac catherezation?
    positioned with the affected leg straight for 4-6hrs. Infants my be held prone on a parents lap. older children remain in bed with a 20 degree incline only.
  58. How should you assess for bleeding in a cardiac cath child?
    Not only on the dressing but on the sheets look for pooled blood under the child, remove diaper if needed.
  59. What should you do if a cardiac cat patient is bleeding?
    Apply pressure for 10-15 min and assess distal perfusion, notifiy the physician
  60. How soon can a cath kid return to school?
    After the third day.
  61. Patent Ductus Arteriosus (PDA)
    Left to rigth shuntin Lesions

    • Increased
    • O2 in the infant’s blood causes the ductus arteriosis to constrict in 10-18 hrs. after birth.
    • This doesn’t happen 10-15% of the time and results
    • in a PDA
  62. S/S of PDA
    Continuous murmer- machiner like sound 

    Widened pulse pressure (increased differecnce between systolic and diastolic readings

    bounding pulse

    cardiac enlargment
  63. Medical managment of PDA?
    Interventions to address heart failure

    admin of indocin- a PG inhibitor that constricts the ducts

    Interventions Cardiac cath

    a coil is place to occlude the ducts, tissue grows around the coil forming a permanent occlusion

    Ligation of the ductus via left thoracotomy usually within the first year of life
  64. Atrial Septal Defect (ASD)
    • ASD causes increased size of R
    • atrium and increased pulmonary blood flow and often closes on its own.
  65. Ventricular Septal defect (VSD)
    • 20-80% close on their own. 
    • Decrease in pulmonary vascular resistance compared to systemic vascular resistance in the weeks after birth results in left to right shunting through the VSD 
    • Increased pulmonary blood flow 

    pulmonary hypetension 

    Progressive pulmonary vascular disease can occur over time.
  66. S/s of VSD?
    Some children remain asymptomatic

    • Loud, harsh systolic murmur varies in intensity and duration depending on degree of shuntin and size of defect palpable thrill 
    • diastolic murmru and gallop rhythm may be present 

    HF may occur with moderate to large defects
  67. Sugical managment of VSD?
    Suture or patch closure using open heart surgery with cardiopulmonary bypass

    Consideration of pulmonary artery banding to reduce pulmonary blood flow
  68. Ostructive/Stenotic Lesions
    Pulmonay stenosis (narrow entrace to the pulmonary artery usually at the valve)
  69. S/S of obstructive/stenotic lesions
    • in symptomatic children 
    • exercise intolerance 
    • signs of right-sided HF
    • systolic ejection murmur
    • possible palpable murmur
    • cardiomegaly on radiograph 
    • cyanosis in severe cases
  70. Aortic Stenosis
    Narrowing of the entract to the aorta may b supravalvular, subvalvular or at the valve level (most common) thickend rigid with some fusion of the leaflets the valve may be bicuspid
  71. What is Tetrology of Fallot (TOF)
    • Most common cyanotic lesion seen in
    • the 1st
    • yr. of life

    •Includes 4 defects

    • –VSD
    • (Ventricular Septal
    • Defect)

    • –Pulmonary
    • Stenosis

    • –Overriding
    • aorta

    • –R
    • ventricular hypertrophy (due to the pulmonary stenosis)
  72. Other
    Cyanotic Lesions
    • Tricuspid atresia (infant has
    • cyanosis within few hrs. after birth)

    • •Pulmonary atresia (profound
    • cyanosis early)

    •Truncus arteriosus

    • •Hypoplastic L heart (95% die if untreated
    • within the 1st
    • months of life)

    • •Transposition of the great vessels
    • (mixing lesion).  Often accompanied by
    • VSD
  73. Cardiac
    Surgery in Pediatrics
    Trend is to do the surgery early

    • •Closed heart surgery includes
    • repair of a PDA, coarctation of the aorta, & some aorta to
    • pulmonary shunts

    • •Open heart surgery is done for ASD,
    • VSD, Tetrology of Fallot,
    • and some other defects.
  74. Acquired
    Heart Disease
    • These are not present at birth;
    • however, if the child has CHD then they may develop acquired heard disease
    • (i.e. dysrrhythmias & endocarditis)
  75. Acquired
    Heart Disease includes
    • Endocarditis  -
    • Cardomyopathies
    • Rheumatic
    • Fever  -
    • Dysrhythmias
    • Kawasaki
    • Disease  -
    • High Cholesterol
    • Hypertension
  76. Factors that play a role in acquired heart disease is?
    • Genetic tendencies
    • autoimmune responses
    • infection
  77. What is Infective Endocarditis
    Infective endocarditis IE is an inflammation resulting from infection of the cardiac valves and endocardium by bacterial or occasionally a fungal viral agent.
  78. Endocarditis
    • Underlying
    • inflammation
    • •Cause can be bacterial or fungal

    • •Seen often in pts. with cardiac
    • defects, rheumatic fever, prosthetic heart valves, cardiomyopathy, mitral valve
    • prolapse, previous bacterial endocarditis with a gram positive organism.

    • •Incidence is higher now than in the
    • past

    •High mortality and morbidity rate
  79. Infections leading to endocarditis can result from?
    • Dental work
    • invasive surgery to respiratory tract
    • however most cases are not attributable to invasisve procedure
  80. S/S of Endocarditis
    • Fever
    • nonspecific complaints of anorexia
    • nausea
    • fatigue 
    • malaise 
    • arghralgias
    • chest pain
    • HF
    • Petechieae
    • neurologic impairment 
    • emoblic events 
    • heart murmur
  81. befor a dental/sugical procedure you should give?
    amoxicillin 1 hour prior to.
  82. Antibiotics for IE from Bacteria includes parenteral admin of antibiotics for how long?
    2-8 weeks depending on pathogen and clinical circustances.
  83. WHat surgical interventions are indicated in acute forms of endocardities?
    excison of the vegetation or removal of an infected valve
  84. Rheumatic
    • Inflammatory condition due to
    • untreated or partially treated group A betahemolytic strep. infection of the resp.
    • tract

    •Affects connective tissues

    • •Causes damage to cardiac valves
    • (mainly effects the mitral and aortic valves)

    • Seen most in 5-15 yr. olds in late
    • winter & sprin
  85. What is Rheumatic FEver?
    a diffuse inflammatory conditon most probably of autoimmune origin of the connective tissue primarily of the heart joints subq tssues brain and blood vessles
  86. Permenant damge to the cardiac valves can be caused by?
    Rheumatic heart disease, most commonly the mitral and aortic valves.
  87. S/S  of RF?

    Carditis- inflammation of the endocardium

    Chorea-Involuntary purposless jerking movements, speech impairment, emotial lability 

    Erythema marginatum- red painless skin lesions tat start flat or slightly raised macule usually over the trunk. has a central clearing

    Subq nodules small nontender lumps attached to the tendon sheaths of joints and on bony promineces associated with SEVERE RF
  88. Rheumatic
    Fever Dx & Tx
    Jones criteria used for Dx (p. 1230). 

    • •Pt. must have 2 major symptoms
    • or          1 major symptom & 2 minor
    • symptoms to be diagnosed with rheumatic fever

    • •Treatment is antibiotics for strep.
    • bacteria and treat the patient’s symptoms

    •Prophylaxis therapy may be for life
  89. Once RF diagnosis is confirmed antiinflammatory agents are used such as?
    Asprin, corticosteroids in the presece of significant cardits
  90. Kawasaki
    Mucocutaneous lymph node syndrome

    • •Acute disease with fever, rash
    • & vasculitis

    • •Major cause of acquired heart
    • disease

    •Coronary artery aneurysms

    • •Cause is unknown, but may be immune
    • mediated after an infection

    • •Affects the medium sized arteries
    • (cardiac)

    • •Seen in children <5 yrs. old
    • (peak 18-24 mos.)

    • •Seen more in late winter and early
    • spring
  91. Kawasaki
    • Acute Phase first 10-14 days with
    • high fever x 5 or more days, unresponsive to antibiotics. SX:
  92. Kawasaki
    Sx (cont)
    Second Phase from day 15-25

    • Fever disappears, irritability, anorexia, desquamation of fingers &
    • toes, arthritis, cardiac symptoms (CHF, dysrhythmias & cardiac aneurysims) can lead to an MI

    • •Third Phase is convalescent stage
    • from day 26 until the sedimentation rate is normal and symptoms are gone (deep
    • grooves in the nails may be noticed)
  93. Kawasaki
    Dis. Diagnosis
    • Diagnosis made if patient has fever
    • x 5 days and has 4 of 5 symptoms of the acute stage
    • -Bilateral nonpurulent conjuctivitis
    • -Orl mucosal alterations (strawberry tounge)
    • -redness of the hands and feet followed by desquamantion
    • -Rash on the trunk
    • -Cervical lymphadenopathy with large nodes 
    • -No other known disease process to explain the signs and symptoms
  94. Treatment of Kawasaki Dis
    • Treatment is to prevent cardiac
    • damage

    • High
    • dose IVIG in early phases

    • –High
    • dose aspirin until fever resolves and then lower doses to decrease platelet
    • aggregation and thereby decrease incidence of aneurysm formation & MI
  95. What is cardiomegaly?
    Enlarged heart.
  96. Maintenance of adequate blood flow accomplished by cadiac and circulatory adjustments?
  97. inability of the heart to maintain adequate circulation.
  98. Pulmonary edema?
    Collection of excess fluid in alveoli?
  99. Increased pressure in pulmonary atreries and atrerioles?
    Pulmonary hypertension
  100. Abnormal blood flow from one part of teh circulatory system to another?
  101. T/F - cental venous pressure (CVP) is measured in the left ventrical.
  102. T/F- A drugs inotropic effect has an affect on myocardial contractility?
  103. T/F- Pulmonary vascular resistance affects the left ventrical?
  104. T/F- Systemic vascular resitance is the amount of pressure exerted by the systemic vascular bed?
  105. In the fetal circulation gas exhange occurs at the ___?
  106. In fetal circulation oxygenated blood from the placenta flows from teh right atrium into the left atrium through the ____?
    Foramen ovale.
  107. After birth teh fetal shunt between teh pulmonary artery and the aorta which is called the _____ closes?
    ductus arteriosus
  108. After birth pulmonary vascular resistance _____ and the systemic arterial pressure_____?
  109. T/F-Clubbing of nail beds indicates chronic hypoxia?
  110. T/F-The point of maximal impulse (PMI) at the 7th intercostal space indicates cardiomegaly?
  111. T/F- Squatting may be an attempt to improve cardiac circulation?
  112. T/F-Gram positive microorganisms are usually responsible for infective endocarditis?
  113. T/F- Immune complexes play a role in rheumatic fever?
  114. T/F- Kawasaki disease is an inmmune-mediated condition resulting in vaculitis?
  115. T/F- Antibiotic prophylaxis with PCN for at least 5 years is part of the management for Rheumatic fever?
  116. T/F- Vegetation seen on echocardiogram suggests Kawasaki disease?
  117. T/F- congenital heart malformations require infective ednocarities prophylaxis?
  118. T/F- Normal B/P for a child is defined as systolic and or diastolic B/P less than teh 90th percentile for age?
  119. T/F= Children with essential hypertension often have a family history of the disease?
  120. T/F- Renal disease is a complication of secondary hypertension?
  121. T/F-Non-Pharmacologic therapies for hypertension are usually not effective?