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S/S of pedi hypovolemic shock
- -Dry mucous membranes
- -Depressed fontanel
- -Cold clammy skin
- -Poor skin tugor
- Delayed capillary refill.
S/s of Distributive Shock (Early Septic shock)
- -Extremities that are warm to the touch
- -Tachycardia, tachypnea
S/s of cardigenic shock
- -Increased central venous pressure
- -Periorbital edema
- -Reduced capilary refill
- -Diffrences in proximal and distal pulses
General symptoms of Shock
- -Hypotension is a LATE sign of shock
- -Watch for change in loc (condition is worsening)
What is the most common cause of shock in children?
Hypovolemia, characterized by an overall decrease in circulating blood or fluid volume.
What are common causes of hypovolemic shock?
- blood loss by trauma
- (Plasma losses)Vomiting
- diabetic keto acidosis
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.
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.
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.
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
Give other forms of Distributive shock
- central nervous injury
- spinal injury
- drug intoxication
When does cardiogenic shock occur?
When myocardial function is impaired and cardiac output is not sufficient to meet the bodies metabolic demands.
What do you look for in cardiogenic shock?
- Low cardiac output
- resp distress
- diffrerent extremity B/P
- poor tissue perfusion
- poor response to fluid resuscitation
What causes cardiogenic shock?
- Structual congenital abnormalities
- heart disease
- infectious and noninfetious cardiomyopatheis
- intactable arrhythmias
- metabolic abnormalites
- drug intoxication
- impaired cardiac function after heart surgery
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.
General appearance Color
Looks good-Pink mucus membranes consistent color over the trunk and extremites
Looks bad- Mottled color gray or pale.
How do you diagnose Shock?
- Chiefly on the basis of clinical manifestatons and medical history
- Chest radiograph.
What will the chest radiograph show in cardiogenic shock
- Enlarged heart
- pulmonary edema
Why is hypotension a late sign of shock?
Children can compensate for 25% blood loss with an increased heart rate.and peripheral vascular resistance.
How do you treat hypovolemic shock?
- Circulation- infuse NS or LR
- crystalloid bolusus
- blood transfusions
How do you treat Ditributive shock?
- Restor hemodynamic status with fluid restriction
- treat undelying cause
How do you treat for septic shock
Which side of the heart has less pressure?
The RIGHT side!!
18 to 30/0 to 5mm
Which blood has less oxygen content??
Venous (return blood)
What is the pressure in the left ventricle?
90 to 140/5 mm hg
What are the o2 sats in the left ventricle?
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.
For a fetus where does gas exchange?
In the placenta
In fetal circulation where is pressure higher right or left ventrical?
In fetal circulation they are Equal pressure.
What are the three fetel shunts?
- Ductus venosus
- foramen ovale
- Ductus arteriosus
What switches gas exchange from placenta to lungs?
Teh baby's first breath.
Why do the shunts close?
They close due to pressure change and increased O2 content of the blood.
How long does it take for fetal shunts to close?
May take several days.
Cardivacular alteration is childresn are either?
where is the usual site for Cardiac Catheterization?
What is the etiology of Congenital Heart Disease?
- but may be linked to
- Maternal infection
- smoking during pregnancy
- exposure to chemicals
What genitec conditions increase risk for CHD?
- Trisomy 21
- Turner syndrome (Girls)
- Klinefelter (boys)
- Marfan syndrome
- velocardiocafacial syndrome
- family history
What is Shunt?
Abnormal blood flow form one part of the circulatory system to another.
What is heart failure?
The hearts inability to circulate blood to maintain sufficeient cardiac output to meet the metabolic demands of the body.
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.
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.
What are the subtle symptoms in early CHF?
- Tachypnea (70-80 breaths)
- poor feeding
- diaphoresis during feeding
- dyspnea during feeding
- abnormal cardic rythm gallop
- periorbital and facial edema n
- neck vein distention
- decreased peripheral perfusion
- decreased urine output
- mottling and cynosis, pallor
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.
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.
If the child has not been able to decrease symptoms and achieve weight gain what would you do?
What can increase the risk for digoxin toxicity?
What is pulmonary hypertension?
- Elevated blood pressure in the blood vessels of the lungs
- Diagnosesd when pressure is>25 mmhg
What is the most common cause PAH
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)
What is used to treat PAH in newborns?
Inhaled nitric oxide because it is an effective pulmonary vasodialator.
Give types of Congenital Heart Disease? CHD
Acyanotic (L to R shunt)
- atreial septal defect
- Defect (VSD)
- Ductus Arteriosus
- –Atrioventricular Septal
- Defect (AVSD)
- Lesions including pulmonary stenosis, aortic stenosis, coarctation of
- the aorta, and interrupted aortic arch
Types of CHD (cont)
•Cyanotic Lesions (R to L shunt)
- valve abnormalities
- of the great arteries
What is the gold standard for cardiac therapeutic modalities
Cardiac Catherterizaton it usually constitutes teh final definitive diagnostic test for many patients.
Complications to be aware of in cardiac cathererization?
- vascular damage
- reaction to the dye
- catheter perforation
How can you tell if there is a thrombus in the venous system?
swelling and inflamation to the affected limb
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.
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.
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.
What should you do if a cardiac cat patient is bleeding?
Apply pressure for 10-15 min and assess distal perfusion, notifiy the physician
How soon can a cath kid return to school?
After the third day.
Patent Ductus Arteriosus (PDA)
Left to rigth shuntin Lesions
- 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
S/S of PDA
Continuous murmer- machiner like sound
Widened pulse pressure (increased differecnce between systolic and diastolic readings
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
Atrial Septal Defect (ASD)
- ASD causes increased size of R
- atrium and increased pulmonary blood flow and often closes on its own.
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
Progressive pulmonary vascular disease can occur over time.
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
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
Pulmonay stenosis (narrow entrace to the pulmonary artery usually at the valve)
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
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
What is Tetrology of Fallot (TOF)
- Most common cyanotic lesion seen in
- the 1st
- yr. of life
•Includes 4 defects
- (Ventricular Septal
- ventricular hypertrophy (due to the pulmonary stenosis)
- Tricuspid atresia (infant has
- cyanosis within few hrs. after birth)
- •Pulmonary atresia (profound
- cyanosis early)
- •Hypoplastic L heart (95% die if untreated
- within the 1st
- months of life)
- •Transposition of the great vessels
- (mixing lesion). Often accompanied by
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.
- These are not present at birth;
- however, if the child has CHD then they may develop acquired heard disease
- (i.e. dysrrhythmias & endocarditis)
Heart Disease includes
- Endocarditis -
- Fever -
- Disease -
- High Cholesterol
Factors that play a role in acquired heart disease is?
- Genetic tendencies
- autoimmune responses
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.
- •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
•High mortality and morbidity rate
Infections leading to endocarditis can result from?
- Dental work
- invasive surgery to respiratory tract
- however most cases are not attributable to invasisve procedure
S/S of Endocarditis
- nonspecific complaints of anorexia
- chest pain
- neurologic impairment
- emoblic events
- heart murmur
befor a dental/sugical procedure you should give?
amoxicillin 1 hour prior to.
Antibiotics for IE from Bacteria includes parenteral admin of antibiotics for how long?
2-8 weeks depending on pathogen and clinical circustances.
WHat surgical interventions are indicated in acute forms of endocardities?
excison of the vegetation or removal of an infected valve
- Inflammatory condition due to
- untreated or partially treated group A betahemolytic strep. infection of the resp.
•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
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
Permenant damge to the cardiac valves can be caused by?
Rheumatic heart disease, most commonly the mitral and aortic valves.
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
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
Once RF diagnosis is confirmed antiinflammatory agents are used such as?
Asprin, corticosteroids in the presece of significant cardits
Mucocutaneous lymph node syndrome
- •Acute disease with fever, rash
- & vasculitis
- •Major cause of acquired heart
•Coronary artery aneurysms
- •Cause is unknown, but may be immune
- mediated after an infection
- •Affects the medium sized arteries
- •Seen in children <5 yrs. old
- (peak 18-24 mos.)
- •Seen more in late winter and early
- Acute Phase first 10-14 days with
- high fever x 5 or more days, unresponsive to antibiotics. SX:
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)
- 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
Treatment of Kawasaki Dis
- Treatment is to prevent cardiac
- dose IVIG in early phases
- dose aspirin until fever resolves and then lower doses to decrease platelet
- aggregation and thereby decrease incidence of aneurysm formation & MI
What is cardiomegaly?
Maintenance of adequate blood flow accomplished by cadiac and circulatory adjustments?
inability of the heart to maintain adequate circulation.
Collection of excess fluid in alveoli?
Increased pressure in pulmonary atreries and atrerioles?
Abnormal blood flow from one part of teh circulatory system to another?
T/F - cental venous pressure (CVP) is measured in the left ventrical.
T/F- A drugs inotropic effect has an affect on myocardial contractility?
T/F- Pulmonary vascular resistance affects the left ventrical?
T/F- Systemic vascular resitance is the amount of pressure exerted by the systemic vascular bed?
In the fetal circulation gas exhange occurs at the ___?
In fetal circulation oxygenated blood from the placenta flows from teh right atrium into the left atrium through the ____?
After birth teh fetal shunt between teh pulmonary artery and the aorta which is called the _____ closes?
After birth pulmonary vascular resistance _____ and the systemic arterial pressure_____?
T/F-Clubbing of nail beds indicates chronic hypoxia?
T/F-The point of maximal impulse (PMI) at the 7th intercostal space indicates cardiomegaly?
T/F- Squatting may be an attempt to improve cardiac circulation?
T/F-Gram positive microorganisms are usually responsible for infective endocarditis?
T/F- Immune complexes play a role in rheumatic fever?
T/F- Kawasaki disease is an inmmune-mediated condition resulting in vaculitis?
T/F- Antibiotic prophylaxis with PCN for at least 5 years is part of the management for Rheumatic fever?
T/F- Vegetation seen on echocardiogram suggests Kawasaki disease?
T/F- congenital heart malformations require infective ednocarities prophylaxis?
T/F- Normal B/P for a child is defined as systolic and or diastolic B/P less than teh 90th percentile for age?
T/F= Children with essential hypertension often have a family history of the disease?
T/F- Renal disease is a complication of secondary hypertension?
T/F-Non-Pharmacologic therapies for hypertension are usually not effective?