Unit 2- Peds Cardiac

What's the magic number for remembering important things for Kawasaki Disease?

"5" 1. Child is probably younger than 5 2. Has to have fever for 5 days 3. Has to meet 5 clinical criteria

What is tell tale sign for patent ductus arteriosus?

"Machine-like" murmur heard

What kids are at increased risk for having Infective Endocarditis (IE)?

(Hint... Think Valves & Central Lines) Kids with Congenital heart defects (septum or valve defects) or prosthetic valves are at increased risk - If a kid has CHD, they're gonna have surgeries and some kind of prosthetic valve - these kids also have central and PICC lines, which are sites at risk for infection

What are minor criteria for having rheumatic fever? How many does a pt have to have to be diagnosed?

1 Major criteria + 2 minor MINOR CRITERIA (Pt MIGHT ALSO HAVE): pretty generic lad values CLINICAL: 1. Arthralgia (joint stiffness) 2. Fever LAB: 1. Elevated ESR 2. Elevated CRP 3. Abnormal EKG

Tetralogy of Fallot Clinical Manifestations:

1. Acute cyanosis at birth or mild cyanosis that progresses as Pulmonic Stenosis worsens 2. + Systolic murmur 3. Tet spells/Anoxic spells = acute episodes of hypoxia & cyanosis. - Oxygen requirements exceed blood supply. - Happens whenever pressure in right side of heart is greater than left side of heart - Usually during crying or feeding - Increases pressure on right side of heart

Rheumatic Fever Tx:

1. Antibiotic treatment of streptococcal infections (Penicillin) 2. Aspirin -1st line or steroids-controversial) to combat inflammatory process 3. Bedrest in acute phase (decrease cardiac demand on heart) 4. Those who have had RF are susceptible to recurrent RF & further heart damage - Prophylaxis with antibiotics for possibly years to prevent recurrance https://www.osmosis.org/learn/Rheumatic_heart_disease

Atrial Septal defect Clinical manifestations:

1. Asymptomatic OR 2. Heart Failure Symptoms 3. + Murmur

What are congenital heart diseases with increased pulmonary blood flow? What do these type of congenital heart diseases result in?

1. Atrial septal defect 2. Ventricular septal defect 3. Patent ductus arteriosus Result = Heart Failure symptoms

How is hypertension classified in kids?

1. BP persistently > 95th% for age, gender & height 2. Prehypertension persistently between 90-95% for age, gender, & height

Nursing interventions for administering digoxin to kids:

1. Calculating & administering correct dose 2. Check apical pulse x 1 minute - Hold if < 90 bpm (infants & young kids) or < 70 bpm (older kids) - CO = HR x SV - If kid already has low heart rate and you give them digoxin lowering their heart rate even more, they cannot make that up by increasing SV because their heart is so small, so their CO will end up decreasing 3. Observing for toxicity - Narrow margin of safety - N/V, anorexia, bradycardia, dysrhythmias (lengthening PR interval) 4. Parental teaching - Return demonstrations from parents on how to admin meds - teach parents that they NEED to be compliant, keep up with giving drug as prescribed

Care after Cardiac Catheter

1. Change the pressure dressing on the day after the procedure. Apply a dry sterile dressing or adhesive bandage for the next several days. Keep the dressing dry; cover it with plastic if there is a chance that the dressing could become wet or soiled. 2. When changing the dressing, inspect the insertion site for redness, irritation, swelling, drainage, and bleeding. Report any of these to the physician or nurse practitioner. 3. Check the temperature, color, sensation, and pulses on the child's extremities and compare. Report any changes to the physician or nurse practitioner. 4. Resume the child's usual diet after the procedure; report any nausea or vomiting. 5. Check the child's temperature at least once a day for approximately 3 days after the procedure. Report any temperature elevation of 100.4°F or greater. 6. Avoid giving the child a tub bath for approximately 3 days after the procedure; use sponge baths or showers instead. - because there is a chance for INFECTION (sepsis) 7. Discourage strenuous exercise or activity for approximately 3 days after the procedure. 8. Watch for changes in the child's appearance, such as changes in skin color, reports of the heart "fluttering" or "skipping a beat," fever, or difficulty breathing. 9. Give acetaminophen (Tylenol) or ibuprofen (Motrin) for complaints of pain. 10. Schedule a follow-up appointment with the physician or nurse practitioner in the time specified

What are the obstructive congenital heart defects?

1. Coarctation of the aorta 2. Aortic stenosis 3. Pulmonic stenosis

Risk factors for congenital heart disease in children

1. Congenital malformations 2. Genetic syndromes - if child has this they are very likely to have a heart defect 3. Family history 4. Maternal drug or alcohol exposure, infection, and diabetes 5. Prematurity -things that should be closing, like shunts, stay open when they shouldn't

Truncus Arteriosus Clinical Manifestations:

1. Cyanosis 2. HF 3. +Holosystolic murmur 4. +/- diastolic murmur 5. High association w/ 22q11 deletions

Aortic Stenosis Clinical Manifestations: -include how it affects infants vs older kids

1. Decreased cardiac output 2. Infants = faint pulses, hypotension, tachycardia, poor feeding (bad CO= activity intolerance = poor feeding for infants) 3. Older = Exercise intolerance, chest pain, dizziness 4. +/- Systolic ejection murmur Ejection murmur= valve problem

What are some uses of cardiac catheterization?

1. Diagnostic tool for heart disorders 2. Interventional tool - can stick catheter up to heart to fix a problem that we know already exists 3. Electrophysiologic- there's some cells that are pretending to be pacemaker cells in the heart that need to be zapped and get rid of

How to improve cardiac function in children with heart failure:

1. Digoxin = Improved contractility, make pump work better 2. ACE Inhibitors ("pril" sisters) = Reduce afterload, indirectly reduce preload - Check HR and BP 3. Beta-Blockers ("-lol) = Block epi & norepi allowing heart to relax, beat slower - Check HR and BP

What are the classifications of congenital heart diseases?

1. Disorders with decreased pulmonary blood flow (cyanotic) 2. Disorders with increased pulmonary blood flow (acyanotic) 3. Obstructive disorders 4. Mixed disorders

How to remove accumulated fluid and sodium in children with heart failure:

1. Diuretics (#1 way) 1. Furosemide (Lasix) - Common - Loop diuretic so can decrease electrolyte values - Caution: Hypokalemia can enhance effects of digoxin (which we also give to HF pts) 2. Chlorothiazide (Diuril) 3. Spironolactone (Aldactone) - Weak diuretic - K+ sparing 2. Fluid restriction (common to do in adults, less common in infants/kids) 3. Sodium restriction (common to do in adults, less common in infants/kids) - Hard to do because can't really alter Na in breastmilk and formula - Doc may give special formula w/ less sodium

Hypertension Tx:

1. Fix the organ that's the problem 2. Secondary HTN - Diagnosis & treat underlying cause (whichever organ causing it) 3. Primary HTN: Lifestyle modifications first line therapy 4. If unresponsive to lifestyle changes combination of lifestyle and meds used: 1. Beta-blockers 2. Calcium channel blockers 3. Angiotensin-converting enzyme (ACE) inhibitors 4. Angiotensin receptor blockers Diuretics

Patent Ductus Arteriosus Tx and prognosis:

1. Fixable (surgery or cardiac cath) - Good prognosis 2. Pharmacologically: 1. Indomethacin (prostaglandin inhibitor) may be given to try to close ductus arteriosus - this is like when the umbilical cord is cut, the placenta can no longer give the prostaglandin it produces to the ductus arteriosus, causing it to close

Ventricular Septal defect Tx and prognosis?

1. Fixable (surgery) 2. Many close spontaneously in 1st year of life 3. Prognosis depends on location, #, and other associated defects (single membranous = good prognosis)

What are some acquired pediatric heart disorders?

1. Heart Failure (most common) 2. Infective endocarditis 3. Rheumatic fever/heart disease 4. Kawasaki's Disease 5. Cardiomyopathy 6. Hyperlipidemia 7. Hypertension

Ventricular Septal defect Clinical manifestations?

1. Heart Failure Symptoms (common) 2. + Loud Holosystolic (all of systole) Murmur

Coarctation of the Aorta Clinical Manifestations: -include how it affects infants vs older kids

1. Hyperdynamic perfusion upper extremities - Pulses will prob be bounding, +4 - Arm blood pressure high - Good cap refill on fingers 2. poor perfusion lower extremities - Pulses will prob be weak, +1 - Leg BP low - Bad cap refill toes 3. Brachial-Femoral delay - Quality of pulse will be worst/weaker in femoral pulse than brachial pulse 4. Infants = HF symptoms even hemodynamically instability 5. Older kids = Dizziness, HA, fainting, nose bleeds d/t hypertension

What are the 4 management goals of heart failure in children?

1. Improve cardiac function 2. Remove accumulated fluid and sodium 3. Decrease cardiac demands 4. Improve tissue oxygenation

How to improve tissue oxygenation in children with heart failure:

1. Improve myocardial function - do what you said for improving cardiac function and decreasing cardiac demands 2. Lessen tissue oxygen demands (think nursing interventions) 3. Alter feeds 4. Minimize stress 5. Normothermia(avoid cold/heat stresses) 6. Avoid preventative insults (skin breakdown, colds) 7. Oxygen AS ORDERED to maintain SpO2 as ordered - Remember Oxygen is a drug! - ask the goal SpO2 for each specific patient

Infective Endocarditis (IE) Tx:

1. IV antibiotics (long course) (2-8 weeks) 2. Periodic blood cxs (blood culture) to monitor response 3. Periodic echos to monitor cardiac function 4. +/- Surgery to repair damaged valve

Infective Endocarditis (IE) Pathophys:

1. Infection (typ bacterial) of the valves & inner lining of the heart (endocardium) - Infective emboli can result 2. Organisms can enter bloodstream from any site of localized infection: - Brushing teeth/dental (very common) - UTIs (why we don't like foleys) - Surgery - catheters/needles - Central lines (Hint.. think valves and central lines)

Risk factors for acquired heart disease in children

1. Infections (rheumatic fever, Kawasaki disease, endocarditis) 2. Obesity 3. Diabetes 4. Drug or alcohol exposure 5. Hypertension 6. Chemotherapy 7. Other diseases (connective tissue disorders, autoimmune or endocrine diseases) 8. Organ transplant 9. Hyperlipidemia

fetal blood flow

1. Inferior vena cava has both oxygenated blood from the placenta and deoxygenated blood from the fetus 2. Blood then travels to the right atrium 3. Most of the blood, because it includes oxygenated blood, will go through the foramen ovale (shunt btwn right and left atrium) - This is so the left side of the heart can receive oxygenated blood to send out to the rest of the body through the aorta 4. From the right atrium some of the blood will travel to the right ventricle and up the pulmonary artery - Some of this blood will travel to the lungs so the tissue is perfused - But most of the blood will be shunted by the ductus arteriosus (shunt connecting pulmonary artery and aorta) to the aorta and out to the rest of the fetal body instead of going to the lungs

What are the reasons for heart murmurs occurring?

1. Innocent: No anatomic or physiologic abnormality 2). Functional: No anatomic abnormality but a physiologic abnormality present - if you change the blood, like decrease hemoglobin, it'll flow differently through the heart than blood with a normal hemoglobin 3). Organic: Anatomic abnormality present with or without a physiologic abnormality

Infective Endocarditis (IE) Clinical Manifestations

1. Insidious/sneaky onset 2. Unexplained low-grade and intermittent fever 3. Anorexia/Weight loss - Because they tired and don't feel good 4. Malaise 5. New murmur 6. Dysrhythmias 7. CHF - Because endocarditis affects how heart is pumping Findings Caused by Extracardiac Emboli 1. Splinter hemorrhages = thin, black lines under nails 2. Oral mucosa petechiae 3. Osler nodes = red, painless nodes on finger pads 4. Janeway lesions = painless hemorrhagic areas on palms & soles 5. Roth Spot = Retinal red spot w/ pale center

Kawasaki disease Tx:

1. Intravenous immunoglobulin (IVIG) - reduces incidence of coronary artery abnormalities - Retreatment can be given if response incomplete (pt remains febrile) - Treat like a blood product (consent, frequent vitals, monitor for allergic reaction) 2. Acetylsalicyclic acid (ASA) at high-dosing (anti-inflammatory dosing) - Once fever subsides, ASA decreased to low-dose (anti-platelet dosing) of 3 to 5 mg/kg/day - Low-dose ASA continued until platelet count returns to normal (6-8 weeks)

Kawasaki disease Discharge Teaching

1. Irritability can persist for up to 2 months 2. Peeling of the hands and feet painless and occurs in the second and third weeks 3. Arthritis, especially of the larger weight-bearing joints, may persist for several weeks. Passive range-of-motion exercises in bathtub helpful in increasing flexibility 4. Live immunizations (e.g., measles-mumps-rubella, varicella) should be deferred for 11 months after administration of IVIG because may not produce necessary amount of antibodies to confer immunity 5. Decision to give the varicella (chickenpox) vaccine while the child is receiving aspirin therapy is made individually by the practitioner. 6. Temperature should be recorded daily for 1-2 weeks after and any recurrence reported. 7. CPR teaching with coronary artery involvement 8. Must keep all cardiology appts and echos!! - Compliance compliance compliance from parents

What does rheumatic fever affect?

1. Joints 2. skin 3. brain 4. serous surfaces/membrane - thin membrane that lines the internal body cavities and organs (heart, lungs, and abdominal cavity). - allows for frictionless movement of vital organs - ex: pericardium surrounding heart & blood vessels, pleural membranes surrounding lungs, peritoneal membrane surrounding abdominal cavity 5. HEART

How do you document heart murmurs?

1. Location heard best 2. Time heard within the cardiac cycle (S1-S2) 3. Intensity in relation to child's position (sitting, standing, lying, etc.) 4. Loudness -> Grade

Pulmonic stenosis Clinical Manifestations: -include how it affects infants vs older kids

1. May be asymptomatic 2. Mild cyanosis or HF 3. Progressive narrowing causes increased symptoms 4. Severe narrowing = cyanosis - Bc this is an oxygen prob defect 5. Loud systolic ejection murmur LUSB - murmur may be softer if severe d/t decreased cardiac output & shunting 6. Cardiomegaly on CXR

Infective Endocarditis (IE) Prevention:

1. Prophylactic antibiotics to at-risk patients prior to dental or invasive procedures given 1 hour prior to procedure - at -risk pts: 1. Previous Infective Endocarditis 2. Prosthetic cardiac valve 3. Congenital heart disease pts per AHA criteria 2. Encourage medical card identification

Hypoplastic Left-sided Heart Syndrome Clinical manifestations:

1. Mild cyanosis & HF symptoms until PDA closes then deterioration, cyanosis, & cardiovascular collapse. 2. FATAL without intervention.

Kawasaki disease Nursing care

1. Minimize skin discomfort, cool cloths; unscented lotions; and soft, loose clothing are helpful. 2. Mouth care, including lubricating ointment to the lips, is important for mucosal inflammation. 3. Clear liquids and soft foods can be offered. 4. Patient irritability most challenging problem. Need a quiet environment that promotes adequate rest. - DO NOT cohort this child with other patients - This child needs to be in their own room down the hall where it's quiet 5. Parents need to be supported in efforts to comfort an often inconsolable (irritable)child. May need time away from their child. - You may see test question that literally says stay w/ child while parent takes a break

Tetralogy of Fallot Pathophys: Result of defect:

1. Pressures in rt and lt ventricles often equal so shunt direction (blood flow direction) depends on difference between pulm and systemic vascular resistance - If pulm vascular resistance higher = Shunt right -> left (cyanosis) - If systemic vascular higher = Shunt left -> right 2. Degree of Pulmonic Stenosis determines degree of cyanosis Result = Cyanosis + Hypercyanosis (Reduced pulm blood flow + Rt-> Lt shunt with Tet spells (hypercyanotic spells))

Hypoplastic Left-sided Heart Syndrome Tx:

1. Neonates require stabilization, CMV (mechanical ventilation), & inotropic support. - inotropes = increase myocardial contractility, increasing heart rate (ex: digoxin) Pharm: 2. Prostaglandin E1 infusion needed to keep PDA open to ensure systemic blood flow. Surgery: 3. Multi-stage surgical correction. 4. Transplantation may be needed.

How to decrease cardiac demands in children with heart failure:

1. Normothermia (avoid cold/heat stresses) 2. Treat existing infections 3. Reduce the effort of breathing 4. Sedation if needed 5. Decreased environmental stimuli 6. Individualized feeds (short intervals, NG, caloric density) - Ex: may let baby bottle feed for 20 minutes instead of an hour like they normally do and then put the rest of the feed down NG tube - May increase caloric density since kid is doing less and/or shorter feedings

Assessment findings in heart failure in children

1. Poor feeding 2. Poor growth/FTT(failure to thrive) 3. Tachypnea (+/-quiet) - May or may not hear abnormal lung sounds - If you don;t hear abnormal lung sounds, listen to heart really well 4. Increased WOB 5. Tachycardia 6. Diaphoresis 7. Crackles 8. Hepatomegaly 9. Polycythemia (Chronic) 10. Cyanosis 11. Mottling 12. Poor or unequal pulses 13. Murmur 14. Extra heart sounds 15. Sternal lift 16. N/V 17. Clubbing (chronic)

Transposition of the Great Arteries or Transposition of the Great Vessels Clinical Manifestations - include difference in s/s of newborn w/ minimal communication vs s/s of newborn w/ PDA or large septal defects

1. Presentation depends on associated defects 2. Newborns with minimal communication have severe cyanosis & poor function 3. Newborns with PDA or large septal defects less cyanotic but HF symptoms 4. Heart sounds vary by associated defects 5. Child has high probability to develop HF

What patient would be given prophylactic antibiotics prior to dental or invasive procedures to prevent infective endocarditis (IE)?

1. Previous Infective Endocarditis 2. Prosthetic cardiac valve 3. Congenital heart disease pts per AHA criteria

What is a tall tale sign of kawasaki disease?

strawberry tongue

Truncus Arteriosus Pathophys: Result:

1. SINGLE blood vessel (truncus arteriosus) comes out of the right AND left ventricles 2. Blood from both ventricles mixes in the common great artery. 3. Blood ejected from the heart prefers the lower pressure pulmonary arteries than aorta leading to increase in pulmonary blood flow & decrease in systemic blood flow Result: relies on mixed blood

Perfusion assessment of the Child

1. Temperature - Skin color - good: pink - bad: blue, pallor, grey - Skin temp - good: warm - bad: cool 2. Extremity evaluation for: - Peripheral edema - Clubbing (chronic dx like congenital heart disease) - Peripheral pulses: - pedal: top of foot - radial: wrist - posterior tibial: inside ankle - may mark this pulse on a cardiac kid - Central pulses: - brachial - femoral 3. Activity tolerance: - "work"/ activity in infants: Feeding - how long does it take them to feed? - they shouldn't be sweating and working hard when feeding - feeding should be calm and relaxing - "work"/activity in older children: Play 4. Weight measurements (kg) - Urine output (I & O)

What congenital heart defects causes decreased pulmonary blood flow?

1. Tetralogy of Fallot** (NEED TO KNOW THIS DEFECT) 2. Tricuspid atresia

What are some congenital heart MIXED defects?

1. Transposition of the great vessels 2. Total anomalous pulmonary venous connection 3. Hypoplastic left heart syndrome

What genetic disorders put kids at increased risk for congenital heart defects?

1. Trisomy 21: you NEED to ask them if that child has any heart issues when taking history 2. Turner's

Hypoplastic Left-sided Heart Syndrome Pathophys: Result:

1. Underdevelopment of left side of the heart leading to hypoplastic left ventricle & aortic atresia. 2. Blood from left atrium flows into right atrium via ASD or PFO. It then goes to right ventricle & out the pulmonary artery. From the pulmonary artery, blood flows to the lungs & to the descending aorta through the PDA. 3. The coronary & cerebral vessels rely on retrograde flow through the hypoplastic ascending aorta. Result: relies on mixed blood flow

What should you assess for after a cardiac catheterization? What are some normal and abnormal assessment findings?

1. Vital signs of course 2. Evaluate pressure dressing over catheter site q15 minutes for 1st hour and then every 30 minutes for 1 hour - assess for heavy bleeding! 3. Check pulses distal to the catheter site BILATERALLY (both legs) -Normal: weak pulse right after catheterization 4. Color and temp of extremity - Abnormal: Cool, cold, pale extremity - indicates obstruction to blood flow 5. Cap refill and sensation - evals blood flow to area

Newborn blood flow

1. When newborn takes breath for first time, this causes the lungs to expand 2. this causes pulmonary pressures to fall and systemic pressures to rise - this pressures change causes the shunts in the fetal heart to close 3. Foramen ovale closes - bc pressure in left atrium is now bigger than it is in the right atrium 4. ductus arteriosus closes - bc oxygen concentration increases in the blood - also the high pressure drops in the pulmonary artery - because that high pressure in the pulmonary artery is gone now, blood cannot be shunted to the aorta from the pulmonary artery - the placenta also released prostaglandin, which kept the ductus arteriosus open, but when the fetus is born, the umbilical cord is cut so shunt is no longer receiving prostaglandin to stay open

What can cause the right side of the heart to have higher pressure than the left side of the heart?

1. pulmonary vascular resistance 2. obstruction

Normal heart rate for children

120

Example of functional reason for heart murmur

Anemia

What 4 defects are involved in the Tetralogy of Fallot?

4 Defects Involved: 1. Ventricular Septal Defect 2. Pulmonic Stenosis 3. Rt Ventricular Hypertrophy - Bc of the 1st 2 defects 4. Overriding Aorta - Will shift to middle of heart between ventricle rather than being on left side of heart

Infant heart rate

90-160 bpm this decreases as child ages and grows bigger and they can accommodate more volume of blood in their heart so their HR doesn't have to make up for that to reach appropriate cardiac output

What is holter monitoring?

long-term ecg the patient wears a monitor at home that constantly records the heart's activity

What helps prevent the development of rheumatic heart disease?

ANTIBIOTICS - treats the strep infection - lowers the threshold of recurrent RF becoming RHD

What areas of heart should you auscultate?

APETM Aortic Pulmonic Tricuspid area Mitral (apical) area

Aortic Stenosis Pathophys: Result of defect:

AS = Narrow or stricture of the aortic valve 1. Difficult for blood to eject from left ventricle 2. Decreased cardiac output 3. Left ventricular hypertrophy 4. Pulmonary vascular congestion d/t back up of pressures (leftt ventricle -> left atria -> pulmonary veins) Result = Heart Failure Symptoms (decreased CO distal to defect)

Kawasaki disease pathophys

An acute systemic vasculitis (inflammation) of unknown etiology that causes endothelial/vessel damage) 1. Thought that KD is triggered by an infection (unidentified) followed by autoimmune response but we don't really know what causes Kawasaki disease 2. Geographic & seasonal outbreaks (late winter/early spring peak)

What causes rheumatic fever and when does it usually occur?

Any strep infection cause cause it: 1. Typically pharyngitis/strep throat 2. But could also be from scarlet fever strep (red rash on body and arms) Rheumatic fever occurs 2-6 weeks after a strep infection

What are tet/ hypercyanoic spells precipitated by?

Anything that causes pressure in the right side of the heart to be greater than the left side of the heart: 1. crying 2. feeding 3. straining (BMs) 4. fevers 5. dehydration 6. nap awakening

What area do you auscultate to take heart rate?

Apical/mitral area -this is where the heart beats loudest

When do blood pressure screenings start/ when do we start taking kids' BP?

BP screenings started at 3 YO & those high risk Initially, 4 extremity BPs taken & recorded

Infective Endocarditis (IE) Causative agent

BACTERIA (don't need to know any specific ones) So we're gunna have to treat IE w/ abx

When does HR and BP reach adults levels?

By adolescence

How are congenital heart disease classified?

By their hemodynamic characteristics

What account foe the largest percentage of all birth defects?

CHD- congenital heart disease

Coarctation of the Aorta Pathophys: Result of defect:

COA= Narrowing of the aorta near ductus arteriosus The coarctation/narrowing happens pretty high up on the aorta There's increased pressure PROXIMAL to the defect/narrowing = INCREASED pressure to the head and upper extremities There's DECREASED pressure DISTAL to the defect/narrowing = DECREASED pressure to the lower extremities Result = Heart Failure symptoms - bc there's poor cardiac output distal to the defect

What is CRP and ESR?

CRP= indicates inflammation and infection ESR = inflammation in body

Example of organic reason for heart murmur

Cardiac defect

What is a chest radiograph?

Chest x-ray (CXR)

Patent Ductus Arteriosus Clinical manifestations:

Clinically: 1. Asymptomatic or heart failure 2. + Machine-like murmur How murmur is described, if you see this as a symptom, PDA is probably the answer!!

What does S2 represent?

Closure of pulmonic and aortic valves

What is an important teaching point for Kawasaki Disease?

Compliance to serial echocardiograms IS VERY IMPORTANT - One echo isn't enough, need multiple to prove they don't have any aneurysms (complication of KD) - educate parents that kid will need to do these echocardiograms even when they're outpatient

If you look at CBC and see a child has polycythemia what could this indicate cardiac wise?

Congenital heart defect - can cause CHRONIC hypoxemia, so body compensates stimulates EPO to increase red blood cell count (polycythemia) so blood can carry more oxygen

Cardiomyopathy Tx:

Cure underlying cause (often not possible)

Tricuspid Atresia Clinical Manifestations:

Cyanosis

How does someone get diagnosed with Rheumatic Fever?

Diagnosis: SUPPORTING EVIDENCE - JONES CRITERIA + GAS INFECTION - Throat Cx - Rapid GAS test - Elevated or rising ASO titer (antistreptolysin O) - Important lab value for RF

Acquired heart disease

Disorders that occur after birth Can result from being a complication or long-term effect of CHD

Hyperlipidemia pathophys

Excessive fats in the blood High lipids increase chance of atherosclerosis (plaque on arteries), increasing chance of CAD

Kawasaki disease Diagnosis criteria:

FEVER FOR 5 DAYS + 4/5 CLINICAL CRITERIA: 1. Extremity changes: Erythema +/-desquamation of hands/feet (subacute), edema - Swollen, red hands 2. Bilat conjunctival injection w/o exudation - Both eyes are Red and fiery - No pus 3. Oral mucous membrane changes: Erythema lips and/or oropharynx, "strawberry tongue"(if you see this = kawasaki) 4. Polymorphous rash - Many differently shaped rashes all over body 5. Cervical lymphadenopathy - Swollen cervical lymph nodes

Tricuspid Atresia Pathophys: Result of defect:

Failure of Tricuspid Valve to develop. 1. No blood flow from rt atrium to rt ventricle - Blood flows from an ASD or PFO to get to left atrium then through a VSD to get to rt ventricle to get to lungs. - Complete mixing of saturated & unsaturated blood in left side of heart = Cyanosis & decreased pulm blood flow - PDA allows blood flow to pulm artery & lungs (duct-dependent). - PFO or ASD required so blood can get to left atrium. - VSD allows blood flow to pulm artery & lungs. Result = Cyanosis - Relies on abnormal connections (ducts/defects)

Atrial Septal defect Tx and prognosis:

Fixable (surgery or cardiac cath) - Good prognosis

Coarctation of the Aorta Tx

Fixed by balloon angioplasty and/or surgery

What's an exercise stress test?

Hooking pt up to ekg and having them perform exercises on the treadmill

What are the grades for heart murmurs and what do they mean?

I - Very faint, often not heard if child sits up II - Usually readily heard, slightly louder than grade I, audible in all positions III - Loud, no thrill IV - Loud, + thrill V - Loud enough to be heard with the stethoscope barely touching the chest, + thrill VI - Loud enough to be heard with stethoscope not touching the chest, + thrill

Why is it important to deliver oxygen as ordered in kids with HF?

If HF is the result of CHD, delivering too much oxygen can be detrimental! - Remember Oxygen is a drug! - Pulmonary vasodilator decreases PVR and thereby increasing pulmonary blood flow, which we don't want for some CHDs - ask the goal SpO2 for each specific patient

tet/ hypercyanoic spells patho

If pressure on the right side of the heart is greater than the left side of the heart, blood will flow to the left side of the heart where there's less pressure and deoxygenated blood will flow through the aorta and out to the rest of the body resulting in acute hypoxic and cyanotic episodes

Kawasaki disease What age does it affect?

In 75% of cases, the child is younger than 5 years of age

Congenital heart defects that increase pulmonary blood flow lead to increased _________ blood flow and decreased _________ blood flow

Increased PULMONARY blood flow Decreased SYSTEMIC blood flow

Incomplete Kawasaki Disease

Kawasaki Disease that can be diagnosed with fewer clinical criteria (2-3 criteria)

What are the major criteria for Rheumatic fever and how many criteria does someone have to have to get diagnosed?

MAJOR CRITERIA (MUST HAVE 2 CRITERIA): Joints ->Polyarthritis - swollen, red, hot painful large joints lasting 1-2 days then moves to a different joint O (shaped like heart): Carditis - new murmur, tachycardia, CP, cardiomegaly, rub Nodes - Subcutaneous Nodes - nontender, gradually resolve Erythema marginatum - nonpruritic rash trunk & extremities) Sydenham's Chorea - Aimless, irregular extremity movements, "dance" like movements-> can develop months later) https://www.youtube.com/watch?reload=9&v=wTCnbga3sqg

What does S3 represent?

May be normally heard in some kids, but is considered ABNORMAL - ventricular wall not fully expanding & rapid filling of ventricle

Tricuspid Atresia Tx:

Meds: Prostaglandin E1 to keep PDA (patent ductus arteriosus) open - Bc this is a duct dependent defect Surgery: Individualized staged surgical repairs leading to Modified Fontan Procedure

Is one CRP and ESR value useful?

Not really, it's better to look at a trend of CRP and ESR values because you can see if they're consistently high, indicating inflammation and possibly infection

Pulmonic Stenosis Pathophys: Result of defect:

PS=Narrowing at entrance to pulm artery 1. Right ventricular hypertrophy - may lead to rt atrial increase in pressure & reopening of foramen ovale & shunting of unoxygenated blood to lt atrium = cyanosis 2. Decreased pulmonary blood flow 3. Pulm Atresia = Extreme pulmonic stenosis = total fusion & no blood flow to lungs - Duct-dependent: - We will give child prostaglandin infusion to keep shunts open since the pulmonary artery valve is extremely stenosed and we need the blood to get to the lungs somehow Result = Cyanosis (Reduced pulm blood flow) This is an oxygen/sat prob

Patent Ductus Arteriosus Pathophys? What did this result in?

Pathophys: 1. Failure of fetal ductus arteriosus to close after birth 2. Blood flows from aorta to pulm artery a. Because aorta has higher pressure than pulmonary artery b. So more blood is gunna flow into the lungs than usual 3. Left-> Right shunt Result = Heart Failure Symptoms (volume overload if large)

Pediatric hypertension cause

Pediatric hypertension is generally secondary to a structural abnormality or an underlying pathologic condition: 1. Renal disease (most common) 2. Cardiovascular disease (2nd most common) 3. Endocrine or neurologic disorders

Transposition of the Great Arteries or Transposition of the Great Vessels Tx:

Pharm: Prostaglandin E1 may be given to keep PDA shunt open to increase mixing. Surgery: - A balloon atrial septostomy may be performed to increase mixing (creates ASD). - Definitive surgical repair varies by defects.

What are the most common causes of cardiomyopathy?

Primary or Idiopathic 1. Familial or genetic cause 2. Infection 3. Deficiency states 4. Metabolic abnormalities 5. Collagen vascular disease

Transposition of the Great Arteries or Transposition of the Great Vessels Pathophys: Result:

Pulmonary artery leaves from left ventricle instead of right ventricle & aorta leaves from right ventricle instead of left ventricle 1. No communication between systemic & pulmonary circulation. 2. PDA, PFO, or other defects must be present to allow mixing of blood. Result: relies on mixed blood flow

What should you be listening for when auscultating the heart?

Quality (how well do I hear it?) intensity rate rhythm (how predictable is the beat?)

Rheumatic Fever/Heart disease Pathophys:

Rheumatic Fever is an IMMUNE RESPONSE 1. The same antibodies produced to fight the GAS (Group A streptococcus) infection cross-react and attack the cells of the heart (particularly endocardium->valves), brain, skin, and joints causing damage 2. Recurrent GAS infections can cause cumulative inflammation and damage to heart valves (RHD)

When do we screen for hyperlipidemia? Rules for screening:

Screen between 9-11 YO and again between 18-21 YO 1. Fasting for 12 hrs prior 2. No febrile illness within 3 weeks

How common is cardiomyopathy in children?

Rare

What is cardiomyopathy?

Refers to abnormalities of myocardium in which the ability of muscle to contract is impaired.

Who usually gets strep infections?

School-age to adolescents (5-15 yo) Rare in children <3 yo and adults

What's the most common arrhythmia in kids?

Sinus arrhythmia Increase in rate on inspiration & decrease on expiration can be normal in kids

Aortic Stenosis Tx

Surgery or balloon angioplasty via cardiac cath to repair

Pulmonic stenosis Tx:

Surgery or balloon dilation via cardiac cath

Tetralogy of Fallot Tx:

Surgery required. May have palliative shunt (BT shunt) placed before complete repair. - BT shunt: Increases pulm blood flow which increases oxygen saturation. BT SHUNT = BANDAID

Truncus Arteriosus Tx:

Surgical repair w/ additional surgeries throughout life.

Ventricular Septal defect Pathophys? What did this result in?

THE MOST COMMON HEART DEFECT IN CHILDREN PATHOPHYS: 1. There's a hole or numerous holes in septum of heart between left and right ventricle 2. Increased blood volume on the right side of the heart. 3. Increased pulmonary blood flow 4. Decreased systemic blood flow Result = Heart Failure Symptoms (volume overload)

Congenital heart disease

structural anomalies present at birth

Atrial Septal defect Pathophys? What did this defect result in?

There's a hole or numerous holes in septum of heart between left and right atrium Pathophys: 1. Increased blood volume on the right side of the heart. a. Since pressure on left side of heart is bigger, blood is gunna flow from left atrium to right atrium 2. Increased pulmonary blood flow a. Because there is more blood on right side of heart now so more blood will flow to the lungs from through the pulmonary artery 3. Decreased systemic blood flow a. Because we robbed blood from the left side of the heart Result: Heart failure symptoms - volume overload

What is happening physiologically with congenital heart defects that result in increased pulmonary blood flow?

There's an abnormal connection btwn the two sides of the heart, either: 1. the septum - ASD - VSD 2. the great vessels - PDA

Why do congenital heart defects that increase pulmonary blood flow cause heart failure symptoms?

These defects cause there to be INCREASED BLOOD VOLUME ON THE RIGHT SIDE OF THE HEART, increasing pulmonary blood flow since the right side of the heart leads to the pulmonary artery, and causing HEART FAILURE SYMPTOMS from the excess blood volume in the lungs

What does S4 represent?

This IS NOT a normal heart sound

What should you know about Total Anomalous Pulmonary Venous Connection?

This isn't a very important defect to know Just know that it's one of the bad CHD and can lead to development of HF

Hyperlipidemia Tx:

Treatment is lifestyle modification: 1. Restrict intake of cholesterol and fats 2. Increase intake of whole grains, fruits, and vegetables 3. Exercise for 60 minutes a day 5 days a week 4. Stop smoking and avoid second-hand smoke If there is no response to lifestyle changes then medications may be tried

Nursing management of tet/hypercyanotic spells:

We want to: decrease PVR, increase SVR, and increase Pulmonary blood flow 1. Knee-chest position - increases SVR and pressure on left side of heart 2. Calming child (duh, decreases O2 demand, reduces hypoxia and cyanosis) 3. Oxygen - Ask parents baseline SpO2 - Pulmonary vasodilator, decreasing PVR 4. Morphine - decreases PVR

How do we measure urine output in infants?

We weigh their wet diapers! - we don't like catheters/foleys! - put dry diaper on scale, zero it out, then put wet diaper Can also do this with linens the child has urinated on - put dry linen on, zero scale, put wet linen on 1g on scale = 1 mL urine 50g on scale = 50 mL urine

If Kawaski disease isn't treated what can it result in?

Without treatment, 25% will develop coronary artery dilation or aneurysm formation - Having aneurysm in coronary artery bad bc it supplies blood to heart tissue

What is an arteriogram?

an artery is cannulated and contrast is put in there and the pathway of that artery is looked at -ex: can see aneurysm

What is a BMP?

basic metabolic panel - sodium - potassium - chloride - calcium - bicarb - BUN - creat - glucose sodium and potassium are important to assess heart function

What is the definitive study for infants and children w/ cardiac disease?

cardiac catheterization

What does S1 represent?

closure of tricuspid valve

What's the aspirin dosing regiment for kawasaki disease treatment?

high dose 1st then low dose - ultimately depends on where kid is in course of disease

Blood flow travels from areas of _____ pressure to areas of _____ pressure

high, low blood flow takes path of least resistance

The higher the pressure gradient, the _________ the rate of blood flow

faster

What is cardiac cathetization?

radiopaque catheter is inserted into a blood vessel and is guided through the vessel to the heart w/ the aid of fluoroscopy; contrast material is used for visualization provides info about: - heart anatomy - ventricular wall motion and ejection fraction - intracardiac pressures and hemodynamic parameters - cardiac valve function, structural abnormalities

What's the most common complication of rheumatic fever?

rheumatic heart disease - ~3% RF cases cause this - causes cardiac valve damage (typ mitral)

ductus arteriosus

shunt between the pulmonary artery and the aorta - the pressure coming from the lungs into the pulmonary artery causes blood to flow from the pulmonary artery (high pressure) through the ductus arteriosus into the aorta (lower pressure) instead of flowing to the lungs

foramen ovale

shunt between the right atrium and left atrium - pressure on right side of fetal heart is greater than left side because of the pressure coming through the pulmonary artery from the fluid filled lungs where there's A LOT of pressure - this pressure gradient causes blood to flow from the right atrium to the left atrium through the foramen ovale

common arrhythmia found in children

sinus arrhythmia -Increase in rate on inspiration & decrease on expiration can be normal in kids

The higher the resistance, the _______ the rate of blood flow

slower

What is an echocardiogram?

ultrasound of the heart to get a visual of it Useful for looking at the heart's anatomy, blood flow, and ability to pump blood

Infant Blood pressure

~80-55 mm Hg systolic Lower in infancy, it increases as the child ages