cardiac disorder pedia

8/12/2019 Cardiac Disorder Pedia

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Cardiac Lecture


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Cardiac

Ball & Bindler


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Focused Health History

Family history of defects / early cardiac

disease / siblings with defects

Maternal history of stillborns or miscarriages

Congenital anomalies / genetic anomalies /

fetal alcohol syndrome / Down Syndrome and

Turner Syndrome

Maternal exposure to rubella


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Heart murmur

Tires while eating

Low weight for height

Sweats while eating (diaphoretic)

Cyanosis, worsens with feeding or activity

level

Irritable weak cry


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In the older child additional symptoms may

include:

Chest pain

Decreased activity level

Syncope

Slight of build


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Focused Physical Assessment

General appearance

Integumentary system

Face, nose, and oral cavity

Thorax and lung

Cardiovascular system


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Heart Sounds


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Heart Murmurs

These sounds are produced by blood passing

through a defective valve, great vessel, or

other heart structure.

Murmurs are classified by: intensity, location,radiation, timing, and quality.


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Pulses

Alert:

Weaker pulses or lower blood pressure in the

lower extremities may indicate coarctation of

the aorta (COA)

Bounding pulses can indicate a patent ductus

arteriosus (PDA) or aortic insufficiency.


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Vital Signs

Heart rate: tachycardia in the absence of

fever, crying, or stress may indicate cardiac

pathology.

Tachypnea, even with rest, chest retractionsindicate respiratory distress, possibly

resulting from congestive heart failure


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Knee-chest Position

Child with a cyanotic heartdefect squats (assumes a knee-chest position) to relievecyanotic spells. Some times called tet spells. Ball &

Bindler

Nurse puts infant in knee-chestposition. Whaley & Wong


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First Breath

Pulmonary alveoli open up

Pressure in pulmonary tissues decreases

Blood from the right heart rushes to fill the

alveolar capillaries Pressure in right side of heart decreases

Pressure in left side of heart increases

Pressure increases in aorta


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Treatment Modalities

Palliative procedures

Pulmonary artery banding

Shunts

Corrective procedures


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Diagnostic Test

Chest x-ray to define silhouette of the heart. Heart size, shape, pulmonary markings, and

cardiomegaly.

Electrocardiogram ECG or EKG to defineelectrical activity of the heart.

Echo-cardiogram to visualize anatomicstructures.

Non-invasive


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Cardiac Conduction


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Echo-Cardiogram


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Cardiac Catheterization

An invasive test to diagnose or treat cardiac

defects.

Visualizes heart and vessels.

Measures oxygen saturation of chambers.

Measures intra-cardiac pressures.

Determines muscle function and pumping action

of the heart.


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Toxicity to Dye

Watch for signs of toxicity to the dye usedduring the procedure. Increased temperature

Urticaria Wheezing

Edema

Dyspnea

Headache*Allergy response


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Pre-cardiac Catheterization

Assess vital signs with blood pressure.

Hemoglobin and hematocrit

Pedal pulses

NPO

Hold digoxin

IV if child is polycythemic


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Post-cardiac Catheterization

Vital sign, with apical pulse, and blood

pressure q 15 minutes for first hour.

Apical pulse for 1 minute to check for

bradycardia or dysrhythmias.


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Post-cardiac Catheterization

Assess pulses below the cath site.

Record quality and symmetry of pulses.

Assess temperature and color of affected

extremity.

Check dressing for bleeding or hematoma

formation.


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Home Care Instructions

Keep dressing in place for 24 hours.

Keep site dry and clean.

Observe site for redness, swelling, drainage,

or bleeding. Check temperature.

Avoid strenuous exercise.

Acetaminophen for pain. Keep follow-up appointment

Pre-procedure medications as ordered.


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Left to Right Shunt

Pressures on the left side of the heart are

normally higher than the pressures in the

right side of the heart. If there is an abnormal

opening in the septum between the right andleft sides, blood flows from left to the right.


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Left to Right Shunt


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Clinical Manifestations

Dyspnea and pulmonary edema due to the

lungs receiving blood under high pressure

from the right ventricle.

Increased number of respiratory infections

due to blood pooling in the the lungs

promoting bacterial growth.


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Right to Left Shunts

Occurs when pressure in the right side of the heart

is greater than the left side of the heart.

Resistance of the lungs in abnormally high

Pulmonary artery is restricted

Deoxygenated blood from the right side shunts to

the left side


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Right to Left Shunt

Hole in septum + obstructive lesion =

Deoxygenated blood from the right side of the

heart shunts to the left side of the heart and

out into the body.


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Hypoxemia = the result of decreased tissue

oxygenation.

Polycythemia = increased red blood cell

production due to the bodys attempt tocompensate for the hypoxemia.

Increase viscosity of the blood = heart has to

pump harder.


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Potential Complications

Thrombus formation due to sluggish

circulation.

Brain abscess or stroke due to the un-

oxygenated blood bypassing the filteringsystem of the lungs.


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Heart Failure

Major manifestation of cardiac disease

Under 1 year of age due to congenital

anomaly

Over 1 year with no congenital anomaly may

be due to acquired heart disease


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Clinical Manifestations of HF

Systemic Venous Congestion

Weight gain, hepatomegaly, edema, jugular vein

distension

Pulmonary Venous Congestion Tachypnea, dyspnea, cough, wheezes

Compensatory Response

Tachycardia, cardiomegaly, diaphoretic, fatigue,failure to grow


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Digoxin Therapy

Digoxin increases the force of the myocardial

contraction.

Take an apical pulse with a stethoscope for 1 full

minute before every dose of digoxin. Ifbradycardia is detected.

< 100 beats / min for infant and toddler

< 80 beats in the older child

< 60 beats in the adolescent

* Call physician before administering the drug.


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Signs of Digoxin Toxicity

Bradycardia

Arrhythmia

Nausea, vomiting, anorexia

Dizziness, headache

Weakness and fatigue


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Interventions

Fluid restriction

DiureticsLasix (potassium wasting) orAldactone (potassium sparing)

Bed rest Oxygen

Small frequent feedingssoft nipple withsupplemental NG for adequate calorie intake

Pulse oximeter

Sedatives if needed


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Feeding

Small frequent feedings

Soft nipple to easy energy needed to suck

24 calorie formula for added calories

NG feed if not taking in adequate calories to

gain weight


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Patent Ductus Arteriosus

PDA

Incidence 10%

One of the most common benign defects

Ductus normally closes within hours of birth

Connection between the pulmonary artery

(low pressure) and aorta (high pressure)

High risk for pulmonary hypertension


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PDA


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Diagnosis and Treatment

Diagnosis by

Chest x-rayenlarged heart and dilated

pulmonary artery

Echo-cardiogramshow the opening betweenpulmonary artery and aorta


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Treatment

Indomethocin given poconstricts the

muscle in the wall of the PDA and promotes

closure

Cardiac Catheterizationcoil is placed in theopen duct and acts like a plug

Closed heart surgerysmall incision made

between ribs on left hand side and PDA isligated or tied and cut


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Atrial Septal Defect

ASD

10% of defects

Blood in left atrium flows into right atrium

Pulmonary hypertension

Reduced blood volume in systemic circulation

If left untreated may lead to pulmonary

hypertension, congestive heart failure or

stroke as an adult.


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ASD


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Diagnosis: heart murmur may be heard in the

pulmonary valve area because the heart is

forcing an unusually large amount of blood

through a normal sized valve. Echocardiogram is the primary method used

to diagnose the defectit can show the hole

and its size and any enlargement of the rightatrium and ventricle in response to the extra

work they are doing.


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Treatment

Surgical closure of the atrial septal defect

After closure in childhood the heart size will

return to normal over a period of four to six

months. No restrictions to physical activity post

closure


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Ventricular Septal Defect

VSD

30% of defects

Opening in the ventricular septum

Left-to-right shunt

Right ventricular hypertrophy

Deficient systemic blood flow


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VSD

Small holes generally are asymptomatic

Medium to moderate holes will cause

problems when the pressure in the right side

of the heart decreases and blood will start toflow to the path of least resistance (from the

left ventricle through the VSD to the right

ventricle and into the lungs) This will generally lead to CHF


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Treatment VSD

CHF: diuretics of help get rid of extra fluid in

the lungs

Digoxin if additional force needed to squeeze

the heart FTT or failure to grow may need higher

calorie concentration

Will need prophylactic antibiotics beforedental procedures if defect is not repaired


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Surgical Repair

Over a period of years the vessels in thelungs will develop thicker wallsthe pressurein the lungs will increase and pulmonaryvascular disease

If pressure in the lungs becomes too high theun-oxygenated blood with cross over to theleft side of the heart and un-oxygenated

blood with enter the circulatory system. If the large VSD is repaired these changes

will not occur.

f A


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Coarctation of Aorta

COA

7 % of defects

Congenital narrowing of the descending aorta

80% have aortic-valve anomalies

Difference in BP in arms and legs (severe

obstruction)


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Di i d T


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In 50% the narrowing is not severe enough to

cause symptoms in the first days of life.

When the PDA closes a higher resistance

develops and heart failure can develop. Pulses in the groin and leg will be diminished

Echocardiogram will show the defect in the

aorta

T


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Treatment

Prostaglandin may given to keep the PDA open to

reduce the pressure changes

The most common repair is resection of the

narrowed area with re-anastomosis of the two ends

Surgical complicationskidney damage due to

clamping off of blood flow during surgery

High blood pressure post surgerymay need to be

on antihypertensives Antibiotic prophylactic need due to possible aortic

valve abnormalities.

T l f F ll (TOF)


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Tetralogy of Fallot (TOF)

6% of defects

Most common cardiac malformation

responsible for cyanosis in a child over 1 year


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TOF


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TOF

Four Components

VSD

Pulmonary stenosisnarrowing of pulmonary

valve Overriding of the aortaaortic valve is enlarged

and appears to arise from both the left and right

ventricles instead of the left ventricle

Hypertrophy of right ventriclethickening of themuscular walls because of the right ventricle

pumping at high pressure

Cli i l M if i


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Dependent on degree of right ventricular

outflow obstruction.

Right-to-left shunt

Clubbing of digits

tet spells - treated by flexing knees forward

and upward

Severe irritability due to low oxygen levels

Di i


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Diagnosis

Cyanosis

Oxygen will have little effect on the cyanosis

Loud heart murmur

Echocardiogramdemonstrates the four

defects characteristic of tetralogy

T


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Treatment

If oxygen levels are extremely low prostaglandinsmay be administered IV to keep the PDA open

Complete repair is done when the infant is about 6

months of age

Correction includes

Closure of the VSD with dacron patch

The narrowed pulmonary valve is enlarged

Coronary arteries will be repaired Hypertrophy of right heart should remodel within a few

months when pressure in right side is reduced

L T O t


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Long Term Outcomes

Leaky pulmonary valve that can lead to

pulmonary insufficiency

Arrhythmias after surgery

Heart blockoccasionally a pacemaker isnecessary

Periodic echocardiogram and exercise stress

test or Holter evaluation

A ti St i


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Aortic Stenosis

6% of defects

Aortic valve: has two rather than three

leaflets. Leaflets are thickened or fused.

Obstruction of blood flow from left ventricle

Mild symptoms: dizziness, syncope, angina,

fatigue

30% incidence of sudden death


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A ti St i


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Aortic Stenosis

Causes obstruction to blood flow between the

left ventricle and aorta.

Most common form is obstruction of the valve

itself When the aortic valve does not open properly

the left ventricle must work harder to eject

blood into the aorta. Left ventricular muscle becomes

hypertrophied.

Di i


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Diagnosis

Heart murmur or AS is a turbulent noise

caused by ejection of blood through the

obstructed valve.

Electrocardiogram is usually normal Echocardiogram will show the obstruction

and rule out other heart anomalies

Exercise stress testprovides information onimpact of the stenosis on heart function


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Hypoplastic Left Heart


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Hypoplastic Left Heart

One of the most complex defects seen in thenewborn and the most challenging of all the

congenital defects

All the structures on the left side of the heartare severely underdeveloped.

Mitral and aortic valves are either completely

closed or are very smallleft ventricle is tinyaorta is small and often only a few

millimeters in diameter


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HLH


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HLH

Life threatening shock develops when theductus arteriosis closes

Low oxygen saturationswill not increase

with oxygen administration Pulses will be weak in all extremities

Plan to deliver infant in a hospital capable of

providing the aggressive treatment needed

Treatment


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Treatment

Three staged procedure to reconfigure thecardiovascular system

Norwoodright ventricle becomes the systemic

ventricle pumping blood to the body Glenn done at 3-6 months

Fontan done at 2 -3 years of age

Long Term Complications


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Long Term Complications

Easily tiring when participating in sports orother exercises

Formation of blood clotsheparin or

Coumadin use Heart arrhythmiaspace maker

Cardiac failure

Bacterial Endocarditis


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Bacterial Endocarditis

Infection of endocardial surface of the heart

History of CHD, Kawasaki Disease,

Rheumatic Fever, or prosthetic valves are

more susceptible to infection Prophylactic antibiotics with dental care,

throat, intestinal, urinary or vaginal infections

or surgery.


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Kawasaki Disease


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Kawasaki Disease

Acute-self limiting disease

Generalized vasculitis

Peak incidence 6 months to 2 years

More common in males and Japanese

http://www.aafp.org/afp/990600ap/3093.html
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High fever

Conjunctivitisno drainage

Strawberry tongue

Edema of hands and feed

Reddening of palms and soles

Lymph node swelling


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Edema Hands and Feet


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EdemaHands and Feet

Peeling Finger Tips


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Peeling Finger Tips

Blood Values


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Blood Values

Elevated WBC

Elevated ESR

Elevated platelets

Interdisciplinary Interventions


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Interdisciplinary Interventions

Intravenous gamma globulin

High dose of ASA while in hospital

Low dose ASA upon discharge

Base-line echocardiogram to assess

coronary artery status

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