congestive heart failure in children
TRANSCRIPT
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Heart FailureHeart Failure- C.S.N.Vittal- C.S.N.Vittal
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Definition
• HEART FAILURE IS A CLINICAL HEART FAILURE IS A CLINICAL
SYNDROME IN WHICH HEART CANNOT SYNDROME IN WHICH HEART CANNOT
PUMP AT A RATE COMMENSURATE PUMP AT A RATE COMMENSURATE
• WITH REQUIREMENTS OFWITH REQUIREMENTS OF
• TISSUE METABOLISM.TISSUE METABOLISM.
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Possible types
Excessive work load on myocardium (pressure and volume loading)
Primary alterations in myocardial performance (inflammatory disease)
Metabolic derangements
Combinations of these
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Pathophysiology
HEART IS A PUMP WITH OUTPUT HEART IS A PUMP WITH OUTPUT PROPORTIONAL TO FILLING VOLUME & PROPORTIONAL TO FILLING VOLUME & INVERSELY PROPORTIONAL TO INVERSELY PROPORTIONAL TO RESISTANCE AGAINST WHICH IT PUMPS .RESISTANCE AGAINST WHICH IT PUMPS .
SYSTEMIC OXYGEN TRANSPORT IS SYSTEMIC OXYGEN TRANSPORT IS PRODUCT OF COP AND SYSTEMIC PRODUCT OF COP AND SYSTEMIC OXYGEN CONTENTOXYGEN CONTENT
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Cardiac output is determined by...
• PRELOAD
• AFTERLOAD
• CONTRACTILITY
• HEART RATE
Systemic oxygen content is...
•DECREASED IN ANEMIA &
HYPOXIA
•INCREASED IN HYPERMETABOLIC
STATES
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General manifestationsPulmonary and systemic venous congestion
Decreased systemic perfusion
Operation of several potentially adaptive mechanisms
increased adrenal activity
fluid retention
ventricular dilatation and hypertrophy
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Aetiology
FetusSevere anemia
SVT
Complete heart block
CHD
High output failuers (A-V malformations, teretoma)
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AetiologyPreterm
Fluid overload
Bronchopulmonary dysplasis
Full term neonateAsphyxia
AV - malformations
Lt. sided obstructive lesions
TGA
Large shunt diseases
Viral myocarditis
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AetiologyInfant or Toddler
Lt to Rt ShuntsAV malformationsMetabolic cardiomyopathyAcute hypertension (hemolytic uremic syndromeSVTKawasaki diseasePost operative repair of CHDs
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AetiologyChildren & Adolescents
Rheumatic fever
Acute hypertension ( glomerulonephritis)
Viral myocarditis
Thyrotoxicosis
Anemias Eg. Sickle cell disease
Infective Endocarditis
Cor pulmonale ( cystic fibrosis)
Cardiomyopathy
Cancer therapy (radiation, adriamycin)
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Compensatory mechanisms
•SYMPATHETIC STIMULATION
•INCREASED HEART RATE
•INCREASED CONTRACTILITY
•REDISTRIBUTION OF BLOOD DUE TO PERIPHERAL VASOCONSTRICTION
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Prolonged sympathetic stimulation may lead to..
INCREASED OXYGEN DEMAND
INCREASED AFTER LOAD
HYPERMETABOLISM
MYOCARDIAL TOXICITY
DECREASED GIT RENAL HEPATIC FLOW
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Precipitating Causes of CHF
INFECTIONS
ANEMIA
INFECTIVE ENDOCARDITIS
EXCESSIVE PHYSICAL ACTIVITY
SODIUM OVER LOAD
ARRHYTHMIAS
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TYPES OF HEART FAILURE
SYSTOLIC OR DIASTOLICSYSTOLIC OR DIASTOLIC
ACUTE OR CHRONIC
RIGHT OR LEFT
FORWARD OR BACKWARD
HIGH OUTPUT OR LOW OUTPUT
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Clinical FeaturesHISTORY
• INFANTS
• POOR FEEDING
• POOR WEIGHT GAIN
• DYSPNOEA WHILE SUCKING
• PERSPIRATION
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Clinical FeaturesHISTORY
• OLDER CHILDRE
BREATHLESSNESS
ORTHOPNEOEA
EASY FATIGABILITY
EDEMA
ABDOMINAL PAIN
ANOREXIA
COUGH
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PULMONARY VENOUS CONGESTION
TACHYPNEA
DYSPNEA
ORTHOPNEA
COUGH
WHEEZING
SYSTEMIC VENOUS
CONGESTION
• EDEMAHEPATOMEGALYRAISED JVPANOREXIAABDOMINAL PAIN
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Clinical Signs of CHF
Cardiomegaly
Gallop sounds
Coarse rales in the lung bases
Sputum frothy and blood tinged
Hydrothorax
Hepatojugular reflux (Pasteur-Randot reflux)
Ascites
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Framingham Criteria for CHF
Major CriteriaPND/ orthopnoea
JVP
Rales
Cardiomegaly
Ac. pul. edema
S3 gallop
CT > 25 sec.
Hepatojugular reflux
Minor CriteriaAnkle edema
Night cough
Dyspnoea on exertion
Hepatomegaly
Pleural effusion
Vital capacity to 1/3 max.
Tachycardia( > 120/m)
Major or Minor : Wt. loss > 4.5 kg in 5 days with treatment
Diagnosis of CHF : 2 major OR 1 major + 2 minor
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DIAGNOSIS
CXR Cardiomegaly
ECGChamber hypertrophy,
arrhythmias, myocarditis
ECHO Detection of actual lesion
Ventricular Function
BNP
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Management of CHF - General
Rest Reduces COP
Oxygen Improves oxygenation in pulm. edema
Na and Fluid restriction
Decreases vascular congestion and preload
Diuretics - frusemide
Reduces preload, vasodialatation
Combination DCT diuretic
Better salt excretion
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Management of CHF - Inotorpes
DigoxinInhibits membrane Na+K+ ATPase,
Increases intracellular Ca++, Improves cardiac contractility and myocardial O2 consumption
DopamineReduces myocardial norepinephrine,
direct beta receptor action - increase in systemic BP
Dobutamine Beta 1 agonist, often used with dopamine
AmrinoneNon-sympathomimetic, non-cardiac glycoside with inotropic effect, also -
vasodialatation
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Management of CHF - Afterload reducing agents
Hydralazine Arterial vasodialatation
NitroprussideArterial & venous relaxation, reduces
preload also
Captopril/ enalapril
ACE Inhibitors, reduce Angiotensin II production
PrazosinOral alpha adrenergic blocker, arterial & venous dialatation, reduces preload also
Mechanical Counter
pulasationsImproves coronary flow, afterload
Partial Lt. ventriculotomy _ mitral valve
Improves Laplace relationship by less wall tension
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DigitalizationPO : Half initially followed by 1/4th every 8 - 12 hrs X 2
Dose:
Preterm : 20 microG/kg
Term neonate: 2-=30 mcg/kg
Adolescent : 0.5 - 1.0 mg in div doses
IV : 75% of oral dose