Gavin Burgess R5, PEM. General Review common presentations Uncommon Paediatric ECG Congenital...

Gavin Burgess R5, PEM

General

Review common presentations Uncommon Paediatric ECG Congenital heart disease Rhythm disturbances Long QT HOCM Rheumatic fever Carditis – myo, endo, peri

General

Innocent murmurs Kawasaki disease

Fetal circulation

“Normal”

Age Respiratory rate

Pulse rate Systolic BP

O-1mo 30-60 120-160 50-70

1-12mo 20-40 80-140 70-100

1-5y 20-30 80-130 80-110

6-12y 20-30 70-110 80-120

adolescents 12-20 60-100 110-120

“Normal”

Ball-park BP? Neonate? Older?

“Normal”

Gestational age should equal MAP Systolic BP = 70 + (2 x age)

“Normal” ECG

Typically have shorter PR, QRS, QT RV dominance, RAD

RVH

Causes Tetralogy of Fallot PS Coarct ASD TAPVD Large VSD with Pulm HT

LVH

Causes AS VSD PDA Complete AV block Cardiomyopathy

Diagnosis?

Superior or “north west” axis Endocardial cushion defect

2% of congenital heart disease Down syndrome account for 70% Fatal due to pulm HT Banding in infancy

Myocardial infarction

AT III Cardiomyopathy Congenital heart disease CAD (ALCAPA) Drugs (cocaine) Homocystinuria Hyperlipidaemia and cholesterolaemia Kawasaki Leukaemia Marfans Haemoglobinopathies Tumours (myxoma) Rheumatic fever SLE

Diagnosis?

Diagnosis?

Diagnosis?

Which lesions give cyanosis? Tetralogy of Fallot Tricuspid atresia Transposition of the great arteries (IDM) Truncus arteriosus Total anomalous pulmonary venous

drainage Hypoplastic left heart Ebstein’s anomaly (lithium) Pulmonary atresia/severe stenosis

Pulmonary markings

Decreased: Pulmonary atresia/stenosis Tetralogy Tricuspid atresia Ebstein’s anomaly

Increased: TGA TAPVD Truncus

What’s the hyperoxia test? ABG Give 100% O2 Repeat ABG after 10 min If rises by >10%, likely pulmonary

lesion

When does the ductus close? 10-14 days after birth, it is

physiologically closed

Neonatal and infant presentations to ED What are the 4 presentations in and

infants neonates? 1) shock 2) cyanosis 3) cardiac failure 4) murmur

What are the ductal-dependent lesions? Systemic

Coarct/interrupted arch Aortic stenosis HLH

Pulmonary PS/atresia Tricuspid atresia

Shock

L ventricular outflow obstruction Coarct AS HLH

Shock

Management: ABC’s Start prostin CXR ECG

What’s prostin?

Prostaglandin E1 Rate 0.05-0.2 mcg/kg/min Side effects?

Apnoea Fever Flushing Hypotension

Prostin has an “all or nothing” action Should work in 15min

Time to presentation of cyanotic lesions

Age ECG X-ray

0-1 week TGA RVH Increased

1st week TAPVD RVH Increased

1-4weeks Tricuspid Atresia

LVH Decreased

Severe PS RVH Decreased

1-12weeks TOF RVH Decreased

Anytime in infancy

Truncus arteriosus

BVH Increased

Cyanosis

What is a tetralogy of Fallot? RVH Overriding aorta VSD RV outflow obstruction

What’s a “tet spell”?

Change in the balance of pulmonary and systemic flow

Hypoxic and cyanotic event Decreased system vascular

resistance or increased RV outflow obstruction

Increasing hypoxia

How do I treat it?

O2 Chest-knee (why?) Analgesia B-blocker (why?)

Cardiac failure

History: Fussy Sweating FTT Short frequent meals

Physical: HSM Murmur FTT You will NOT see a JVP AVM – auscultate the head

Murmurs

Features of an innocent murmur 80% of children will have a murmur at

some time in their lives All have normal ECG and X-rays Never diastolic

Common innocent murmurs

Type Description Age

Still’s LLSB, 2/6, “twang” 3-6y

Pulmonary flow ULSB, blowing, transmits

Gone in 3-6mo

Venous hum Supra clavicular, rotate head, supine goes

3-6y

Carotid bruit Over carotid Any age

Arrhythmia

SVT Very common Tolerated well, occasional LOC change Child is fussy Newborn >220 bpm <12y often accessory pathway

Arrhythmia

SVT treatment In shock vs stable Vagal stim Adenosine Amiodarone ,verapamil use extreme

caution. Frequently develop profound hypotension and die

Arrhythmia Long QT

History Deafness Single person MVC Swimming syncope Exercise syncope Family history of sudden death Seizure of unknown etiology Recurrent syncope/lightheadedness Sibling with SIDS

Physical Infant with bradycardia

Arrhythmia

All first degree family members should be screened with ECG

HOCM

2% under 2 y, 7% under 10y Variable history

CP Palpitations SOB Syncope Sudden death High risk if syncope Sudden death with strenuous exercise

HOCM

Physical S4 gallop, mid systolic murmur Increased PVR decreases murmurs

Rheumatic fever

Who was Jones? What where his criteria? What do you need to make a

diagnosis? Which valve? Then?

Rheumatic fever

What about Sydenham’s chorea? And the rash?

Rheumatic fever

Treatment ASA 75-100mg/kg Prednisone 1-2mg/kg Benzathine (Pen G) 600 000U (27kg), 1.2

million U (27kg) Prophylaxis Age questioned

Myocarditis

Various causes, most notably viral Coxsackie A,B, ECHO, flu’ Non-specific viral prodrome Non-specifc fussiness, lethargy etc Heart failure IVIG may be indicated

Infective endocarditis

Rheumatic fever, congenital heart defects, catheters, IVD

S. aureus, viridans are the usual suspects

Fungi in neonates, usually in the NICU

Infective endocarditis

Major 2 + BC, (viridans, s. bovis, HACEK, S. aureus,

enterococci Persistently + BC (1 hr between multiple, or

12h or 3h +) + echo mass at typical sites Intracardiac abscess Prosthesis failure New regurgitant murmur

Infective endocarditis

Minor Fever (38C) Predisposing condition/IVD Vascular phenomena Non-specific echo findings

Prophylaxis -1997

Prophylaxis

High risk Prosthesis Previous IE Transplants Complex CHD

Dropped from the list……. Moderate risk

(PDA,VSD,primumASD,coarct,bicuspidAV) Calcified AS,RF,HOCM,MVP

Pericarditis

Classic chest pain worse when lying flat

Radiation to L shoulder Friction rub Most often viral causes Diffuse ST changes, “saddle”shaped CXR important Cefotaxime, ASA, prednisone,

colchicine

Kawasaki disease

Etiology unkown, presumed infectious

More common in Asian and Pacific islanders

Peaks around 1-2years, 80% under 4y, 50% under 2y

Slight male preponderance 3mo-8y is typical range

Kawasaki disease

3 phases Acute phase (10 days)

High fever for 5 days 4 of

rash (ANY rash, no bullae/vesicles), oedema of extremities/ peeling of extremities Non-exudative bulbar conjuctivitis Mucosal changes (cracked lips, strawberry

tongue – even on HISTORY) Cervical LN (1.5cm)

Carditis, other organs (arthritis, pyuria, gallbladder/liver, menigitis, irritable

Kawasaki disease

Acute ESR, CRP WCC, plt Lipids, LFTs Echo coronary artery aneurysms unusual

before 10d

Subacute phase Desquamation Coronary disease Rash, fever, LN disappear plt

Kawasaki disease

Convalescent phase ESR, plt normalise Beau’s lines

Kawasaki disease

Rx IVIG ASA Vaccinations Steroid of no benefit Reduces CAD from 25% to 5% Untreated mortality 1-5%