Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children CVS Topics to be discussed Introduction to CVS diseases Cyanotic CHD VSD & ASD PDA Rheumatic fever Rheumatic heart disease Congestive heart failure Infective endocarditis Myocarditis and pericarditis
CVS Clinical Examination
Dr. D. Gunsekaran,Consultant Paediatrician
Dr. D. GunasekaranConsultant Paediatrician
Introduction to CVS diseases
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
1. Symptoms - suggestive of heart disease?
BreathlessnessBluish extremities
CoughChest pain
FeverFeeding difficultiesFailure to ThriveFrequent RTI
SyncopePalpitation Swelling of feet (Pedal
edema)
Joint PainDancing movements (Chorea)
Painful swellings in finger pulps
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children 2. Is it congenital or acquired?
Congenital: Symptoms from infancy Feeding difficulties FTT Recurrent hospital admissions
Acquired: Rheumatic fever: Fever, joint pain, chorea
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children 3. If it is congenital, is it cyanotic or acyanotic?
Why cyanosis occurs?
What are the two types of cyanosis?
Which one is present in Cyanotic CHDs?
How to differentiate?
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children Criteria Peripheral
cyanosisCentral cyanosis
Basic pathology
Poor circulation in peripheral parts
Poor oxygenation in lungs
Areas involved
Peripheries (nail beds, tip of nose & ear lobes)
Peripheries + oral mucosa & tongue
Clubbing Absent Present
Polycythemia
Absent Present
Touch of the peripheries
Cool Warm
How to reduce cyanosis
Warming the peripheries
Administration of oxygen
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Cyanotic CHD
PBF PBFTOFTRICUSPID ATRESIATGADORV WITH PSSINGLE VENTRICLE WITH PS
TRUNCUS ARTERIOSUSTAPVCDORIV WITHOUT PSSINGLE VENTRICLE WITHOUT PS
4. If it is Cyanotic CHD, what is the actual CHD?
Based on murmurs, change in heart sounds investigations
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Acyanotic CHD
Volume overload (Shunt)
Pressure over load (Obstn)
PSASCoA
ASDVSDPDA
5. If it is Acyanotic CHD, what is the actual CHD?
Based on murmurs, change in heart sounds investigations
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children 6. Is it Rheumatic fever or RHD?
If so, which valves are involved?
Is there any evidence of pericarditis or myocarditis?
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children 7. Are there any complications?
CCF
Infective Endocarditis
Pulmonary Hypertension
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
CVS Clinical Examination
Pulse
Blood Pressure
Apical Impulse
General examination
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Pulse
Four information
Which artery you will choose for examination of pulse?
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Pulse - Rate
Tachycardia:
Rheumatic fever Congestive cardiac failure Arrythmias
Bradycardia:
Arrythmias
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children Normal range of Pulse rates for different ages
NB-2 months: 80 - 200 3 months -1 year: 80 - 180 1-8 years: 60 - 180
>8 years: 60 - 160
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Pulse - Rhythm
Observe the pulse for one full minute.
Regularly irregular: Ectopics
Irregularly irregular: Atrial fibrillation
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Pulse - Volume
High volume pulse:
Low volume pulse:
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Pulse – Volume Depends on pulse pressure; What is PP? Normal PP?
High volume: high PP high SBP: PDA & AR low DBP: Septic shock (warm
shock)
Low volume: low PP low SBP: AS, MS, CoA, CCF high DBP: Hypovolemic shock
(Vasocons)
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Pulse - Character
Slow rising pulse : AS
Collapsing pulse: AR, PDA
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children Apical Impulse - Definition
LV & part of inter ventricular septum
Age Position
Up to 4 years
4th ICS 1 cm lateral to MCL
5-8 years 4th ICS just lateral to MCL
> 8 years 5th ICS 1 cm medial to MCL
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children Use of Apical Impulse in clinical exam?
Shift indicates what?
What are the abnormal types of AI?
What are the conditions causing abnormal AI?
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Blood Pressure
What size cuff is preferable?
Width: 40% of circumference
Length: 80-100 % of circumference
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Normal range of BP
For proper interpretation:
We should refer to the standard charts
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Normal range of BP
Average Systolic BP: At Birth: 60 Neonate: 70 6 months: 85 1 year: 90
Systolic BP for 1-10 years: 90 + (age in yrs X 2) Diastolic BP : 2/3 of Systolic BP
Pulse pressure:
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
General examination
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
General examination
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
General examination
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
General examination
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
General examination
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children General examination (splinter hemorrhages)
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children General examination (Rheumatic- arthritis)
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children General examination (Rheumatic -subcutaneous nodule)
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children General examination (Rheumatic - erythema marginatum)
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children Investigations – Egg on side - TGA
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children Investigations – Boot shaped - TOF
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children Investigations - Cardiomegaly
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Incidence of CHD 6-8 per 1000 live births
1 in 10 still born infants
NADAS CRITERIA
MAJOR CRITERIA MINOR CRITERIA
SYSTOLIC MURMUR Grade 3 OR MORE
SYS. MURMUR LESS THAN Grade 3.
DIASTOLIC MURMUR ABN.SECOND SOUND
CYANOSIS ABN. ECG
CHF ABN. CxR
ABN. BP
DIAGNOSIS OF CHD
For Diagnosis of CHD: 2 Major or 1 Major + 2 Minor
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Common CHDs
Acyanotic: VSD 32% PDA 12% PS, ASD, Co A, & AS
6%
Cyanotic: TOF 6% TGA 5%
Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.
Approach to a child with Heart disease in children
Aetiology of CHD Chromosomal anomalies: 8% Ex: Trisomies-21,18,13;
Turner’s Environmental teratogens: 2% Ex: Intrauterine infections, Maternal drug intake
(Phenytoin) Maternal diseases
(Diabetes, SLE)
Single gene mutations: 90%