12.09.13 Cardiology

VSD

• • Loud, pansystolic murmur, LLSB

    • NOT from flow through the defect; more from turbulent flow in the R ventricle

  • Loud S2 if pulmonary HTN

  • Potential for Eisenmenger Syndrome

    • Also caused by ASD, PDA

    • Left-to-right shunt => increased pulmonary flow => damage => pulmonary HTN => Right-to-left shunt => Cyanosis

    • Presents with cyanotic episodes in teenage years

Innocent murmur

• • Systolic

    • Except venous hum, which is innocent but systolic + diastolic

  • Soft

  • Normal heart sounds

  • Normal pulses

  • No thrill

  • No radiation

  • Position dependent

  • Asymptomatic

  • Normal CXR and ECG

Kawasaki syndrome

• • Autoimmune medium-vessel vasculitis

  • Diagnosis:

    • Fever of ≥5 days' duration plus 4 of:

      • Bilateral nonsuppurative conjunctivitis

      • One or more changes of the mucous membranes of the upper respiratory tract

        • Pharyngeal injection, dry fissured lips, injected lips, "strawberry" tongue

      • One or more changes of the extremities

        • Peripheral erythema, peripheral edema, periungual desquamation, generalized desquamation

      • Polymorphous rash

        • Pimarily truncal

      • Cervical lymphadenopathy

        • >1.5 cm in diameter

  • Can cause fatal coronary artery aneurysms

  • Treatment:

    • IVIG

    • Aspirin

      • One of the few conditions for which it's indicated in kids

      • cf Rey's syndrome

    • Plasma exchange

    • Corticosteroids?

      • Poor evidence and may increase risk of coronary artery aneurysms

IVIG therapy

• • Contains the pooled, polyvalent, IgG from the plasma of over one thousand blood donors

  • Effects last between 2 weeks and 3 months

  • Mechanism unclear

    • Activates inhibitory Fc receptors on dendritic cells

    • => anti-inflammatory effects

  • Indications

    • Immune deficiencies

      • X-linked agammaglobulinemia

      • Hypogammaglobulinemia

      • Acquired compromised immunity conditions featuring low antibody levels

    • Autoimmune disease

      • e.g. ITP

    • Inflammatory diseases

      • e.g. Kawasaki disease.

    • Acute infections

Tet spells

• • Problem

    • Not entirely clear

    • Sudden decrease in pulmonary blood flow and therefore oxygenation?

      • Increased pulmonary vascular resistance? (Crying)

      • Fall in systemic vascular resistance

    • Begins a cycle:

      • Acidosis => Hyperventilation

      • => More systemic venous return

      • => More R=>L shunt

      • => Even less pulmonary blood flow

    • Also spasm of pulmonary artery?

  • Place in a knee-chest position

  • Increase systemic vascular resistance

  • Oxygen

  • IV morphine

    • Venoconstriction => More peripheral venous blood pooling => Less venous return => Less R=>L shunt

    • Sedative effect

  • IV propranolol

    • Relaxes the infundibular muscle spasm causing right ventricular (RV) outflow tract obstruction (RVOTO)

Coarctation of the aorta

• • HARD TO FIND PULSES

  • Ejection systolic murmur radiating to between the shoulder blades

  • Symptoms depend on where to coarctation is

    • Pre-dutal

    • Ductal

    • Post-ductal

• • See rib notching on CXR, due to collateral vessels

Transverse myelitis

• • Pathogenesis

    • Inflammatory process of the spinal cord

    • => axonal demyelination

  • Transverse implies that the inflammation is across the thickness of the spinal cord

  • Causes

    • Post infection

      • CMV?

    • MS

  • Progresses vary rapidly

    • Hours-days

  • Presentation

    • Depends on level

      • Upper cervical cord => Quadriplegia, Resp. paralysis

      • C5–T1 => Combination of upper and lower motor neuron signs in the upper limbs; exclusively upper motor neuron signs in the lower limbs

      • T1–12 => Upper motor neuron signs in the lower limbs, presenting as a spastic diplegia

      • L1–S5 => Combination of upper and lower motor neuron signs in the lower limbs

    • Motor impairment

    • Sometimes have some sensory impairment

Notes

• • AMPLE

    • Allergies

    • Medications

    • Past Medical History

    • Last Eaten

    • Events Leading

  • Breathlessness in a baby makes it hard for them to feed => FTT