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