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Pediatrics (week 3): Cardiorespiratory

Cardio and Resp

PEDIATRIC CARDIOLOGY

SBE: subacute endocarditis
sx: fuo, mild anorexia, wt loss, malaise, myalgia, jt pn, nt sweat
risk: hx of cardiac surgery, dental surgery, valve dz, congenital heart defect
pe: listen for new or changes to existing heart murmurs
pe: low grade fever, pallor, may present like meningitis with rash
labs: esr elevated, cbc shows wbcs, must do 3 cultures to get positive, poss hematuria dt immune complexes
imaging: echo for valve dmg, vegetations
tx: hospitalize, 6 wks iv abx
complic: embolism, heart dmg, valve dmg

KAWASAKI SYNDROME
mucocutaneous lymph node synd
rare, idiopathic, multisys
young kids most 12-24 mo, almost all under age 5
most present like vasculitis
SX: high fever lasting over 5 days, at least 4 of the following: conjunctivitis s exudate, nonvesicular polymorphic rash (maculopap on trunk, may desquamate, poss petechiae), oral inflam (erythema, strawberry tongue, ulcers, crusts, dryness), edema or erythema of extremities (palms and soles turn bright red, mb indurated, painful, perungual desquamation at subacute phase, poss bose lines in convalescent phase), oft cervical LAD (oft unilat, mb large, entire chain swollen)
3 STAGES
1) acute 1st 2 wks, v toxic look "bad sick", high fever 104-107, irrit, oral inflam, rash, hand and feet swell
2) subacute weeks 3-8, aneurisms can appear if untxd, grad improvement w/o tx
3) convalescent stage: weeks to years, labs return to normal, sx resolve, aneurisms & cardiac probs may resolve or persist, aneurisms regress over 1-2 years
COMPLICATIONS: ANEURISM is #1 in 25% if untxd in acute, thrombosis, MI, death, ruptured aneurisms, mc in kids under 1 over 8 more in males more in fever over 16d, when esr over 100 or over 30 days elevated, hgb under 10, wbc over 30,000, if arrhythmia, cardiomeg, eck abn, also PERICARDITIS or effusion, death usu dt cardio complic, mortality up to 2%
LABS: wbcs over 20,000, left shift, mild anemia, elevated crp, esr, echo shows aneurisms (showing up weeks 1-4) and pericardial effusions
TX: emergency hospitalization, iv immunoglobins before day 10, high dose aspirin, no corticosteroids they incr aneurisms, bed rest for 2-3rd wk or until child is afebrile for 72 hrs, restrx from strenuous even when asx, sig improvement in days
TX: nd support? coq10, vit e, c, fish oil, general bv health

CONGENITAL HEART DZ
usu already dxd
present in 1%
may present like CHF: orthopnea, dyspnea, tachypnea, sweating w mild exertion (nursing even), cyanosis, poor nursing, vomiting, lethargy, easy fatigue, failure to thrive despite adequate nutrition, developmental delay at any age
xsm abn ie trisomy 21/down syndrome oft assoc
PE: central cyanosis usudt R->L shunt, requires urgent hospital workup, run errands later
TX: usu surgical

CHF
sx: gray, sweaty, fatigued
etio: at birth usudt tricuspid or pulmonic insuff, L ventricle undeveloped
1st month, any of above plus transposition of great vessel, coartation of aorta, VSD, truncus ...
complic: decompensation

MURMURS
PPS
newborns mc have pulm stenosis
hear in L axilla or on back, grade 1-2, med to high pitch "squishy"
worse with feeding, crying, incr workload
resolves with time, growth, is a backflow issue

MVP
mitral prolapse is #2
present in 1-6%
2/1 female
PE: mid-late systolic click and regurge murmur, can change sound and location
SX: usu asx, if sx or arrhythmia then halter monitor
dx: 2D echo
complic: SBE, adult murmurs-->arrhythmias
TX: prophylactic abx to prevent SBE but less now

ASD
usu L-->R shunt
1/500 births
2/1 female
mc is patent foramen ovale
PE: soft midsystolic murmur
SX: none sig, often not recognized
TX: surgical repair age 2-6
mc w/ trisomy 21

VSD
L-->R shunt dt ventricular septum not fully formed
3/1000 births
size of shunt decr w/ growth, may close, normal to close within 1yr
sx vary with size of defect
holosytolic parasternal murmur heard most at 2-3 wks when heart fx incr in str
sx: failure to thrive, diaphoresis, recurrent infx
if pulm htn then cyanosis
tx: surgery if large

PATENT DUCTUS ARTERIOSUS
cyanotic murmur
"machinery murmur" loudest in 1-2nd intercostal or high in L axilla
more in premies, high alt, females
if not resolved at 6-8 wks get cardiologist eval
tx: 6mo-3yrs surgery
surgeons like to wait as long as possible, 1yr and 20lbs is goal for surgery tolerance

TETROLOGY OF FALLOT
persistent ductus arteriosus, overriding aorta, hypertrophy of R vent, 1 more
injx murmur
gradual onset of cyanosis, dyspnea, hypoxmia, resp distress, coma, altered LOC after activity (nursing for newborn)
tx: surgery, PGE1 keeps ductus arteriosus open
dx: mb dxd via US prenatally

ARRHYTHMIAS
SX: mb vague, fussy, poor feeding in infants, poorly localized chest pain, syncope or pre in school age
hist: ask about cardiac sudden death in family
PE: irreg rhythm, normal to change with breath
PACs on EKG usu b9
sinus tachy if freq pacs
PVCs can be felt by pt, usu b9 if not too frequent, usu abate w exercise
SVT is mc symptomatic arr in kids, poor feeding, lethargy, hr over 200
DX: refer to ped cardiologist, even if you think it's normal, tell parents and refer anyway
COMPLIC: various, chf mc


Michael Choy (Megan's father) in Davis, Ca is pediatric cardiologist on our list of preceptors
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RESPIRATORY

COUGH
v common presenting, drives parents crazy, hard to tx
mc: cough keeps us awake at night, or kid was sick and cough is lingering x2wks
cough as article of faith: she believes parent report of cough all night long, etc
most coughs last x3wks, often more even in uncomplicated cases
etio: infx, reactive airway dz, rare pneumonia (parents' worst fear), pharyngitis, strep, laryngitis, sinusitis, pertussis, influenza, URI in general, allergies, CF, GERD if after nursing, foreign body, chem, fumes,
more concern with infants
etio: RSV and H flu type B (HIB) common and much more serious in infants
synagist is vaccine for RSV, only given in hospitals with premies
vaccine for HIB not given before 6mo
persistent cough may indic asthma or CF
PE: vitals, pulm exam (wet or dry cough?), upper airway noise (post nasal drip), wheezing, rales?
drooling: strep, epiglottitis?
fever, tachypnea: w lower resp infx, looks sicker
Tx for foreign body: anesthesia and bronchoscope to retrieve inhaled crayon
Tx for routine cough:
herbs, BEMP tincture tastes disgusting, hard to get kids to take it, rarely uses homeop for cough in kids, she is not a classical homeopath, uses combos, acutes and chronics
likes combo cough remedies, easy to get into kids
honey is good cough remedy after age 1 dt botchelism risk, simmer onion and sweeten water
honeyed tea, ginger for clearing out mucus
wisewoman herbal cough elixirs 1 and 2, gaia herbs wet cough mixture, ed hoffman smith uses mother earths, tastes good but isn't strong so she blends the gaia wet with the mother earth or other blends, likes pure encap immune support
hydro works, gives constitutional instrx then "any is better than none" for infants, modify as necc
hot bath then cold onesy and towel wrap, or finish with cold shower
or hot bath and cold washcloth on back, breast feed etc to distract kid while cold on
wet sox good if dt sinus congestion
NAC hard to get into kids, "smells like cat pee"
PHP physicians health products, desensitization drops, combo homeop, she loves them
one called mucolytic drainage that she likes, she grafts them, puts a couple drops in water
Tx: she uses abx if sinusitis, bloody discharge
Tx: strep: offers abx, amox used to work but doesn't anymore 70% they're back in 2 weeks with relapse, gives zpack instead now, some cephalosporins work sometimes tries them first
Tx: sent them home with script so she's not getting weekend calls, give instrx as to when to use, decr stress level and decr pressure on herbal stuff, need patience to give herbal meds
croup: tx like any other cough, homeop: spongia, aconite, hepar sulf, try one, if it doesn't work wait a couple hrs and try next, she's never seen them need steroids
DDX: serious causes: upper resp: asthma, uri infx, ear, throat, epiglottitis, pneumo, CF (heel stick tests for this), premie, assisted or mechanical ventilation, croup/laryngiotracheobronchitis (a cough with a name, any of several viruses and not a big deal unless RSV and under 6mo)
lower resp: bronciolitis, bronchitis, pneumo, viral exacerbation of asthma, few require hosp: 1% with pneumo, 2% with bronchiolitis,

PRODUCTIVE COUGH
adult spits
little kids swallow

rales = air passing over retained secretion, or sudden opening of collapsed airway, insp or exp, discontinuous, coarse mc in lower dt secretions, "gurgly"
rhonchi = wheezes during insp, exp or both dt airway narrowing/partial airway obstrx dt secretions or swelling, more likely to be continuous
crackles =
wheeze = musical, more continuous, narrowed airway

*schwartes ped prim care table for hx to dx lower resp, copy this page

BRONCHITIS
SX: dry harsh cough, rhonchi, fever, no hypoxemia/toxemia, mb preceded by URI, usu tachypnea, some elevation of resp rate, no chest retractions or decr breath sounds, no rales,
Tx: usu self limiting unless secondary infx, hydro, herbs, honey

BRONCHIOLITIS
rapid onset
usu viral, RSV mc under 1yr, rarely serious outside of infancy when it can be deadly
bronchiolitis preceded by URI, rhinorrhea, cough
HX: ask about birth, premie, congenital issues
Sx: looks toxic, fever not that high, sev insp stridor, drooling, sore throat (young: asks for cup takes one sip then gets mad), rare cough: if cough it's dry, v pale under 6mo old
restless, lethargy, decr o2, apnea usu sends parents to ER, cyanosis-->er,
PE: tachypnea, decr breath sounds, high wheeze, mb rales, fine insp crackles, rales, access mm use, retractions, nostril flaring, low grade fever, cyanosis (nails, oral), hyperinflated lungs can cause abd distension (she's not seen this)
LABS: high wbcs, may see infiltrate, ateletasis, rarely do viral cultures,
Tx: 1-5% need hospital
more in premies, under 3mo of age, decr o2 sat, other cardiopulm dz or immune def
send to hospital if under 6mo and looks like RSV: pale, low fever, cough, toxic
most self resolving in 3-5 days
steroids sometimes, bronchodilators used more in hosp

RSV: Dec-Mar mc time, incubat 2-4d, contagious 24 days, starts URI (days 4-5) and spreads lower
assoc w croup & bronchiolitis, accompanying OM
incr tachypnea is serious concern

PNEUMONIA
not that common
usu after URI
sx: dyspnea, fever, malaise, headache, cough, chest pain, n/v, sometimes d
risk: previous pneumo-->more phos given
PE: tachypnea, dyspnea, cough, grunting, retractions, splinting, abd distension
decr breath sounds, dullness on percussion, rales
lung exam mb normal
less wheeze in bact than viral
LABS: pa and lateral chest xray is diagnostic
6wks before xray looks better: don't repeat chest xray
CBC: usu high whites esp with bact
Hospital: pulse ox etc
Tx: abx well indicated if bact
viral usu self limiting but parents want abx instead of CBC
so she offers abx to prevent 2ndary infx, parents tend to use abx
supp o2
bronchodilators, inhaler with spacer
hydrotherapy: lots
herbs: teas etc

ASTHMA
airways hyperresponsive and inflamed
fhx: atopy mb sig in parents, 60% more asthma if both parents have it
risk: atopic triad in family: asthma, eczema, hayfever, exposure to inhaled esp cigs, viral infx esp RSV
mc chronic illness in children, 5-10% of schoolage kids
some outgrow it
DDX: CF, GERD, more
must have pattern to dx: wheeze, dyspnea, chest tightness (hard to breathe), SOB, cough poss esp if chronic and dry in kid, pattern: more when triggers are high, seasonal pollen? dust and mold? exercise? emotional, hormonal, drugs (aspirin, nsaids, beta blockers, acei)? mb better w preg.
repeated episodes of similar description
Hx: seasonal or year round, continuous vs acute, duration and frequency of episodes
Hx: ask about triggers, teach parents what to look for, usu parents will identify trigger, not you,
get them to log what's up whenever there's an atopic response
PE: pulm exam usu normal unless attack ongoing
PE: may hear wheeze, end exp cough
if you can provoke wheeze/cough every time w forced expiration then there is breathing problem
assess accessory mm use, general allergic sx (shiners, denies lines, rhinitis, post nasal drip, congestion, salute sign
DX: pulm fx test essential for dx & management, difficult to do on kids under 6, impossible under 4
allergy testing, GER testing, CXR, peak flow meter
TX: wet sox, tinctures must be well labelled in order to be acceptable at schools and still may be problematic as the kid may have to report to some office to take their prn rescue inhaler meds
bronchodilators may be easier to use because schools are more accepting
nebulizers good, easy to get meds in, albuterol, metoproterenol, salmeterol (longest t1/2)
theophylline less done than beta2 agonists
antiinflammatories much used, daily use not just for acute
mast cell stabilizers used for both allergic and non
corticosteroids: inhaled, oral or IV
leukotriene modifiers, blocks early and delayed responses
GOAL OF TX: aim for prn meds and remove triggers
triggers: carpets, bedding, pets, etc etc etc

Cardiology

I. Infections
A. Subacute Bacterial Endocarditis
1. infection lodges in valves and inner lining of heart
a. Commonly presents as FUO
b. risks
c. presenting symptoms
2. PE
a. fever
b. murmurs
c. neurological
d. general
3. diagnosis
a. labs:
blood culture is definitive
b. echocadiogram
4. complications
a. valve damage
b. heart failure
c. Embolism
5. treatment
a. antibiotics

B. Kawasaki Syndrome (aka mucocutaneous lymph node syndrome)
1. idiopathic disease of young children. Affects multiple systems, complications mainly related to vasculitis.
a. presents as fever lasting >5 days along with at least 4 of the following:
i. conjunctivitis
ii. non-vesicular rash
iii. oral inflammation
iv. edema or erythema of extremities
v. cervical lymphadenopathy
b. can see atypical cases
c. most common in children under 5
d. three phases
i. acute (1-2 weeks from onset)
ii. subacute (3-8 weeks)
iii. convalescent: generally 4 months
2. PE
a. high fever
b. rash
c. conjunctivitis
d. oral lesions
e. limb involvement
i. desquamation
ii. Beau lines
f. cervical lymphadenopathy
3. diagnosis
a. WBC increased, left shift, mild anemia
b. elevated CRP
c. ESR
d. echocardiogram
4. complications
a. aneurysm
b. pancarditis, pericardial effusion
c. death
5. treatment
a. hospitalize and give IVIG (intravenous immuneglobulin) before day 10 of clinical illness
b. high dose ASA
c. no corticosteroids
d. bedrest
e. restriction from strenuous activity

II. Congenital Problems
A. General info
1. typically will come to you already diagnosed
a. more than 1% of kids will have some form of congenital heart defect
2. serious symptoms include
a. signs of CHF
b. cyanosis, pallor, grayish skin
c. poor nursing in newborns or young infants, vomiting
d. lethargy
e. failure to thrive
f. developmental delays
g. other known congenital abnormalities
B. PE usually shows signs of cardiac disease
1. central cyanosis
a. generally results from a right to left shunt
tetralogy of fallot
transposition of great arteries
tricuspid or pulmonary atresia
truncus arteriosus
transitional circulation
total anomalous pulmonary venous return
b. always requires workup at hospital
c. treatment
2. CHF
a. causes
i. at birth: Severe tricuspid or pulmonic insufficiency Underdeveloped left ventricle Severe pulmonic or aortic stenosis
ii. first month: all above plus trasposition of great vessels (with shunt), coarctation of aorta
iii. infancy: VSD, truncus arteriosus, PDA
3. murmurs
a. peripheral pulmonary stenosis
i. benign
ii. short, midsystolic, medium to high pitch; heard in back, L axilla. Usually grade I or II
iii. accentuated after feeding, crying, with anemia
iv. resolves
b. mitral valve prolapse
i. 1-6% of all kids
a. 2:1 female:male ratio
ii. PE
a. mid to late systolic click and late systolic murmur
b. generally asymptomatic
c. murmur can change
iii. diagnosis
a. echocardiography
b. holter monitor
iv. complications
a. SBE
b. lethal arrhythmias in adults
v. treatment
a. prophylactic ABX during surgery to prevent SBE

c. Atrial Septal Defect (ASD) : abnormal opening between atria. L to R shunting usually involved.
i. patent foramen ovale
ii. soft pulmonic midsystolic murmur, generally grade III or lower.
iii. no significant symptoms
iv. surgical repair
v. commonly seen in Trisomy 21
c. Ventricular Septal Defect (VSD): opening between ventricles. Shunting from L to R common in systole. Generally no cyanosis.
i. relative size decreases as child grows
ii. small defect: holosystolic parasternal murmur, generally absent at birth but present by 2-3 weeks.
iii. large defect: harsh murmur and split S2: failure to thrive, diaphoresis, recurrent LRTI/ pneumonia
iv. if pulmonary hypertension present, cyanosis may present
d. patent ductus arteriousus (PDA): persistence of fetal circulation. Can be subtle in first few days and most resolve spontaneously. Acyanotic
i. classic machinery murmur
ii. more common in: preemies, high altitude, females
iii. evaluation by cardiologist
e. Tetrology of Fallot: 4 defects combined
i. pulmonary stenosis
VSD
Overriding aorta (dextroposition)
Hypertrophy of R ventricle
ii. ejection murmur upper L sternal border
iii. gradual onset of cyanosis from R to L shunt
iv. poor growth, marked dyspnea
v. may have “spells”
vi. surgery required


III. arrhythmias
A. can present with vague sxs in children
1. FH can be important
B. PE
1. irregular rhythm on regular PE
a. sinus arrhythmia that coincides with respiration and is benign
b. Premature atrial contractions (PAC) that can be seen on ECG
c. Premature ventricular contractions (PVC) also on ECG
d. Supraventricular tachycardia (SVT) is most common symptomatic arrhythmia in children
C. diagnosis
1. ECG
2. Holter monitor
D. complications
1. if related to underlying disease or congenital defect, will relate to that issue
2. CHF
E. treatment
1. refer for appropriate diagnosis, management, treatment

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