Chapter 26 PDF

Preview

Summary

chapter notes...

Description

Daisy Luna Rojas November 29, 2018 Chapter 26: Caring for the Child with a Cardiovascular Condition   



 

Anatomy- a child’s heart contract 60-180 bpm depending on age Chambers- the heart contains 4 chambers: two of them act as reservoirs (atria) and two as pumping chambers (ventricles) to direct the blood flow of the heart 4 Valves in the heart: o Atrioventricular Valves:  Tricuspid Valve- connects the right atrium to the right ventricle and is so named because it consists of 3 cusps or “doors”  Mitral Valve (bicuspid valve)- connects the left atrium to the left ventricle o Semilunar Valves:  Aortic Valve- located at the junction of the right ventricle and pulmonary artery  Pulmonary Valve- located at the junction of the left ventricle and the ascending aorta Vessels o Vena Cava- carry the blood from body tissues to the right atrium  Superior Vena Cava- enters from above the heart and carries blood from the head, arms, and upper body  Inferior Vena Cava- enters from below the heart and carries blood from the legs, abdominal organs, and lower part of the body  Pulmonary Artery- the only named artery that carries deoxygenated blood away from the heart Normal Flow Physiology- the purpose of the hart is to pump blood o Cardiac output- the amount of blood discharged from the left or right ventricle per minute  CO= SV x HR o Stroke volume- the amount of blood ejected by the left ventricle with each heartbeat  SV= preload x afterload x contractility (inotropy) o Preload- the venous blood return to the atria from the body and end diastolic volume of the heart o Afterload- the aortic impedance or the wall stress o Contractility- the force exerted at ejection taking into account the end diastolic volume and the wall stress

Syndromes Associated with Cardiac Disease Syndrome/Disease/Chromosomal Cardiac Other Physical Findings Aberrations Defect/Conditions Down Syndrome AV Canal, VSD Down’s facies, developmental delay Noonan Syndrome Pulmonic valve stenosis, Elfin facies, pectus deformity, joint LVH laxity, undescended testes, spine abnormalities, hypotonia, seizures William’s Syndrome Supravalvular aortic William’s facies: small upturned stenosis, PA stenosis nose, long philtrum (upper lip length), wide mouth, full lips, small chin, and puffiness around the eyes; hypercalcemia, dental abnormalities, renal problems, sensitive hearing, hypotonia, joint laxity, overly friendly personality Decreased immune response, lowInterrupted aortic arch, DiGeorge or Velocardiofacial set ears, palate problems, truncus arteriosus, VSD, Chromosome hypoparathyroidism, hypocalcemia PDA, TOF Duchenne’s Muscular Dystrophy Cardiomyopathy Generalized weakness and muscle wasting first affecting the muscles of the hips, pelvic area, thighs, and shoulders; calves are often enlarged Marfan Syndrome Aortic aneurysm, aortic Arms disproportionately long, tall, and/or mitral regurgitation and thin with laxity of joints, dislocation of lenses, spinal problems, stretch marks, hernia, pectus abnormalities, restrictive ling disease Trisomy 18 VSD, PDA, PS Multiple joint contractures, spina bifida, hearing loss, radial aplasia (underdevelopment or missing radial bone on forearm), cleft lip, birth defects of eye Trisomy 13 VSD, PDA, dextrocardia Omphalocele, holoprosencephaly (an anatomical defect of the brain involving failure of the forebrain to divide properly), kidney defects,

CHARGE

TOF, truncus arteriosus, vascular ring, interrupted aortic arch

Fetal Alcohol Syndrome

VSD, PDA, ASD, TOF

VATER(VACTERLS)

VSD, and others

Turner’s Syndrome

CoA, ASD, AS



 

skin defects of the scalp Coloboma of the eye, heart defects, atresia of the choanae, retardation of growth and development, genital abnormalities, and ear abnormalities and deafness Growth deficiencies, skeletal deformities, facial abnormalities, organ deformities, genital malformations, kidney and urinary defects, central nervous system handicaps Vertebral anomalies, vascular anomalies, anal atresia, cardiac anomalies, tracheo-esophageal (T.E) fistula, esophageal atresia, renal anomalies, radial dysplasia, limb anomalies, single umbilical artery Kidney problems, high blood pressure, overweight, hearing difficulties, diabetes, cataracts, and thyroid problems, lack of sexual development, a “webbed” neck, a low hairline at the back of the neck, drooping of the eyelids, lowset ears, abnormal bone development, multiple moles

Prevention of Heart Disease in Children o Some congenital heart defects and heart disease can be prevented with good prenatal care, vitamins, and low viral exposure Caring for a Child with a Cardiovascular Condition Congestive Heart Failure (CHF)- the inability of the cardiac muscle to perform its proper function of moving blood forward o Signs and Symptoms:  Infants present with:  Poor feeding  Poor growth  Irritability

 SOB/excessive sweating  Enlarged liver  Ascites  Older children:  Poor growth  Exercise intolerance  Babies and toddlers:  Puffy eyelids  Swelling of hands and feet  Bulging fontanel o Diagnosis:  Vital signs  Weight gain  Changes in breath sounds  B-type Natriuretic Peptide  Chest x-ray  Exercise test  Echocardiogram  MRI  Cardiac catheterization 

Congenital Heart Disease- a defect in the heart, great vessels, or a noted disease pattern after birth o Signs and Symptoms:  Low oxygen level  Cyanosis of the lips, nose, or nailbeds  Clubbing of the fingernails  Polycythemia  Hemoglobin greater than 15 d/dL  Thrombi  Stroke o Diagnosis:  Chest x-ray  Electrocardiogram (ECG)  Echocardiography  Cardiac catheterization  Magnetic resonance imaging  CT angiogram

Class L-R shunt

Obstructive Lesions

Cyanotic Defects



Classification of Cardiac Defects Name Atrial-septal defect Ventricular septal defect Patent ductus arteriosus AV canal Pulmonary stenosis Aortic stenosis Coarctation of the aorta Interrupted aortic arch Transposition of the great arteries Tetralogy of Fallot Total anomalous pulmonary venous return Tricuspid atresia Pulmonary atresia Epstein’s anomaly Truncus arteriosus Single Ventricle Double outlet right ventricle Splenic syndromes

Segmental Classification of Congenital Heart Defects o Left-to-Right Shunt Lesions  Atrial Septal Defect (ASD)- a single defect of the atria  Signs and Symptoms: o Possible murmur o Possible right ventricle (RV) heave or a thrill o Possible right atrial enlargement cause by fluid overload from left-to-right shunting through the opening in the atrial wall o Possible right ventricular enlargement o Right axis deviation o A fixed, split, second heart sound o Hepatomegaly o Risk for stroke o S/S of cardiac failure unless repaired  SOB  Respiratory distress

   

Periorbital edema Failure to thrive Increased respiratory infections

Diagnosis: o Echocardiography o Cardiac catheterization o Chest x-ray o ECG o Ventricular Septal Defect (VSD)- the most common congenital heart defect; can be a single opening or the wall may be fraught with multiple defects, sometimes referred to as a Swiss cheese VSD  Signs and Symptoms:  Large VSD with a significant left-to-right shunt: symptoms of right ventricular failure:  SOB  Feeding difficulties  Poor growth  Easy fatigability  Recurrent pulmonary infections  Murmur  Diagnosis:  Audible heart murmur  Chest x-ray  ECG  Echocardiogram  Cardiac catheterization  Cardiac MRI o Patent Ductus Arteriosus (PDA)- the simplest form of vessel defects  Signs and Symptoms: o Murmur o Frequent colds o Susceptibility to respiratory syncytial virus o Fatigue o Poor feeding o Poor growth patterns o Blood pressure reveals a wide pulse pressure  Diagnosis: o Machine-like murmur



o Chest x-ray o Echocardiogram o Atrioventricular Canal Defect (AVC)- a large hole in the center of the heart  Known as: o Complete AVC o Endocardial cushion defect (ECD)  Somewhat a combination of: o ASD and VSD  Signs and Symptoms: o SOB o Respiratory distress o Periorbital edema o Failure to thrive o Increased respiratory infections o Distended liver  Diagnosis: o Chest x-ray o ECG o Echocardiogram o Cardiac catheterization o Cardiac MRI Obstructive Lesions o Pulmonic Stenosis (pulmonic valve stenosis)- a malformation of the pulmonary artery or pulmonic valve  Signs and Symptoms:  Grade II to IV out of VI systolic murmur, may have ejection click  Dyspnea  Cyanosis  Diagnosis:  ECG  Echocardiogram  Cardiac catheterization o Aortic Stenosis (AS) (aortic valve stenosis [AVS])- a malformation and narrowing in the aorta or around the aortic valve  Signs and Symptoms:  Murmur  Chest pain, fatigue, or syncope on exertion  Critical AS causes HF in neonates  Diagnosis:



 Echocardiogram  Chest x-ray  ECG o Coarctation of the Aorta (CoA)- a narrowing or stricture of the descending aorta distal to the carotid arteries  Signs and Symptoms:  Murmur  Signs of CHF  Pain in the legs or cyanotic lower extremities  Diagnosis:  Difference in the pressure between the arms and the legs Cyanotic Congenital Heart Defects o Tricuspid Atresia (TA)- caused by an error in the formation of the tricuspid valve  Signs and Symptoms:  Cyanotic  Tachycardic  Dyspneic  Diagnosis:  Routine prenatal US/at birth  ECG  Echocardiogram  Chest x-ray  Cardiac catheterization o Total Anomalous Pulmonary Venous Return (TAPVR)- a condition in which the pulmonary blood flow returns to the heart through the right atrium rather than the left  Signs and Symptoms:  Murmur  Cyanosis  Respiratory distress  Lethargy  Poor and rapid breathing  Poor feeding  Frequent respiratory infections  Signs of HF  Diagnosis:  ECG  Echocardiogram  Chest x-ray  Cardiac catheterization





Surgical Repairs of Cardiac Defects Repair and Intended Effect Defects Palliative Repairs o PA banding o VSD, single ventricle, tricuspid atresia o Cyanotic heart defects (HLHS, TOF, o Blalock-Taussig shunt pulmonary atresia, tricuspid atresia) (modified) Definitive (Complete) Repairs o ASD, VSD, AV canal o Patch closures o Valvuloplasty

o Destructive endocarditis, valvular stenosis

o Ross procedure

o Destructive endocarditis, valvular stenosis

o Konno procedure

o Any left-ventricular outflow tract obstruction (hypoplasia, subaortic stenosis)

o Damus-Kaye Stansel procedure

o TGA with VSD; double outlet right ventricle (DORV) with VSD

o Rastelli



o Arterial Switch (ASO) Staged Repairs o Modified Norwood

o DORV, TGA + VSD +subaortic stenosis/pulmonic stenosis truncus arteriosus type I o TGA o Stage I repair for HLHS

o Glenn o Stage 2 repair for HLHS, tricuspid atresia o Fontan o Stage 3 repair for HLHS, tricuspid atresia 

Infrequent Repairs o Blalock-Taussig shunt (classic)

o Cyanotic heart defects (HLHS, TOF, pulmonary atresia, tricuspid atresia)

o Waterson-Cooley shunt

o Cyanotic heart defects

o Potts Shunt

o Cyanotic heart defects

o Senning

o TGA

o Mustard 

o TGA

Clonal-Truncal Defects o Transposition of the Great Arteries or Vessels (TGA/TGV)- occurs in utero when the signals cross, and instead of twisting, there is simply a septation and the aorta arises from the right side of the heart and the pulmonary artery arises from the left  Signs and Symptoms:  Cyanosis  SOB  Poor feeding  Eventual clubbing of fingers and toes  Murmur not always present  Diagnosis:  Pulse oximetry  ECG  Echocardiogram  Chest x-ray  Cardiac catheterization o Truncus Arteriosus- a complicated cyanotic lesion with a poor prognosis if not treated surgically  Signs and Symptoms:  Cyanosis  CHF  Low cardiac output  Systolic ejection murmur with possible thrills at left sternal border  Diagnosis:  Pulse oximetry  ECG  Echocardiogram  Chest x-ray  Cardiac catheterization o Tetralogy of Fallot (TOF)- a combination defect; tetra= four, Fallot= name of physician who defined it  4 associated conditions: (PROVE)  Pulmonary stenosis  RV hypertrophy  Overriding aorta  VSD  E end; doesn’t stand for anything  Signs and Symptoms:

 Tachypnea  Dyspnea on exertion (DOE)  Growth failure  Cyanosis after ductus arteriosus closes  Loud systolic ejection murmur  Right ventricular hypertrophy  Diagnosis:  ECG  Echocardiogram  Chest x-ray  Cardiac catheterization o Complex Single Ventricle-Type Defects- cyanotic conditions with full mixing of oxygenated and deoxygenated blood o Hypoplastic Left Heart Syndrome (HLHS)- the ventricle is extremely small or hypoplastic and unable to maintain an adequate cardiac output; a life-threatening defect that must be treated shortly after birth to sustain life 

Remembering the names of cardiac defects  all defects starting with a “T” are cyanotic defects

Location of Sound Aortic

Pulmonic

Tricuspid

Heart Murmurs Associated Defect/Condition Ao valve stenosis Supravalvular aortic stenosis Subvalvular aortic stenosis Aortic regurgitation Pulmonary valve stenosis ASD PA stenosis Ao stenosis CoA PDA PAPVR TAPVR Pulmonic ejection murmur Pulmonary flow murmur Pulmonary insufficiency VSD Tricuspid regurgitation TOF

Phase Systolic

Diastolic Systolic

Diastolic Systolic

Vibratory innocent murmur HOCM Tricuspid stenosis Mitral regurgitation Aortic stenosis MV Prolapse Vibratory innocent murmur HOCM Mitral stenosis

Mitral

Diastolic Systolic

Diastolic

Classification of Murmurs Grade 1 2 3 4 5

6



Description Soft murmur, heard under quiet conditions usually by an expert Quiet murmur, heard even if it is noisy Moderately loud murmur, easily heard Loud murmur associated with a thrill Very loud murmur heard with the edge of the stethoscope tilted against the chest plus a thrill Very loud murmur that can be heard with the stethoscope 5-10 mm from the chest plus a thrill; also, may be heard without a stethoscope

Cardiac Diseases o Subacute Bacterial Endocarditis (SBE)- aka infective endocarditis, occurs subsequent to a bacterial infection or introduction of an infective agent into the child’s bloodstream  Signs and Symptoms:  Vague Symptoms: o Low-grade fever o Malaise o Loss of appetite o Muscle aches  Acute illness: o High fever o Chills o Sweating o Stiff joints o Back pain



Prolonged untreated illness: o Symptoms of HF  Diagnosis:  History and physical examination  Blood culture o Kawasaki’s Disease (mucocutaneous lymph node syndrome)- a multisystem disease affecting the cardiovascular system  Signs and Symptoms:  Persistent fever (5 days or more spiking to 104°F [40°C]), if the patient has four of the five signs listed below: o Skin rash • o Cervical lymphadenopathy, typically unilateral, greater o than 1.5 mm in diameter o Edema and erythema of hands and feet with eventual o peeling of skin o Irritation and inflammation of the mouth with “strawberry tongue,” erythema, and cracking lips o Conjunctivitis without exudate  Diagnosis:  No specific test  Complete blood count (CBC)  Erythrocyte sedimentation rate (ESR)  Electrocardiogram  Echocardiogram o Cardiomyopathy (CM)- a condition in which the cardiac muscle becomes dilated, hypertrophied, stiff, or inflamed.  3 Classes: 1. Dilated (DCM) or congestive cardiomyopathy- the most common form and is caused by weakened contractions leading to dilation of all four chambers of the heart 2. Hypertrophic cardiomyopathy (HCM)- is usually a familial disorder. It is a condition in which the ventricle is hypertrophied, swollen, or thickened in the absence of other cardiac conditions 3. Restrictive cardiomyopathy (RCM)- is the least occurring type of cardiomyopathy and is characterized by unusually non- compliant ventricular walls that fail to relax  Signs and Symptoms:  Weakness  Excessive tiredness  Shortness of breath

      

Exercise intolerance Heart palpitations Chest pain Poor feeding Slow weight gain Syncope (fainting) Light-headedness



Diagnosis:  Electrocardiogram  Echocardiogram o Rheumatic Fever- a group-A hemolytic streptococcal infection affecting multiple body systems such as the heart, the joints, subcutaneous tissue, and, at times, the nervous system  5 Major Criteria (Jones Criteria):  Arthritis (predominantly involving the large joints and is migratory [moves from joint to joint])  Carditis and valvulitis  Sydenham’s chorea (jerky purposeless movements of hand, changes in handwriting, emotional outbursts)  Erythema marginatum (a circular red rash) with clearly demarcated raised edges seen most often on the trunk  Subcutaneous nodules (palpable nodules in the subcutaneous tissue)  4 minor criteria:  Arthralgia  Fever  Elevated ESR or C-reactive protein  Prolonged PR interval 

Additional Cardiac Conditions o Cardiac Trauma  Blunt cardiac trauma- uncommon and can result from a variety of injuries  MVA  Electrocution- injury from electricity  Commotio cordis is a type of trauma caused by a small dense object colliding with the chest at a rapid velocity  baseball/hockey puck  Signs and Symptoms:  Bruising

 Pain, mild to severe (probably related mostly to surface  musculoskeletal pain)  Pulsus paradoxus or pulse deficit  Muffled heart sounds or murmur  Dysrhythmia  Shortness of breath  Hypotension  Severe cardiac shock  Diagnosis:  Electrocardio- gram (ECG)  Echocardiogram  Cardiac enzymes  Troponin I  Chest x-ray exam o FAST  Focused Assessment (focused assessment with sonography in Trauma) o Hypercholesterolemia–hyperlipidemia in children is classified as primary or secondary.

Total Cholesterol LDL Cholesterol

Cholesterol Levels in Children Desirable Borderline...