Congenital heart disease mumurs pediatric electrocardiograms

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Congenital heart disease mumurs pediatric electrocardiograms Powered By Docstoc
					Newborn Congenital Heart
Disease
Matthew Snyder, DO, Maj
Family Medicine/Obstetrics
31 Mar 10
Pre-Test
• Question 1:

• Question 2:

• Question 3: List 3 murmur referral criteria

• Question 4: What’s your next move?
Objectives
•   Become comfortable with newborn cardiac exam
•   Identify cardiac exam “red flags”
•   Describe referral criteria
•   Describe initial mgnt of cyanotic newborn
First things first!
• Epidemiology
  ▫ CHD occurs in 8/1000 births
  ▫ Spectrum ranges from asymptomatic/benign to
    fatal
  ▫ Most cases multifactorial, but may be due to:
    Chromosomal disorders
    Teratogens
    Maternal metabolic disease
Initial Newborn Assessment
• Points to consider:
 ▫ Have high index of suspicion
 ▫ Consider maternal/antenatal risk factors and
   prenatal testing
 ▫ Don’t rush through exam
 ▫ Perform in quiet environment
 ▫ Perform cardiac exam before infant cries if
   possible
The Basics
• Inspection for cyanosis – central cyanosis is
  NEVER normal
 ▫ Common causes:
    Respiratory Distress Syndrome
    Sepsis
    Cyanotic heart disease
 ▫ May present with little or no tachypnea
 ▫ Peripheral cyanosis with tachypnea/tachycardia -
   sepsis
                          Neonatal Cyanosis Differential Diagnosis
System/Disease                   Mechanism
Pulmonary
Respiratory distress syndrome    Surfactant deficiency
Sepsis, pneumonia                Inflammation, pulmonary hypertension, ARDS
Meconium aspiration pneumonia    Mechanical obstruction, inflammation, pulmonary hypertension
Persistent pulmonary             Pulmonary hypertension
hypertension of the newborn
Diaphragmatic hernia             Pulmonary hypoplasia, pulmonary hypertension
Transient tachypnea              Retained lung fluid
Cardiovascular
Cyanotic heart disease with      Right-to-left shunt as in pulmonary atresia, tetralogy of Fallot
decreased pulmonary blood flow
Cyanotic heart disease with      Mixing lesion as in single ventricle or truncus arteriosus
increased pulmonary blood flow
Cyanotic heart disease with      Right-to-left shunt with pulmonary edema and poor cardiac output as in hypoplastic left
congestive heart failure         heart and coarctation of aorta
Heart failure alone              Pulmonary edema and poor cardiac contractility as in sepsis, myocarditis,
                                 supraventricular tachycardia, or complete heart block; high-output failure as in PDA or
                                 vein of Galen or other arteriovenous malformations
CNS
Maternal sedative drugs          Hypoventilation, apnea
Asphyxia                         CNS depression
Intracranial hemorrhage          CNS depression, seizure
Neuromuscular disease            Hypotonia, hypoventilation, pulmonary hypoplasia
Hematologic
Acute blood loss                 Shock
Chronic blood loss               Congestive heart failure
Polycythemia                     Pulmonary hypertension
Methemoglobinemia                Low-affinity hemoglobin or red blood cell enzyme defect
Metabolic
Hypoglycemia                     CNS depression, congestive heart failure
Adrenogenital syndrome           Shock (salt-losing)
The Basics
• Palpate pulses in all four extremities

• Consider PMI/thrill to r/o:
  ▫ Dextrocardia
  ▫ Outflow tract obstruction
  ▫ Restrictive VSD
The Basics
• Heart Rate – increased with shock, heart failure,
  dysrhythmias

• Resp. Rate – increased with left-to-right
  shunting
 ▫ Hypoplastic left heart
 ▫ Critical AS
 ▫ Coarctation
The Basics
• Blood pressure (if indicated)
 ▫ Perform right arm first (preductal), if elevated
   then left arm/leg

 ▫ R/o aortic coarctation
Listen to the Beat!
• Note the heart sounds (S1,S2) first
• S2 may be split with inspiration
• Widely split S2:
 ▫   ASD
 ▫   Pulmonary stenosis
 ▫   MR
 ▫   AS
What’s that sound?
• Murmur evaluation:
 ▫ Systolic
 ▫ Diastolic
 ▫ Continuous
• Note intensity and frequency
• May have murmur during first few hours of life
  as PDA closes
Telling the difference…
• Innocent murmurs
 ▫   Intensity ≤ grade II, LSB
 ▫   Normal S2
 ▫   No audible clicks
 ▫   Normal pulses
 ▫   No other abnormalities
Telling the difference…
• Still Murmur
 ▫ Age 3-6 mo, LUSB, Grade II-III
• Pulmonary Flow Murmur
 ▫ Newborn (Premie), systolic, LUSB, radiates to
   back, Grade I-II, resolves by 3-6 mo.
• Venous Hum
 ▫ Systolic/diastolic, supraclavicular, Grade I-III
 ▫ Key: disappears/diminishes when head turned to
   the side or jugular vein compressed
Telling the difference…
• CHD murmurs – referral criteria
 ▫   Intensity ≥ grade III
 ▫   Harsh quality
 ▫   Pansystolic duration
 ▫   Loudest ULSB
 ▫   Abnormal S2
 ▫   Absent or diminished femoral pulses
 ▫   Other abnormalities (clicks, S3, etc)
 ▫   Diastolic murmur
Classification
• Acyanotic CHD           • L-to-R
• Either left-to-right or   ▫ VSD
  obstructive stenotic      ▫ ASD
  lesions                   ▫ PDA
• Increased pulmonary • Obstructive
  flow with normal SpO2 ▫ Pulm. Stenosis
                         ▫ Aortic Stenosis
                         ▫ Coarctation of the
                           Aorta
Classification
•   Cyanotic CHD            • 5 “Ts”
•   Right-to-left shunting    ▫ Tetralogy of Falot
•   Bypasses the lungs        ▫ Transposition of the
•   Present clinically in       Great Arteries
    the first 2 wks of life   ▫ Tricuspid Atresia
                              ▫ Truncus Arteriosis
                              ▫ Total Anomalous
                                Pulmonary Venous
                                Return
CHD Newborn Management
• Start with basics:
  ▫ Call for help – Pediatrics/Tertiary Care Unit
  ▫ ABCs via NRP

• May require intubation/respiratory support

• Establish venous and arterial umbilical access
CHD Newborn Management
• If cyanosis, determine if from cardiac or pulm
  etiology

• If unknown cause – assume sepsis and begin abx
  (Amp/Gent or Amp/Claforan)
CHD Newborn Management
• Obtain the following:
 ▫   CBC
 ▫   Blood cx
 ▫   UA
 ▫   CXR
      Cardiomegaly
      Pulm vascular markings – decreased in cyanotic
       CHD
 ▫ EKG
 ▫ ABG
CHD Newborn Management
• Hyperoxia Test
 ▫ Distinguishes b/n cardiac and pulm causes of
   cyanosis
 ▫ Give 100% O2 via oxyhood or ETT for 10 min
 ▫ Measure ABG or pulse ox from right arm
   (preductal)
 ▫ If PO2 rises ≈ likely pulmonary cause
CHD Newborn Management
• Hyperoxia Test (cont)
 ▫ If fails the test (no rise in PaO2):
    Likely ductal-dependent cardiac abnormality

 ▫ If echo not immediately available or metabolic
   acidosis:
    Talk with Peds/Neonatology and consider
     Prostaglandin E1 to maintain ductus arteriosis
Post-Test
• Question 1:

• Question 2:

• Question 3: List 3 murmur referral criteria

• Question 4: What’s your next move?
References
• Kliegman, Rm, et al. Nelson Essentials of
  Pediatrics, 5th ed. 2006.
• Uptodate.com
• http://depts.washington.edu/physdx/heart/de
  mo.html
Ventricular Septal Defect
• 25% of all CHD
• Involves muscular or
  (peri)membranous
  septum (67%)
• Small – asymptomatic
  with loud pansystolic
  murmur (LLSB)
• Split S2
• LAH & LVH on EKG
• 35% close spontaneously
Atrial Septal Defect
• 10% of CHD
• Secundum defect
  (foramen ovale) – most
  common
• SEM Grade I-II, split
  S2
• R axis deviation/RVH
• If present age 3 =
  surgical closure
Patent Ductus Arteriosis
• 5-10% of CHD
• Widened pulse
  pressure
• Continuous machine-
  like murmur/thrill
• Diuretics/Digoxin vs
  surgical closure
Endocardial Cushion Defect
• Failure of septal
  fusion with
  endocardial cushion ≈
  abnormal AV valves
• CHF sx, prominent S2
• L axis deviation, VH &
  AH
• Diuretics/Digoxin vs
  surgical closure
Tetralogy of Falot
• 10% of CHD – most
  common
• VSD, Pulm Stenosis,
  Overriding Aorta,
  RVH
• First finding – pulm
  stenosis murmur
• Hypoxic (“Tet”) spells
• Boot-shaped heart
• R axis deviation, RVH
Transposition of the Great Vessels
• 5% of CHD
• Cyanosis depends on
  mixing via ASD, VSD,
  PDA
• Quiet tachypnea
• R axis deviation, RVH
• “Egg on a string”
• Prostaglandin E1,
  surgery
Triscuspid Atresia
• 2% of CHD
• Hypoplastic RV
• Requires PDA or VSD
• Severe cyanosis, single
  S2
• LVH on EKG
• Prostaglandin E1
  and/or surgery
Truncus Arteriosis
• <1% of CHD
• Large arterial trunk
  with VSD
• Single S2, SEM
• Bil VH, cardiomegaly
• Surgical repair
Total Anomalous Pulm Ven Return
• 1% of CHD
• ASD required
• Widely split S2, SEM
• Obstruction =
  cyanosis
• R axis deviation, RVH
• Pulmonary edema on
  CXR
• Surgical repair
Hypoplastic Left Heart
• 1% of CHD
• Failed development of
  MV, AV or aortic arch
• PDA dependent
• CHF, low cardiac
  output
• RVH on EKG
• Prostaglandin
  E1/surgical repair