approach to cvs disease - dr. gunasekaran

Dr. D. Gunasekaran D, MD., Dept. of Paediatrics, MGMCRI.

Approach to a child with Heart disease in children CVS Topics to be discussed Introduction to CVS diseases Cyanotic CHD VSD & ASD PDA Rheumatic fever Rheumatic heart disease Congestive heart failure Infective endocarditis Myocarditis and pericarditis

CVS Clinical Examination

Dr. D. Gunsekaran,Consultant Paediatrician

Dr. D. GunasekaranConsultant Paediatrician

Introduction to CVS diseases


Approach to a child with Heart disease in children

1. Symptoms - suggestive of heart disease?

BreathlessnessBluish extremities

CoughChest pain

FeverFeeding difficultiesFailure to ThriveFrequent RTI

SyncopePalpitation Swelling of feet (Pedal

edema)

Joint PainDancing movements (Chorea)

Painful swellings in finger pulps


Approach to a child with Heart disease in children 2. Is it congenital or acquired?

Congenital: Symptoms from infancy Feeding difficulties FTT Recurrent hospital admissions

Acquired: Rheumatic fever: Fever, joint pain, chorea


Approach to a child with Heart disease in children 3. If it is congenital, is it cyanotic or acyanotic?

Why cyanosis occurs?

What are the two types of cyanosis?

Which one is present in Cyanotic CHDs?

How to differentiate?


Approach to a child with Heart disease in children Criteria Peripheral

cyanosisCentral cyanosis

Basic pathology

Poor circulation in peripheral parts

Poor oxygenation in lungs

Areas involved

Peripheries (nail beds, tip of nose & ear lobes)

Peripheries + oral mucosa & tongue

Clubbing Absent Present

Polycythemia

Absent Present

Touch of the peripheries

Cool Warm

How to reduce cyanosis

Warming the peripheries

Administration of oxygen



Cyanotic CHD

PBF PBFTOFTRICUSPID ATRESIATGADORV WITH PSSINGLE VENTRICLE WITH PS

TRUNCUS ARTERIOSUSTAPVCDORIV WITHOUT PSSINGLE VENTRICLE WITHOUT PS

4. If it is Cyanotic CHD, what is the actual CHD?

Based on murmurs, change in heart sounds investigations



Acyanotic CHD

Volume overload (Shunt)

Pressure over load (Obstn)

PSASCoA

ASDVSDPDA

5. If it is Acyanotic CHD, what is the actual CHD?

Based on murmurs, change in heart sounds investigations


Approach to a child with Heart disease in children 6. Is it Rheumatic fever or RHD?

If so, which valves are involved?

Is there any evidence of pericarditis or myocarditis?


Approach to a child with Heart disease in children 7. Are there any complications?

CCF

Infective Endocarditis

Pulmonary Hypertension



CVS Clinical Examination

Pulse

Blood Pressure

Apical Impulse

General examination



Pulse

Four information

Which artery you will choose for examination of pulse?



Pulse - Rate

Tachycardia:

Rheumatic fever Congestive cardiac failure Arrythmias

Bradycardia:

Arrythmias


Approach to a child with Heart disease in children Normal range of Pulse rates for different ages

NB-2 months: 80 - 200 3 months -1 year: 80 - 180 1-8 years: 60 - 180

>8 years: 60 - 160



Pulse - Rhythm

Observe the pulse for one full minute.

Regularly irregular: Ectopics

Irregularly irregular: Atrial fibrillation



Pulse - Volume

High volume pulse:

Low volume pulse:



Pulse – Volume Depends on pulse pressure; What is PP? Normal PP?

High volume: high PP high SBP: PDA & AR low DBP: Septic shock (warm

shock)

Low volume: low PP low SBP: AS, MS, CoA, CCF high DBP: Hypovolemic shock

(Vasocons)



Pulse - Character

Slow rising pulse : AS

Collapsing pulse: AR, PDA


Approach to a child with Heart disease in children Apical Impulse - Definition

LV & part of inter ventricular septum

Age Position

Up to 4 years

4th ICS 1 cm lateral to MCL

5-8 years 4th ICS just lateral to MCL

> 8 years 5th ICS 1 cm medial to MCL


Approach to a child with Heart disease in children Use of Apical Impulse in clinical exam?

Shift indicates what?

What are the abnormal types of AI?

What are the conditions causing abnormal AI?



Blood Pressure

What size cuff is preferable?

Width: 40% of circumference

Length: 80-100 % of circumference



Normal range of BP

For proper interpretation:

We should refer to the standard charts



Normal range of BP

Average Systolic BP: At Birth: 60 Neonate: 70 6 months: 85 1 year: 90

Systolic BP for 1-10 years: 90 + (age in yrs X 2) Diastolic BP : 2/3 of Systolic BP

Pulse pressure:



General examination


Approach to a child with Heart disease in children General examination (splinter hemorrhages)


Approach to a child with Heart disease in children General examination (Rheumatic- arthritis)


Approach to a child with Heart disease in children General examination (Rheumatic -subcutaneous nodule)


Approach to a child with Heart disease in children General examination (Rheumatic - erythema marginatum)


Approach to a child with Heart disease in children Investigations – Egg on side - TGA


Approach to a child with Heart disease in children Investigations – Boot shaped - TOF


Approach to a child with Heart disease in children Investigations - Cardiomegaly



Incidence of CHD 6-8 per 1000 live births

1 in 10 still born infants

NADAS CRITERIA

MAJOR CRITERIA MINOR CRITERIA

SYSTOLIC MURMUR Grade 3 OR MORE

SYS. MURMUR LESS THAN Grade 3.

DIASTOLIC MURMUR ABN.SECOND SOUND

CYANOSIS ABN. ECG

CHF ABN. CxR

ABN. BP

DIAGNOSIS OF CHD

For Diagnosis of CHD: 2 Major or 1 Major + 2 Minor



Common CHDs

Acyanotic: VSD 32% PDA 12% PS, ASD, Co A, & AS

6%

Cyanotic: TOF 6% TGA 5%



Aetiology of CHD Chromosomal anomalies: 8% Ex: Trisomies-21,18,13;

Turner’s Environmental teratogens: 2% Ex: Intrauterine infections, Maternal drug intake

(Phenytoin) Maternal diseases

(Diabetes, SLE)

Single gene mutations: 90%

approach to cvs disease - dr. gunasekaran

Healthcare