‘ The Pedi-Cardiac Lecture ’ Part 1 Pediatric Cardiovascular Disorders Jerry Carley MSN, MA, RN, CNE

Concept Map: Pediatric Cardiac Conditions Congenital Acquired

Concept Map: Pediatric Cardiac Conditions ( Congenital ) Tetralogy Of Fallot (TOF) AtriAl-Septal Defect (ASD) Atrio-Ventricular Septal Defect (AVSD)  Congenital Heart Disease Ventricular Septal Defect (VSD) Transposition Of the Great Arteries (TGA) Persistant Ductus Arteriosus (PDA) Coarctation of The Aorta (COA) Pulmonary Stenosis Aortic Stenosis Cyanotic Acyanotic VS Right to left shunt ( R L ) Left to right shunt ( R L )

Concept Map: Pediatric Cardiac Conditions ( Acquired ) Rheumatic Fever Hypertension Acquired Heart Disease Infective Endocarditis Cardiac Rhythm Disturbances Kawasaki Disease

Focused Health History Family history of defects / early cardiac disease / siblings with defects Maternal history of stillborns or miscarriages Congenital anomalies / genetic anomalies / fetal alcohol syndrome / Down Syndrome and Turner Syndrome Maternal exposure to rubella Prenatal diagnosis the key to treatment of CHD http://www.youtube.com/watch?v=PjxjvEB1w_I&noredirect=1

Focused Health History Heart murmur Tires while eating Low weight for height Sweats while eating (diaphoretic) Cyanosis, worsens with feeding or activity level Irritable weak cry

Focused Health History In the older child additional symptoms may include: Chest pain Decreased activity level Syncope Slight of build

Focused Physical Assessment General appearance Integumentary system Face, nose, and oral cavity Thorax and lung Cardiovascular system

Review: Heart Sounds

Review: Heart Murmurs These sounds are produced by blood passing through a defective valve, great vessel, or other heart structure. Murmurs are classified by: intensity, location, radiation, timing, and quality.

Pulses Assessment Alert: Weaker pulses or lower blood pressure in the lower extremities may indicate coarctation of the aorta (COA) Bounding pulses can indicate a patent ductus arteriosus (PDA) or aortic insufficiency.

Vital Signs Heart rate: tachycardia in the absence of fever, crying, or stress may indicate cardiac pathology. Tachypnea, even with rest, chest retractions indicate respiratory distress, possibly resulting from congestive heart failure

Review: Fetal Circulation

At First Breath Pulmonary alveoli open up Pressure in pulmonary tissues decreases Blood from the right heart rushes to fill the alveolar capillaries Pressure in right side of heart decreases Pressure in left side of heart increases Pressure increases in aorta

Treatment Modalities Palliative procedures Pulmonary artery banding Shunts Corrective procedures

Diagnostic Testing Chest x-ray to define silhouette of the heart. Heart size, shape, pulmonary markings, and cardiomegaly. Electrocardiogram ECG or EKG to define electrical activity of the heart. Echo-cardiogram to visualize anatomic structures. Non-invasive

Cardiac Conduction

Echo-Cardiogram

Cardiac Catheterization An invasive test to diagnose or treat cardiac defects. Visualizes heart and vessels. Measures oxygen saturation of chambers. Measures intra-cardiac pressures. Determines muscle function and pumping action of the heart.

Cardiac Catheterization

Diagnostics: Potential Toxicity to Dye Watch for signs of toxicity due to the dye used during the procedure* Increased temperature Urticaria Wheezing Edema Dyspnea Headache *Allergy response

Pre-cardiac Catheterization Assess vital signs with blood pressure. Hemoglobin and hematocrit Pedal pulses NPO Hold digoxin IV if child is polycythemic

Post-cardiac Catheterization Vital signs, with apical pulse and blood pressure (at leaST) q 15 minutes for first hour. Apical pulse for 1 minute to check for bradycardia or dysrhythmias.

Post-cardiac Catheterization Assess pulses DISTAL to the cath insertion site. Record quality and symmetry of pulses. Assess temperature and color of affected extremity. Check dressing for bleeding or hematoma formation.

Home Care Instructions Keep dressing in place for 24 hours. Keep site dry and clean. Observe site for redness, swelling, drainage, or bleeding. Check temperature. Avoid strenuous exercise. Acetaminophen for pain. Keep follow-up appointment Pre-procedure medications as ordered.

Pressures Right Heart=Low Pressure System Left Heart=High Pressure System 100-110 mm Hg Normal child 50-60 mm Hg Preterm infant 65-80 mm Hg Full term infant

Left to Right Shunt ( R L ) Here, it is all about pressure gradients Pressures on the left side of the heart are normally higher than the pressures in the right side of the heart. If there is an abnormal opening in the septum between the right and left sides, blood flows (and is forced) from left to the right.

Left to Right Shunt Lungs Lungs Right Left

Clinical Manifestations The infant is not cyanotic. Tachycardia due to pushing increased blood volume. Cardiomegaly due to increased workload of the heart.

Clinical Manifestations Dyspnea and pulmonary edema due to the lungs receiving blood under high pressure from the right ventricle. Increased number of respiratory infections due to blood pooling in the the lungs promoting bacterial growth.

Right to Left Shunts ( R L ) Occurs when pressure in the right side of the heart is greater than the left side of the heart. Resistance of the lungs in abnormally high Pulmonary artery is restricted Deoxygenated blood from the right side shunts to the left side

Right to Left Shunt Hole in septum + obstructive lesion Deoxygenated blood from the right side of the heart shunts to the left side of the heart and out into the body.

Clinical Manifestations R L Hypoxemia = the result of decreased tissue oxygenation. (“CYANOTIC”) Polycythemia = increased red blood cell production due to the body’s attempt to compensate for the prolonged hypoxemia. (Normal RBC Count for 6 month-1 year old ~3,500,000-5,200,000 /µl) Increase viscosity of the blood = heart has to pump harder.

Potential Complications Thrombus formation due to sluggish circulation. Brain abscess or stroke due to the un-oxygenated blood bypassing the filtering system of the lungs.

Heart Failure Major manifestation of heart disease Under 1 year of age usually due to congenital anomaly (CHD) Over 1 year with no congenital anomaly may be due to acquired heart disease

Signs & Symptoms Of Congenital Heart Disease (CHD) R L R L Dependent upon structure(s) effected Left to Right Shunt Signs & Symptoms Of Congenital Heart Disease (CHD) Murmurs R L Two Causes: pulmonary Blood Flow Mixing of pulmonary & venous return ( Right to Left Shunt ) Acyanotic versus Cyanotic R L S/S CHF: -Failure to Thrive (FTT) -Cardiomegaly -Edema -Hepatomegaly -Tachypnea -Tachycardia -Weight Gain Heart Failure

Clinical Manifestations of HF Systemic Venous Congestion Weight gain, hepatomegaly, edema, jugular vein distension Pulmonary Venous Congestion Tachypnea, dyspnea, cough, wheezes Compensatory Response Tachycardia, cardiomegaly, diaphoretic, fatigue, failure to grow (FTT)

Digoxin Therapy Digoxin increases the force of the myocardial contraction ( + inotropic, - chronotropic). Take an apical pulse with a stethoscope for 1 full minute before every dose of digoxin. If bradycardia is detected* < 100 beats / min for infant and toddler < 80 beats in the older child < 60 beats in the adolescent * Call / advise primary provider before administering the drug.

Signs of Digoxin Toxicity Bradycardia Arrhythmia Nausea, vomiting, anorexia Dizziness, headache Weakness and fatigue

Interventions Fluid restriction Diuretics – Lasix (potassium wasting) or Aldactone (potassium sparing) Bed rest Oxygen Small frequent feedings – soft nipple with supplemental gavage for adequate calorie intake Pulse oximetry Sedatives if needed

Feeding Small frequent feedings Soft nipple to easy energy needed to suck 24 kcal formula for added calories NG feed if not taking in adequate calories to gain weight

End of Part 1