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68 Cards in this Set
- Front
- Back
CV assessment should be done at which 2 times (within ____ of birth & again at _______) |
within 6-12 hrs of life again at 1-3 days of life |
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Risk of CHD if mother has CHD vs sibling with CHD |
Mother - 10-15% increased risk Sibling - 1-5% increased risk |
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2 maternal diagnoses that increase babies risk for heart disease (and which heart defects are they) |
Diabetes - 3-4x increased risk for VSD (muscular vs perimembranous. Muscular more likely to close on own) & transposition of great arteries Lupus - complete heart block, presents with HR 50-80 bpm |
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Other maternal factors that increase risk for CHD (3) |
1. Drug use (alcohol, anticonvulsants, lithium, retinoic acid, amphetamines, warfarin) 2. Rubella (PDA - STRUCTURAL so won't close, pulmonary branch stenosis) 3. Viral infections (if occurs in last 2 weeks of pregnancy may result in acute myocarditis) |
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Inspection - what might you see with CHD (4) |
1. Overall appearance - decreased tone, sweating (compensatory reaction to low CO, sympathetic nervous system) 2. Activity (poor feeding) 3. Presence of another anomaly (25%) 4. Cyanosis of skin & mucous membranes (central - visible at 3-5 gm/dL Hgb unbound to O2; cardiac, resp, or CNS problem. Peripheral - OK for 1st 48 hrs d/t vasomotor instability) |
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Polycythemia |
HCT > 65% - increased # of RBCs that need O2 -baby looks purple d/t unsaturated Hgb which is noted as cyanosis at higher saturation levels (absolute # of deoxygenated RBCs, therefore with polycy you see WNL sats bc of extra RBCs) |
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Hypoxemia vs cyanosis |
NOT synonymous An anemic baby may be very hypoxic BEFORE appearing cyanotic bc it's the total amount of deoxygenated hgb that causes a blue color... not level of oxygenation |
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Pallor vs mottling |
pallor - anemia; compromised cardiac status mottling - hypothermia; cardiogenic shock |
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How to check cap refill & what's normal |
Compress skin for AT LEAST 5 seconds and release Check both central & peripheral sites = 3-4 seconds |
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CHD baby & respirations |
NON LABORED IN PRESENCE OF CYANOSIS - THINK CHD SIGNS OF DISTRESS - SOME DO HAVE, BUT NOT ALL (GRUNTING/FLARING/RETRACTING) GASPING IS A LATE SIGN --> BAD |
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Pulse ox screening for CHD picks up _____ % of babies with CHD. Which defects can it pick up? |
80% HLHS, TET, Transposition, Tricuspid atresia, Tricuspid regurgitation, Total anomalous pulmonary venous return, Pulmonary atresia with an intact septum --> 20% NOT picked up, including coarct |
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Positive screen (failed pulse ox) occurs when: |
- Any SaO2 <90% or SaO2 < 95% in both upper and lower extremities on 3 different assessments, each 1 hr apart OR -an absolute difference of > 3% in O2 saturations between R hand & foot on 3 different assessments, 1 hr apart |
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Cyanotic heart lesions |
"TERRIBLE T'S AND P" Transposition (MUST HAVE PFO) TET (pulm stenosis, VSD, overriding aorta) Truncus arteriosus (must have VSD) Tricuspid atresia "single ventricle" (No blood to RV) Total anomalous pulmonary venous return (only 1 that doesn't need pge. Only way to live is ASD or PFO... all blood from lungs back to RA) Pulmonary atresia/stenosis **ALL EXCEPT TAPVR BENEFIT FROM PGE |
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When should you start prostins? |
WHEN I DOUBT, START PROSTINS!!!! KEEP BABY SATTING NO GREATER THAN MID 80% TOO MUCH O2 = OVERCIRCULATION TO LUNGS = LESS TO BODY. LOWER O2 KEEPS LUNG VESSELS SLIGHTLY CONSTRICTED |
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Hyperoxic test |
ABG PaO2 while breathing RA, then ABG PaO2 while inhaling 100% for 10 min
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Precordial activity in term vs preterm. Seen with ? |
Term? May see pulsations in 1st 12 hrs, then abnormal Preterm? Some activity seen dt low SQ fat Increased activity with cardiomegaly - infants with CHF, AV malformation. Also defects with increased ventricular work (L--> R shunts like PDA or VSD.... bc they keep pumping pumping & LV gets large) |
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CT ratio |
Draw line through midline. Measure largest part of heart on each side and divide by widest internal diameter of chest. If A+B / C > 0.6 = cardiomegaly Ex. Epstein's anomaly (HUGE HEART) |
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PMI |
Point of maximal impulse -->forceful thrust of L ventricle during systole located @ 4th ICS @ or to L of midclavicular line Locate with fingertips Displaced? Pneumothorax, dextrocardia, diaphragmatic hernia |
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Heave vs Tap |
Use palm at base of fingers (more discriminating for vibratory sensations) Heave - slow rising & diffuse PMI; volume overload Tap - fast rising and sharp; pressure overload |
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Thrill |
Low frequency palpable murmur, feels like a purring cat Check with palm of hand over upper R and L sternal borders and lower sternal border Also check over suprasternal notch & carotids May be present with coarct, aortic stenosis, aortic valve defects |
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Pulses -- indication of ____; name them |
Check on quiet infant Indication of CO Palmar, radial, brachial, axillary, femoral, popliteal, posterior tibial, & dorsalis pedis HARD TO FEEL POPLITEAL; NORMAL NOT TO FEEL DORSALIS PEDIS IN NBN |
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3 categories of shock |
1. Hypovolemic shock --> from hypovolemia 2. Cardiogenic shock --> from heart failure 3. Septic shock --> from infection |
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Pulse scale |
Check rate, rhythm, character/volume 0-absent 1-thready 2-easy to feel, may be obliterated 3-not easily obliterated 4-bounding |
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Decreased femoral pulse sign of... |
Indicate decreased aortic blood flow ie. aortic stenosis, coarctation, HLHS |
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HLHS |
#1 CHD causing death in 1st month of life Keep O2 sats 70-85% (too high = decreased systemic and coronary blood flow) Avoid hyperventilaton which = low PVR, high pulm blood flow, and decreased systemic blood fow |
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Check which 2 pulses to r/o coarcatation |
one femoral and RIGHT brachial (left may not be pre-ductal) |
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Bounding pulses may be sign of |
PDA, truncus arteriosus d/t low diastolic pressure "aortic run off".... high LV pressure and low diastolic (diastolic steal) therefore BIG difference = bounding pulse |
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Palmar pulse in preterm - normal or no? |
May indicate wide pulse pressure as seen with PDA --> but palmar pulse alone doesn't tell you PDA; prominent peripheral pulses are normal for preterm infants |
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Normal pulse pressures |
Difference between systolic and diastolic BP Average --> 25-30 mmHg in term 15-25 mmHg in preterm |
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Signs of a possible PDA in preterm infant |
-Wide pulse pressure (usually not significant until you see a pulse pressure difference of 30-40 mmHg) - Diastolic in teens, low 20%s |
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Sympomatic PDA: pulmonary, cardiac, and systemic |
Pulmonary - pulmonary edema, increased RR, apnea, increased O2 need, increased ventialtor settings Cardiac - Increased HR/PP difference, boudning pulses, CHF, increased liver size System - Increased acidosis, low UOP, increased feeding intolerance |
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4 cardiac auscultation points on chest |
Aortic, pulmonic, tricuspid, mitral *Random - murmur on back heard with coarctation |
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Normal nbn heart rate |
80-160 bpm |
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Sinus bradycardia (HR & causes) |
< 80 bpm NBN has predominantly parasympathetic system --> any stimulus that results in vagal stim will result in bradycardia (yawn, stool, suction) |
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Sinus tachycardia (HR & causes) |
> 180-200 bpm Any stim that causes increase demands on heart results in transient tachycardia (activity, crying, feeding, fever) |
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SVT (HR & causes & how to fix) |
HR > 200 (sustained, even when asleep/calm) Includes atrial tachycardia, atrial flutter, and atrial fibrillation CO is severely compromised dt short diastolic filling time without treatment --> CHF within 48 hrs --> death Tx --> vagal (ice and water over upper 1/2 of face 15-20 sec), adenosine, cardiovert |
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What do you do if you note an arrhythmia? |
Get an EKG and continuous heart monitoring - Arrhythmias are common & most are benign and do not require treatment (ex. PICC line displaced) |
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Sinus arrhythmia |
irregularity in R-R interval with an otherwise normal cardiac cycle - normal variant |
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Premature atrial beats (PACs) |
early beat arises from supraventricular focus -ventricular conduction is normal -seen in 30% healthy term and preterms -seen with CHF, sepsis, hypoxia, severe resp distress and maternal caffeine use |
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Premature ventricular beats (PVCs) |
early beat arising from irritated ventricle - conduction abnormal with wide QRS complex - may result from hypoxia, irritation by a catheter or a surgical procedure or CHD - if infrequent, no TX needed |
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S1 heart sound - closure of ______, heard best at _______ |
Tricuspid and mitral valves closure -1 sound, both close at same time -occurs just before systole -loudest at apex -loud at birth, intensity decreases in 1st 48 hrs -any factor that increases CO, increases intensity of S1 (she said don't worry about intensity) |
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Increased flow across tricuspid valve could be dt _________ Increased flow across mitral valve could be dt ___________ |
Tricuspid - seen with TAPVR (increased blood return to R atrium) Mitral - seen with PDA, VSD, or mitral insufficiency |
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S2 - closure of ______, heard best at _______ |
Closure of aortic & pulmonic valves -loudest in both aortic and pulmonic areas -usually single sounds at birth, split in 80% of infants by 48 hrs [more blood to RV as time goes on, so aortic may close 1st then pulmonic) "lub dub dub" -end of systole |
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Ejection clicks |
-snappy high-pitched sound after s1, best hear @ LL sternal border -occurs at moment of maximal opening of aortic and pulm valves at time of ventricular ejection -occurs - 1st 24 hrs - represents normal pulmonary hypertension (lasts longer in infants with asphyxia or fluid overload). After 24 hrs, NOT normal -Indicate dilation of a great vessel or deformity of a valve (truncus, aortic stenosis, pulm stenosis, TET) |
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Types of murmurs (4) |
1. Systolic - occurs during muscle contraction of heart (between s1 & s2) 2. Diastolic - occurs during heart muscle relaxation (between s2&s1) - stenosis of Tri or Mitral valves, regurg of aortic or pulm valves **ALMOST ALWAYS PATHOLOGIC 3. Ejection - during systole, may be normal, blood flow through narrowed vessel or irregular valve (pda/pps) or through a relatively stenotic area w/ increased blood flow (small vsd) 4. Regurgitant - during diastole, more problematic, valve backflow dt floppy valve or overdilate ventricle (TR, large VSD) |
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Loudness/Intensity grades (I-VI) |
Grade I - barely audible, only after period of careful listening Grade II - soft, but audible immediately Grade III - moderate, NO thrill Grade IV - louder with thrill Grade V - very loud, with thrill, can be heard with stethoscope barely on chest Grade VI - very loud, with thrill, heard with stethoscope off chest |
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Murmur intensity changes dt.... |
Intensity can change from 1 exam to next dt - changes in PVR - any condition that changes cardiac output (anemia, activity, mechanical ventilation) |
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Where's the best place to hear a PDA |
2nd ICS, left sternal border |
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How to best describe location of a murmur |
WHERE it's best heard (interspace at midsternal, midclavicular, axillary...) NOT... in terms of cardiac auscultation points |
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Radiation of murmurs |
Transmissions of murmurs, common in preemies -normal radiations to left upper back (pulm outflow) - and carotid arteries (aortic outflow) |
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Descriptive terms for quality of murmurs (6) |
Musical
vibratory rumbling rough blowing harsh (machinery) |
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Systolic ejection murmur |
INNOCENT in up to 56% of NBNS -grade I or II / IV -@ mid and upper left sternal border -usually vibratory -presents DOL 1 - week 1 -dt increased flow across pulmonary valve with lowering PVR |
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Continuous murmur |
Harsh, machinery sound, common innocent - 15% of nbns -Grade I or II / IV - upper left sternal border - presents 1st 8 hrs -dt transient L to R flow through PDA while PVR is falling |
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Peripheral pulmonic stenosis (PPS) |
-Soft systolic ejection - med/high pitched - common innocent murmur -preterm infant; grade I or II / IV -presents 1st weeks of life, lasts weeks-months (usually gone by 6 months) - upper L sternal border with wide radiation to both lung fields and to back -turbulence at bifurcation of PA --> broad trunk, small pulmonary arteries. once arteries get big enough, sound goes away. |
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When do pathological murmurs usually occur? Why do the times vary? |
Usually occurs after PVR has decreased significantly (3 DOL or 1 week - 4-6 weeks) --> ASD may not be present until 1-2 years Occur at varying times dt anatomic abnormality or transition from fetal to neonatal circulation --> Won't hear PFO murmur until 1 yo *20% of babies that die from CHD have no murmur |
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Soft murmur heard in asymptomatic infant - what do you do? |
watch for 48 hrs |
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Investigate further if murmur persists > ____ or is louder than ____. What does this work up include? |
> 48 hrs > Gr I or II -CXR -echo -EKG -cardio consult |
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Continuous murmur |
heard in 1/3 preemies with pda av fistula |
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pathologic systolic murmurs |
mitral & tricuspid insufficiency L ventricular failure with L ventricular outlet obstruction TET |
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Pathologic murmurs associated with VSD & PDA present after _____ |
PVR falls in full term infants (already home) |
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Pathological murmurs usually ____ (what grade / type of murmurs) |
Grade II or III - loud systolic ejection murmurs If within hours of birth? pulmonic or aortic stenosis or coarctation |
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Liver palpation |
SIGNIFICANT PART OF CV EXAM Engorgement - dt increase in central venous pressure location - >/= 3 cm below RCM may indicate R side HF in term infants (can be due to lung hyperexpansion).... as blood backs up with CHF, blood from IVC backs into liver = boggy/distended liver |
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BP cuff too small versus too large |
small - high BP large - low BP Cuff width - 20-25% wider than diameter of limb being measured |
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Preemie with CLD... want to start monitoring _____ @ term/post term |
for HTN - this is when it will show up |
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normal BP values |
consider GA, age in hrs & days, method of obtaining BP, cuff size -BP up with GA/chronological age -WNL for term not same for preemie -BP down in 1st 4 hrs then increases to steady level by 4-6 days of age |
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pulse pressure |
difference between systolic and diastolic BP average - 25-30 mmHg in term and 15-25 in preterm narrow = low circulating volume (HF, peripheral vasoconstriction) wide = vascular run off (PDA, AV malformation, truncus) |
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Normal BP sites |
Leg - often slightly higher than arm Systolic BP in upper arm > 20 mmHg higher than leg strongly suggest coarctation of aorta |
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Guidelines for obtaining BP |
-1.5 hrs after a feed or medical intervention -Infant lying prone or supine -appropriate size cuff -right upper arm -leave infant undisturbed 15 min after placing cuff -asleep/quiet awake state -3 readings at 2 min intervals -record middle BP and discard 2 highest |