Assessment Final - Cv Assessment

Front 1

CV assessment should be done at which 2 times (within ____ of birth & again at _______)

Back 1

within 6-12 hrs of life

again at 1-3 days of life

Front 2

Risk of CHD if mother has CHD vs sibling with CHD

Back 2

Mother - 10-15% increased risk

Sibling - 1-5% increased risk

Front 3

2 maternal diagnoses that increase babies risk for heart disease (and which heart defects are they)

Back 3

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

Front 4

Other maternal factors that increase risk for CHD (3)

Back 4

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)

Front 5

Inspection - what might you see with CHD (4)

Back 5

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)

Front 6

Polycythemia

Back 6

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)

Front 7

Hypoxemia vs cyanosis

Back 7

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

Front 8

Pallor vs mottling

Back 8

pallor - anemia; compromised cardiac status

mottling - hypothermia; cardiogenic shock

Front 9

How to check cap refill & what's normal

Back 9

Compress skin for AT LEAST 5 seconds and release

Check both central & peripheral sites

= 3-4 seconds

Front 10

CHD baby & respirations

Back 10

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

Front 11

Pulse ox screening for CHD picks up _____ % of babies with CHD. Which defects can it pick up?

Back 11

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

Front 12

Positive screen (failed pulse ox) occurs when:

Back 12

- 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

Front 13

Cyanotic heart lesions

Back 13

"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

Front 14

When should you start prostins?

Back 14

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

Front 15

Hyperoxic test

Back 15

ABG PaO2 while breathing RA, then ABG PaO2 while inhaling 100% for 10 min

If O2 shoots up, likely respiratory. O2 remains low? Likely cyanotic heart dx

Front 16

Precordial activity in term vs preterm. Seen with ?

Back 16

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)

Front 17

CT ratio

Back 17

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)

Front 18

PMI

Back 18

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

Front 19

Heave vs Tap

Back 19

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

Front 20

Thrill

Back 20

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

Front 21

Pulses -- indication of ____; name them

Back 21

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

Front 22

3 categories of shock

Back 22

1. Hypovolemic shock --> from hypovolemia

2. Cardiogenic shock --> from heart failure

3. Septic shock --> from infection

Front 23

Pulse scale

Back 23

Check rate, rhythm, character/volume

0-absent

1-thready

2-easy to feel, may be obliterated

3-not easily obliterated

4-bounding

Front 24

Decreased femoral pulse sign of...

Back 24

Indicate decreased aortic blood flow ie. aortic stenosis, coarctation, HLHS

Front 25

HLHS

Back 25

#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

Front 26

Check which 2 pulses to r/o coarcatation

Back 26

one femoral and RIGHT brachial (left may not be pre-ductal)

Front 27

Bounding pulses may be sign of

Back 27

PDA, truncus arteriosus

d/t low diastolic pressure "aortic run off".... high LV pressure and low diastolic (diastolic steal) therefore BIG difference = bounding pulse

Front 28

Palmar pulse in preterm - normal or no?

Back 28

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

Front 29

Normal pulse pressures

Back 29

Difference between systolic and diastolic BP

Average --> 25-30 mmHg in term

15-25 mmHg in preterm

Front 30

Signs of a possible PDA in preterm infant

Back 30

-Wide pulse pressure (usually not significant until you see a pulse pressure difference of 30-40 mmHg)

- Diastolic in teens, low 20%s

Front 31

Sympomatic PDA: pulmonary, cardiac, and systemic

Back 31

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

Front 32

4 cardiac auscultation points on chest

Back 32

Aortic, pulmonic, tricuspid, mitral

*Random - murmur on back heard with coarctation

Front 33

Normal nbn heart rate

Back 33

80-160 bpm

Front 34

Sinus bradycardia (HR & causes)

Back 34

< 80 bpm

NBN has predominantly parasympathetic system --> any stimulus that results in vagal stim will result in bradycardia (yawn, stool, suction)

Front 35

Sinus tachycardia (HR & causes)

Back 35

> 180-200 bpm

Any stim that causes increase demands on heart results in transient tachycardia (activity, crying, feeding, fever)

Front 36

SVT (HR & causes & how to fix)

Back 36

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

Front 37

What do you do if you note an arrhythmia?

Back 37

Get an EKG and continuous heart monitoring

- Arrhythmias are common & most are benign and do not require treatment (ex. PICC line displaced)

Front 38

Sinus arrhythmia

Back 38

irregularity in R-R interval with an otherwise normal cardiac cycle - normal variant

Front 39

Premature atrial beats (PACs)

Back 39

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

Front 40

Premature ventricular beats (PVCs)

Back 40

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

Front 41

S1 heart sound - closure of ______, heard best at _______

Back 41

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)

Front 42

Increased flow across tricuspid valve could be dt _________

Increased flow across mitral valve could be dt ___________

Back 42

Tricuspid - seen with TAPVR (increased blood return to R atrium)

Mitral - seen with PDA, VSD, or mitral insufficiency

Front 43

S2 - closure of ______, heard best at _______

Back 43

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

Front 44

Ejection clicks

Back 44

-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)

Front 45

Types of murmurs (4)

Back 45

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)

Front 46

Loudness/Intensity grades (I-VI)

Back 46

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

Front 47

Murmur intensity changes dt....

Back 47

Intensity can change from 1 exam to next dt

- changes in PVR

- any condition that changes cardiac output (anemia, activity, mechanical ventilation)

Front 48

Where's the best place to hear a PDA

Back 48

2nd ICS, left sternal border

Front 49

How to best describe location of a murmur

Back 49

WHERE it's best heard (interspace at midsternal, midclavicular, axillary...)

NOT... in terms of cardiac auscultation points

Front 50

Radiation of murmurs

Back 50

Transmissions of murmurs, common in preemies

-normal radiations to left upper back (pulm outflow)

- and carotid arteries (aortic outflow)

Front 51

Descriptive terms for quality of murmurs (6)

Back 51

Musical

vibratory

rumbling

rough

blowing

harsh (machinery)

Front 52

Systolic ejection murmur

Back 52

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

Front 53

Continuous murmur

Back 53

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

Front 54

Peripheral pulmonic stenosis (PPS)

Back 54

-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.

Front 55

When do pathological murmurs usually occur? Why do the times vary?

Back 55

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

Front 56

Soft murmur heard in asymptomatic infant - what do you do?

Back 56

watch for 48 hrs

Front 57

Investigate further if murmur persists > ____ or is louder than ____. What does this work up include?

Back 57

> 48 hrs

> Gr I or II

-CXR

-echo

-EKG

-cardio consult

Front 58

Continuous murmur

Back 58

heard in 1/3 preemies with pda

av fistula

Front 59

pathologic systolic murmurs

Back 59

mitral & tricuspid insufficiency

L ventricular failure with L ventricular outlet obstruction

TET

Front 60

Pathologic murmurs associated with VSD & PDA present after _____

Back 60

PVR falls in full term infants (already home)

Front 61

Pathological murmurs usually ____ (what grade / type of murmurs)

Back 61

Grade II or III - loud systolic ejection murmurs

If within hours of birth? pulmonic or aortic stenosis or coarctation

Front 62

Liver palpation

Back 62

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

Front 63

BP cuff too small versus too large

Back 63

small - high BP

large - low BP

Cuff width - 20-25% wider than diameter of limb being measured

Front 64

Preemie with CLD... want to start monitoring _____ @ term/post term

Back 64

for HTN - this is when it will show up

Front 65

normal BP values

Back 65

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

Front 66

pulse pressure

Back 66

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)

Front 67

Normal BP sites

Back 67

Leg - often slightly higher than arm

Systolic BP in upper arm > 20 mmHg higher than leg strongly suggest coarctation of aorta

Front 68

Guidelines for obtaining BP

Back 68

-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