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CONGESTIVE HEART FAILURES/STachypnea arrest and with exercise --Ask parent… how does baby breath when asleep? --Ask does kid have trouble keeping up With other kids?Swelling/edema in face. (See facial first)Other respiratory symptomsFatigue --In infants, if they fall asleep while feeding or sleep more than normalLack of appetiteUnusual sweating (@rest) --Classic cardiac symptomUnusual weight gain DIAGNOSTICS*#1 are what clinical symptoms are showingGold Standard: EchoCardiac Cath --Most definitive testEKGTREATMENT GOALS1. IMPROVE CARDIAC FUNCTIONMEDICATION --ACE INHIBITORS: cause vasodilation decrease BP et vascular resistance **Can Cause Hyperkalemia --Captopril (Capoten) --Enalapril (Vasotec) --DIGITALIS (Lanoxicaps) --**Need Baseline EKG --**Need lytes, K+, Calcium, Apical Pulse --ACTION : ^force of conntractions(intropic) and decreases heart rate. Both indirectly enhance diuresis ---EFFECT: ^cardiac output, decrease venous pressure, decrease cardiac size ---5 rights --- APICAL PULSE --Infant 90-110bpm --Older child 70bpm ---PARENT TEACHING --Explain reason for med --**Call MD if dose is missedDIGITALIS CONT…S/S of Digitialis ToxicityN/VLack of AppetitePVC’s**Prolonged PR IntervalTreatment Goals2. Decrease Accumulated Fluid Volume- Fluid Restriction-Medication --Furosemide (Lasix) **DOC --Blocks reabsorption of sodium/water --Spironolactone (Aldactone) -- K+ sparing. --Must be used with another diuretic --Hydrocholorothiazide (Microzide)-^calorie content for infants, DON’T STOP FEEDING THEMTreatment Goals3. Decrease Cardiac Demands- Cluster your care- Feed when hungry, frequent, small amounts- Maintain temperatureTreatment Goals4. Improve Oxygenation- Optimum positioning -- Elevate HOB= breathing easier. Kids may not like- O2 as neededTreatment Goals5. Support the Family- Give written instructions --Use lay terms, write drugs and volume to be given- Allow for verbalization- Provide contact with other families with children with CHD/CHF, if possibleINFECTIVE ENDOCARDITIS-2 factors present -- Structural defect causing turbulent flow -- Bacteremia- Almost all patients diagnosed with SBE have CHD- Any localized infection can cause endocarditis --Abcess --pylonephritis --stomatitis CLINICAL PICTURE- History of tooth ache/dental procedure T&A- Insidious onset of fever (101-103), malaise, anorexia and pallor (80-90%)-Murmur (100%)- Petechiae (50%)- Embolic phenomena (50%) - PE - Seizures - Hematuria or Renal FailureTREATMENT- Cultures: Will have 4-6 in first 24-48 hours- Antibiotics- minimum 4 weeks. -- after 2 weeks, repeat cultures- Operative intervention for prosthetic valvesPREVENTION- **Good oral Hygiene**- Antibiotic Prophylaxis (SBE Prophylaxis)RHEUMATIC FEVER- Inflammatory disease- Attributed to group A Streptococcal pharyngeal infection- involves: --Joints --skin --brain --cardiac valvesPREDISPOSING FACTORS- Family hx of rheumatic fever- Low socioeconomic status- Age 6-15 years oldCLINICAL PICTURE- MAJOR Manifestations --Carditis: dx by new murmur; will see tachycardia --Polyarthritis: @least 2 large joints; caused by edema --Erythema marginatum --subcutaneous nodules- associated w/carditis --Chorea: abnormal late progression --causes loss of motor function- handwriting changes --slow recoveryCLINICAL PICTURE- MINOR manifestations --Arthalgia (no arthritis) --Fever --Lab findings consistent with inflammationRANDOM INFO- No definitive tests, but watch for these s/s- Modified Jones Critieria p.1480 Hockenberry- 2 Major manifestations Or-1 Major or 2 Minor manifestations- Suggestive of Rheumatic FeverTREATMENT- Penicillin *DOC: Eradicates strep- ASA/Prednisone- if there is any cardiac involvement- Bedrest- just limit activities- Prophylaxis: abx up to age 25- Education- Affects MITRAL VALVEKAWASAKI’S DISEASE- Mucocutaneous lymph node syndrome- Acute Systemic Vasculitis- Unkown Etiology --an environmental toxin could be a cofactor- Self Limiting: Resolving in 6-8 weeks- Most common/significant sequel- Ectasia: dilation or aneurism of coronary arteries… @ risk for MI --s/s: abd pain, vomiting, restlessness, pallor, shock (all non-specific)CLINICAL PICTURE- PHASE 1- Acute Phase (1st 10 days)* Fever won’t respond to abx, Tylenol, antipyretic --Fever 5 or more days --VERY irritable -- Bilateral conjunctival inflammation -- Strawberry tounge/diffuse redness of oral cavity --Erythema/edema of hands and feet --unilateral cervical lymphadenopathy --Polymorphus rashCLINICAL PICTURE- PHASE 2- Subacute Phase (11-25 days) --This is stage where aneurism occurs --Desquamation of fingers/toes: as edema goes away, they start to peel. --Rash/fever/lymphadenitis resolve -- CV changes occur --Continued irritability --Thrombocytosis (PLT count > 600,000)CLNICAL PICTURE-PHASE 3- Convalescent Phase- Until ^SED rate and platelet count normalize-Beau’s lines on finger and toe nailsTREATMENT- No specific therapy-IV gamma globulin (high dose)-ASA (6-8 weeks)-F/U --serial cardiac echo to monitor cardiac statusCHD,^ Pulmonary Blood FlowATRIAL SEPTAL DEFECTCLINICAL PICTURE- Asymptomatic- Symptoms may not be exhibited for 6-8 weeks after birth—slow decrease in pulmonary pressure- may or may not have murmur- S/S of CHF- May or may not have atrial dysrhythmias**They will close spontaneously on ownTREATMENT- treatment is for symptomatics - Medical management --CHF- treat s/s of CHS --Arrythmias-Catheter closure-Surgical Closure**Don’t treat if they are asymptomaticCHD, ^Pulmonary Blood FlowVENTRICULAR SEPTAL DEFECTCLINICAL PICTURE- Asymptomatic- Murmur- Delayed growth and development- Frequent pulmonary infections --b/c there’s lots of fluid in lungs-S/S of CHF-CXR: cardiomegaly-EKG- some form of ventricular hypertrophyTREATMENT- Medical management --CHF- No physical restrictions- Antibiotic prophylaxis for infective endocarditis (SBE prophylaxis)- Surgical closure (Catheter closure)- F/U every 1-2 years post-operatively CHD,^ Pulmonary Blood Flow, Abnormal connectionPATENT DUCTUS ARTERIOSUSCLINICAL PICTURE- Bounding pulses/widened pulse pressured- Murmur- Hyperactive precordium- Recurrent lower respiratory tract infections (pneumonia)- CHF- Poor weight Gain TREATMENT- Medication --NSAID --Indomethacin (Indocin): Closes it --Contraindications: hepatic/renal impairment thrombocytopenia, oliguria= need baseline labs --If urine is < .06mL, DON’T give. --Ibuprofen IV (Caldolor) --SBE prophylaxis --Treat CHF, if present- No physical restrictions-Catheter closure-Surgical Closure Mixed ObstructiveTETRALOGY OF FALLOT (TOF)There are 4 classic defects1. Large VSD2. Pulmonic Stenosis3. Aorta shifts to the right (overriding aorta)4. Right ventricular hypertrophyCLINICAL PICTURE- Cyanosis (chronic): will be present until defect is fixed. --will affect brain development- Murmur- Tachypnea- Hypercyanotic episode (TET Spell)- Growth retardation with severe cyanosisCLINICAL PICTURE- “Tet”/ Hypercyanotic spells --Rarely before 2 months of age --Most frequent in the 1st year (peak 2-4 months) --Most often in AM *Requires immediate recognition and intervention *Crying, BM, can cause kids to have a hypercyanotic SpellTREATMEANT FOR ‘TET’ SPELL-Calm the infant: crying ^ pulmonary pressure- Knee to chest position: decreases systemic blood flow, ^ systemic vascular resistance (prevents blood from going back to lungs)-Blow-by oxygen: (it acts as vasodilator)-Get HelpTREATMENT- Educate family in recognition and intervention (before spells is best)- Propranolol can be used to treat spells- SBE Prophylaxis- Monitor for anemia and treat- b/c if chronically hypoxic, make sure RBC’s are available- Surgical proceduresObstructiveCOARCTATION OF THE AORTA “kink”-Coarctation stays the same as kid grows, so it gets worse with growthCLINICAL PICTURE-Poor feeding- Dyspnea- Poor weight gain- Oliguria- decrease blood flow to kidneys- Cyanosis in lower extremities- Cyanosis in lower extremities*Bounding pulses in upper extremities --**Bounding pulses in arms, weak pulses in legsTREATMENT- Medication for CHF- Balloon angioplasty- Surgical Correction- Post-op --HTN --There’s a high rate of recoarctation- F/U: Monthly for 1st 6 months*Watch for recoarctation especially with growth spurtsAORTIC STENOSISCLINICAL PICTURE- MILD-MODERATE STENOSIS --Asymptomatic --Mild Exercise Intolerance-SEVERE STENOSIS --Exertional chest pain --Easily fatigued --Syncope --Sudden DeathTREATMENT-SBE Prophylaxis- Moderate-Severe Symptoms -- NO sustained, strenuous activities- Balloon valvuloplasty: MODERATE- Surgical correction; valve replacement- SEVERE*Watch for re-stenosisPULMONARY STENOSISCLINICAL PICTURE- MILD --completely asymptomatic-MODERATE-SEVERE --exertional dyspnea --Easily fatigued-SEVERE --Exercise restriction --Exertional chest pain --CHF (hepatomegaly)TREATMENT- SBE prophylaxis- MEDICATION -- for CHF- Balloon valvuloplasty (preferred)- b/c its on the low pressure side-Surgical Correction ................
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