Paediatric cardiology for general paediatricians
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Paediatric Cardiology for General Paediatricians. Dr Talal Farha Consultant Paediatrician SpR Regional Teaching Taunton 22 Jan 2008. Essentials in looking at an ECG. Rhythm (sinus….nonsinus). Rate, Atrial and ventricular rates. QRS axis, T axis, QRS-T angle. Intervals: PR. QRS, and QT.

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Paediatric cardiology for general paediatricians l.jpg

Paediatric Cardiology for General Paediatricians

Dr Talal Farha

Consultant Paediatrician

SpR Regional Teaching

Taunton 22 Jan 2008


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Essentials in looking at an ECG

Rhythm (sinus….nonsinus)

Rate, Atrial and ventricular rates.

QRS axis, T axis, QRS-T angle

Intervals: PR. QRS, and QT

P wave amplitude and duration

QRS amplitude and R/S ratio

Q wave

St- Segment and T wave abnormalities


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ECG tips

  • How do you determine Sinus rhythm?

  • What is T axis?

  • What is QRS/T angle?


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Rhythm

  • P before every QRS

  • P axis (0-90). P inverted in aVR


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P wave axis

  • The location of the P-wave axis determines the origin of an atrial-derived rhythm:

    • 0 to 90 degrees = a high right (normal sinus rhythm)

    • 90 to 180 degrees = a high left

    • 180 to 270 degrees = a low left

    • 270 to 0 degrees = a low right


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T wave

  • In most leads, the T wave is positive.

  • A negative T wave is normal in lead aVR.

  • Lead V1 may have a positive, negative, or biphasic T wave. In addition

  • It is not uncommon to have an isolated negative T wave in lead III, aVL, or aVF.


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Inverted (or negative) T waves can be a sign of

  • Coronary ischemia

  • Left ventricular hypertrophy


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T axis

  • Determined by the same methods as QRS

  • 0 to + 90 is normal

  • T Axis out side the normal quadrant could suggest conditions with Myocardial dysfunction.


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QRS-T Angle

Formed by the QRS axis and the T axis

QRS-T angle >60 degrees is unusual but if > 90 degrees, it is abnormal.

Abnormally wide angle, with T axis outside the normal quadrant is seen in

- severe ventricular hypertrophy with starin

- Ventricular conduction disturbances

- Myocardial dysfunction of a metabolic or ischemic nature.


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Top Tip For ECG

  • Read more ECGs



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Syncope examination and detailed history

  • How often related to the heart?

  • What are the related cardiac conditions?

  • How do we approach it?


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Definition examination and detailed history

  • Syncope is a transient loss of consciousness and muscle tone.

  • Near syncope:

    premonitory signs and symptoms of imminent syncope occur; dizziness with or without blackout, pallor, diaphoresis, thready pulse and low BP


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Cause examination and detailed history

  • Brain function depends on Oxygen and glucose.

  • Circulatory, metabolic, or neuropsychiatric causes.

  • Adults syncope mostly cardiac.

  • Children’s mostly benign.


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Causes of Syncope in Children examination and detailed history

  • Extra cardiac causes

    • Vasovagal

    • Orthostatic

    • Failure of systemic venous return

    • Cerebrovascular occlusive disease

    • Hyperventilation

    • Breath holding


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1- Vasovagal Syncope examination and detailed historyNeurocardiogenicCommon Syncope

  • Predrome for few seconds; dizziness, light-headedness, pallor, palpitation, nausea, hyperventilation then Loss of consciousness and muscle tone

  • Falls without injury

  • Lasts about a minute, awake gradually


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Vasovagal Syncope examination and detailed history

  • Anxiety

  • Fright

  • Pain

  • Blood

  • Fasting

  • Hot and humid conditions

  • Crowded places

  • Prolonged motionless standing


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Vasovagal Syncope examination and detailed historyPathophysiology

  • Standing posture without movement shifts blood to the lower extremities

  • Decrease venous return, stroke volume, BP

  • Less stretching of vent muscle and mechanoreceptors (mrcpts), decline in neural traffic form mrcpts, decreased arterial pressure, increase sympathetic output with

  • Higher HR, vasoconstriction (higher diastolic pressure)


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Vasovagal Syncope examination and detailed history Patients

  • Decreased venous return produces large increase in ventricular contraction force

  • Activation of LV mechanoreceptors (normally only responds to stretch)

  • Increase neural traffic mimicking high BP condition


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Diagnoses vasodilatation, hypotension and bradycardia

  • ECG, Holter, EEG, glucose tolerance test all are normally negative in V V E

  • Tilt test


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Management vasodilatation, hypotension and bradycardia

  • Supine +/- feet up

  • Prevention

    • Pseudoephedrine

    • Metoprolol

    • Fludrocortisone

    • Disopyramide

    • Scopolamine


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2- Orthostatic Hypotension vasodilatation, hypotension and bradycardia

  • What happen when we stand up?

    HR, vasoconstriction

    Absent or inadequate upright position response, Hypotension without increased HR


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Diagnoses vasodilatation, hypotension and bradycardia

  • BP and HR supine and standing up.

  • BP drop after 5-10 minutes up still by 10-15 mmHG

  • Positive tilt test without autonomic signs


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Management vasodilatation, hypotension and bradycardia

  • Elastic stockings

  • High salt diet

  • Corticosteroids

  • Slow upright position


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Micturition Syncope vasodilatation, hypotension and bradycardia

  • Rare form of orthostatic

  • Rapid bladder decompression associated with degreased total peripheral vascular resistance.


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3- Failure of systemic venous return vasodilatation, hypotension and bradycardia

  • Increased intrathoracic pressure

  • Decreased venous tone (drugs; nitroglycerin)

  • Decreased volume (bleed…)


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4- Cerebrovascular occlusive disease vasodilatation, hypotension and bradycardia

  • Mainly adult


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Cardiac causes of Syncope vasodilatation, hypotension and bradycardia

  • Structural heart disease

  • Arrhythmia


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Why Cardiac ? vasodilatation, hypotension and bradycardia

  • Syncope at rest

  • Provoked by exercise

  • Chest pain

  • Heart disease

  • FH of sudden death


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What Cardiac vasodilatation, hypotension and bradycardia

  • Obstructive lesions

  • Myocardial dysfunction

  • Arrhythmias


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Obstructive lesions vasodilatation, hypotension and bradycardia

  • AS, PS, HOCM, PHTX

  • Precipitated by exercise, no increase in cardiac output to accommodate increased demand.

    Examination, CXR, ECG, Echo


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Myocardial Dysfunction vasodilatation, hypotension and bradycardia

  • Ischemia, infarction secondary to CHD, Kawasaki’s..

  • Myocarditis


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Arrhythmia vasodilatation, hypotension and bradycardia


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Long QT vasodilatation, hypotension and bradycardia

  • Syncope, seizures, palpitation during exercise or with emotion

  • ECG

  • Ventricular arrhythmias (Tachy) with risk of sudden death


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clinically vasodilatation, hypotension and bradycardia

  • FH 60%

  • Deafness 5%

  • Presentation with Syncope 26%, seizure 10%, cardiac arrest 9%, presyncope palpitation 6%

  • Symptoms during exercise or emotion

  • Normally symptoms related to ventricular arrhythmias, mostly end of second decade of life.


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Tests particular trigger)

  • ECG with QTc >0.46 seconds

    • Frequently finding abnormal T wave

    • Bradycardia (20%)

  • Exercise test, maximum prolongation after 2 minutes of recovery, ventricular arrhythmia in 30% during exercise

  • Holter monitoring may show longer QTc


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Diagnoses Criteria particular trigger)

  • Electrophysiological society

    • QTc >0.44 with no other causes (0.46 sec)

    • Positive family history plus unexplained syncope, seizure or cardiac arrest proceeded by trigger such as exercise, emotion


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Treatment particular trigger)

  • Discuss with cardiologist

  • Avoid drugs associated with long QT

  • Avoid swimming, competitive sports

  • Beta blockers

  • Demand cardiac pacing (Pacemaker and defib)

  • Left cardiac sympathetic denervation


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Prognoses particular trigger)

  • Untreated 75-80% mortality

  • Beta blockers reduce mortality to some extent

  • The adjusted annual mortality rate on treatment is 4.5% (10 year mortality of 50%)


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Advise related to CHD particular trigger)

  • If one child has CHD, what are the chances of the second?

  • One parent has CHD, can offspring be affected? What are the chances?

    See Handouts, statistical list of potential risks










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Pathophysiology Cyanotic lesions lesions PRTGA with good mixing

65%

RV 80%

LV 90%

LA 90%


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Pathophysiology lesions PRTGA with poor mixing

30%

100%

RV 45%

LV 92%

45%

LA 92%

45%


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Pathophysiology lesions PRTGA with poor mixing

30%

100%

RV 45%

LV 92%

45%

LA 92%

45%


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Tips lesions PR

  • Read ECGs, easy to loose ECG skills.

  • Ask for help

  • As all specialties, it is only common sense.


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