Transcript Care of the Pediatric Patient with Cardiovascular Problems

Care of the Pediatric Patient
with Cardiovascular Problems
Elizabeth Allen RN, MSN
• Upon completion the learner will
• Define the 4 classifications of congenital heart disease
• Compare and contrast examples of each among the
classifications
• Recall symptoms and treatments of CHF in pediatric
patients
• State the most common pediatric cardiac dysrhythmia
• Differentiate between congenital and acquired heart disease
• Identify hematologic disorders affecting the pediatric
population
Learning Objectives
Fetal Circulation
• Video of Fetal Circulation
• http://youtu.be/uwswhoKfkmM
• Video of Heart Embryology
• http://youtu.be/5DIUk9IXUaI
Fetal Circulation
• Apex
• 4th ICS left of the MCL
• Apical pulse
• Auscultate
• Murmurs
• S3 is normal in children
• Pulses
• Infant
• Brachial, Femoral
• > 1 year
• Radial, Carotid
• Stroke Volume-Cardiac
Output
• Immature fluid balance
compensatory
mechanisms
Pediatric Anatomic
Differences
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Develop in the first 8 weeks of gestation
One of the most common birth defects
A leading cause of infant mortality in the first year of life
85% survivability
Resource:
• http://www.nhlbi.nih.gov/health/health-topics/topics/chd/
Congenital Heart Defects
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Increased Pulmonary Blood Flow
Decreased Pulmonary Blood Flow
Obstructive Systemic Blood Flow
Mixed Defects
Classification of
Congenital Heart Defects
Classification
Types of Defects
Increased Pulmonary Blood Flow
PDA, Atrial Septal Defect, Ventricular Septal Defect,
Atrioventricular Canal
Decreased Pulmonary Blood Flow
Pulmonary Stenosis, Tetrology of Fallot, Pulmonary or
Tricuspid Atresia, Transposition of Great Arteries
Obstructive Systemic Circulation
Coarctation of Aorta, Aortic Stenosis, Hypoplastic Left
Ventricle, Mitral Stenosis, Interrupted Aortic Arch
Mixed Defects
Transposition of Great Arteries, Total Anomalous
Pulmonary Venous Return, Truncus Arteriosus, Double
Outlet Right Ventricle
Classification
• Diagnostic or Interventional
• Similar process to adults
• Use femoral veins/arteries exclusively
• Generally do not leave sheaths in place post cath
• Pedal pulse and bleeding assessments frequent and very
important!
Cardiac Catherization
• Communication that allows blood flow from L side
(Systemic Circulation) to R side (Pulmonary Circulation)
• Pressures on L side of heart greater than R side
• Corrective surgery performed early in infancy to prevent
irreversible pulmonary vascular disease (pulmonary
hypertension)
Increased Pulmonary
Blood Flow
• Maintain PDA with
Prostaglandin E
• Pharmaceutical
PDA closure with
Indomethacin
• Cath Lab closure of
PDA
• Surgical closure of
PDA- PDA ligation
• Patent Ductus Arteriosus
(PDA)
Increased Pulmonary
Blood Flow
Increased Pulmonary
Blood Flow
• Increased Blood Flow to Pulmonary Circulation
• Pathophysiology
• Decreased cardiac output
• Increased pulmonary blood flow
• Leads to sympathetic nervous response
• Increased heart rate
• Increased vasoconstriction
• Renin-angiotension release (holding Na and H20)
• Resource:
• http://www.cincinnatichildrens.org/health/c/chf/
Congestive Heart Failure
• Symptoms
• Infant
• Tires easily, sweats with
feeds
• Loses weight, FTT
• Tachypnea, grunting,
retractions, Crackles
• Liver palpable below R
costal margin
• Tachycardia, 3rd heart
sound, fatigue
• Symptoms
• Older Child
• Fatigue, exercise
intolerance
• Crackles, tachypnea
• Abdominal pain
• Skin mottling, pallor
Congestive Heart Failure
• Symptoms:
• Respiratory- tachypnea, grunting, retractions, hypoxia,
crackles
• Abdominal- liver palpable below R costal margin,
retractions
• Cardiac- diaphoresis, tachycardia, third heart sound, edema,
JVD, cardiomegaly, fatigue
• Failure to Thrive
Congestive Heart Failure
Treatment
• Pharmacological:
• Digoxin, diuretics, Beta
blocker, ACE inhibitor
• Oxygen
• High calorie tube feeding
• Monitor weight- FTT and
fluid retention
• Monitor urine output- 1
cc/kg/hr.
• Therapies to promote
development
• Rest and avoid excessive
crying
Congestive Heart Failure
• Defects restrict flow of blood from R side of heart to the
lungs
• Usually results in hypoxemia and cyanosis
• Cyanosis or hypoxia that does NOT respond as expected
to oxygen
• Blood flow obstruction to lungs PLUS an ASD or VSD
will cause a R to L shunt and unoxygenated blood in
systemic circulation
Decreased Pulmonary
Blood Flow
• Tetralogy of Fallot (TOF)
• Tetralogy =4
• 4 Defects
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Pulmonary
Stenosis
VSD
Overriding Aorta
R Ventricular
Hypertrophy
Decreased Pulmonary
Blood Flow
• Clinical Manifestations
• Hypoxia after PDA closure
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Polycythemia
Clubbing
Systolic Murmur
Poor growth
• May have signs of CHF
Tetralogy of Fallot
• Pre Surgical Treatment- Avoid or Reduce Hypercyanotic
Episodes!
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Monitor O2 sats, HR, respiratory effort
Oxygen
Avoid excessive crying, agitation
Knee to chest in infant, Treat pain
High calorie feeds- may be NGT
Therapies to promote development
• Surgical Correction
• BT Shunt palliative in infancy to increased pulmonary blood flow
• Complete surgical correction of VSD and Pulmonary Artery
Tetralogy of Fallot
Figure 21–6 A young child with an uncorrected or partially corrected defect that reduces pulmonary blood flow may
squat (assumes a knee–chest position) to reduce systemic blood flow return to the heart.
• Often appear similar to those of Decreased Pulmonary
Blood Flow
• Dependent on Mixed Oxygenated and Un-oxygenated
blood for survival
Mixed Defects
• Clinical
Manifestations:
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Chronic
hypoxemia
Fatigue
Clubbing
Exertional
dyspnea
Increased
metabolic demand
Developmental
delays
Possible CHF
Mixed Defects
• Obstruct Blood Flow from heart to systemic circulation
• Results in elevated L ventricular pressure and LOW
cardiac output
• Symptoms manifest in infants as PDA closes
Obstructive Defects
• Some children have no
symptoms
• Reduced flow to body
post coarct
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Heart Failure
Lower Extremity
cyanosis
BP difference- lower
in legs vs. arms
Radial and brachial
pulses bounding
Renal failure and
necrotizing
enterocolitis in infants
Poor feeding, Failure
to Thrive
CHF symptoms
including dyspnea
(back up into lungs)
• Coarctation of the Aorta
Obstructive Defects
• Coarctation of the Aorta
• Treatment
• Infant with severe obstruction or L ventricular dysfunctionPGE infusion
• Balloon catherization
• Surgical Correction
• Often just follow up post correction, no other problems
Obstructive Defects
• Supraventricular
Tachycardia
• Most common
dysrhythmia in
children
• Electrophysiology
disturbanceoverriding SA Node
• Supra- meaning the
conduction wave
originates in the atria
Dysrhythmias
• Kawasaki Disease
• Rheumatic Fever
Acquired Cardiac Disease
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Kawasaki Disease
Leading cause acquired heart disease in US
80% of cases <5 years, 50% < 2 years
Affects Asians, Pacific Islanders more often
Unknown cause- thought to be infectious, not contagious
Acute fevers, systemic vascular inflammation
• Inflammation of small and midsize arteries, including
coronary arteries
• May cause aneurysms
Acquired Cardiac Disease
• Kawasaki Disease
• 3 Stages- Symptoms
• Acute: irritability, high fever,
red eyes and throat, rash, feet
and hand swelling
• Subacute: cracked lips,
desquamation of fingers and
toes, joint pain, thrombocytosis
and cardiac disease
• Convalescent: normal,
maybe lingering inflammation
Acquired Cardiac Disease
• Kawasaki Disease
• Treatment
• Fever- antipyretic
• IV Immunglobulin
(IVIG)- 1 dose
• Monitor: cardiac, CBC,
bleeding
• Aspirin
• When to stop the aspirin?
Acquired Cardiac Disease
• Rheumatic Fever
• Inflammation of connective tissue from immune
response to some Group A beta-hemolytic
streptococci
• May cause long term disease of heart valves,
brain, skin and joints
• 1-3 weeks post strep infection
Acquired Cardiac Disease
• Rheumatic Fever
Symptoms
• Fever
• Joint pain/swelling
• Murmur (carditis) or
chest pain
• Rash (not on face &
hands
• Subcutaneous nodules
over tendons, bony
prominences
• Rheumatic Fever
Treatment
• Antibiotics
• Aspirin- antipyretic, joint
pain
• Corticosteroids as needed
• Monitor cardiac for CHF
symptoms
Acquired Cardiac Disease
• Cardiomyopathy
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Disorder affects chamber size, wall thickness and contractility
Most common Dilated Cardiomyopathy
Cause: genetic, acquired, secondary to myocardial disorders
Usually presents in CHF
Treatment:
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Digoxin
ACE Inhibitor
Diuretics
Antiarrhythmic
Anticoagulants
Beta blocker
Heart transplant
Acquired Cardiac Disease
• Iron Deficiency Anemia
• Sickle Cell Anemia
• Hemophilia
Hematological Disorders
• Iron Deficiency Anemia
• Who has it?
• < 2years old/adolescent females.
• Pathophysiology
• Secondary to blood loss, malabsorption, or poor nutritional intake
• Symptoms
• Labs
• Treatment
• Dietary, supplements
Hematological Disorders
• Sickle Cell Anemia
• Red blood cells “Sickle” under stress
• Resource
• http://www.nhlbi.nih.gov/health/health-topics/topics/sca/
• Pathophysiology
• Genetic
• Autosomal recessive disorder
• African Americans,
some Mediterranean decent
Partial or complete replacement
of the amino acid glutamic acid
by the amino acid valine
Hematological Disorders
• Sickle Cell Symptoms
• Pain
• Peripheral clotting,
ischemia, obstruction
• Sickle Cell Treatment
• Treat Pain!!
• Treat underlying cause
(ex. dehydration,
infection)
• Hydration
• Oxygen
• Priapism over 4 hours is
a medical emergency
• Splenectomy common
Hematological Disorders
• Hemophilia
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Inherited, sex-linked: almost always affects boys
Mild-to-severe bleeding after injury
Internal bleeding, bruising, joint bleeds
Ineffective Clotting Cascade- missing coagulation Factors
85% have Hemophilia A
Also Hemophilia B and von Willenbrand’s disease
Hematological Disorders
• Hemophilia Treatment
• Monitor for bleeding- especially joint bleeding
• Provide Factor VIII (Hemophilia A)
• Recombinant Factor VIII- not plasma derived
• Cryoprecipitate in emergencies if Factor not immediately
available
Hematological Disorders