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Paediatric Cardiology- after one year of age

Paediatric Cardiology- after one year of age. Jon Skinner. Topics to cover. Murmur in a well four year old ECG in diagnosis of CHD CXR in diagnosis of CHD. Murmur in a well four year old. What are the possibilities?. Murmur in a well four year old. What are the possibilities?

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Paediatric Cardiology- after one year of age

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  1. Paediatric Cardiology- after one year of age Jon Skinner

  2. Topics to cover • Murmur in a well four year old • ECG in diagnosis of CHD • CXR in diagnosis of CHD

  3. Murmur in a well four year old • What are the possibilities?

  4. Murmur in a well four year old • What are the possibilities? • Innocent murmur

  5. Murmur in a well four year old • What are the possibilities? • Innocent murmur • Atrial septal defect

  6. Murmur in a well four year old • What are the possibilities? • Innocent murmur • Atrial septal defect • Ventricular septal defect

  7. Murmur in a well four year old • What are the possibilities? • Innocent murmur • Atrial septal defect • Ventricular septal defect • Valvar stenosis

  8. Murmur in a well four year old • What are the possibilities? • Innocent murmur • Atrial septal defect • Ventricular septal defect • Valvar stenosis • Aortic coarctation

  9. Murmur in a well four year old • What are the possibilities? • Innocent murmur • Atrial septal defect • Ventricular septal defect • Valvar stenosis • Aortic coarctation • Patent arterial duct

  10. Murmur in a well four year old • What are the possibilities? • Innocent murmur • Atrial septal defect • Ventricular septal defect • Valvar stenosis • Aortic coarctation • Patent arterial duct • Miscellaneous rare stuff- HCM, valvar regurg etc

  11. Murmur in a well four year old • No. 1 What is this? • Pulses normal, BP 95/60 • RV lift • 2-3/6 ESM at upper LSE • ECG- • CXR

  12. Murmur in a well four year old No. 1

  13. Murmur in a well four year old No. 1

  14. Murmur in a well four year old • No. 1 What is this? • Pulses normal, BP 95/60 • RV lift • 2-3/6 ESM at upper LSE • ECG- normal axis IRBBB • CXR-mild cardiomeg, plethora, prominent PA

  15. Murmur in a well four year oldNo. 2 • No. 2 What is this? • Pulses normal, BP 95/60 • Normal precordium • 2-3/6 vibratory ESM at upper and lower LSE • ECG- normal axis IRBBB • CXR-normal

  16. Murmur in a well four year oldNo. 2- murmur disappears doing this

  17. Murmur in a well four year oldNo. 2 • No. 2 What is this? • Pulses normal, BP 95/60 • Normal precordium • 2-3/6 vibratory ESM at upper and lower LSE • murmur disappears on stretching the neck • ECG- normal axis IRBBB • CXR-normal

  18. Murmur in a well four year old • No. 3 What is this? • History of recurrent chest infections • Pulses normal, BP 100/65 • RV lift. • 2-3/6 ESM at upper LSE, fixed split of second sound • ECG- IRBBB • CXR- Cardiomeg, plethora, prominent PA

  19. Murmur in a well four year oldNo. 3

  20. Murmur in a well four year oldNo. 3 • No. 3 What is this? • Pulses normal, BP 100/65 • RV lift. Harrison’s sulci • 2-3/6 ESM at upper LSE, fixed split of second sound • ECG- IRBBB • CXR- Cardiomeg, plethora, prominent PA • Diagnosis--

  21. Murmur in a well four year oldNo. 4 • No. 4 What is this? • Pulses normal, BP 100/65 • Parasternal thrill • 4/6 PSM at lower LSE, • ECG- • CXR- Normal

  22. Murmur in a well four year oldNo. 4

  23. Murmur in a well four year oldNo. 4

  24. Murmur in a well four year oldNo. 4 • No. 4 What is this? • Pulses normal, BP 100/65 • Parasternal thrill • 4/6 PSM at lower LSE, • ECG- Borderline LVH • CXR- Normal • Diagnosis?

  25. Murmur in a well four year oldNo. 5 • No. 5 What is this? • Slim child, recurrent chest infections • Pulses normal, BP 95/60 • Overactive precordium • 2/6 low pitched PSM at lower LSE, 2/4 diastolic murmur at apex • ECG- • CXR-

  26. Murmur in a well four year oldNo. 5

  27. Murmur in a well four year oldNo. 5

  28. Murmur in a “well” four year oldNo. 5

  29. Murmur in a well four year oldNo. 5 • No. 5 What is this? • Slim child, recurrent chest infections • Pulses normal, BP 95/60 • Overactive precordium • 2/6 low pitched PSM at lower LSE, 2/4 diastolic murmur at apex • ECG- RVH, LVH • CXR- Cardiomegally and plethora • Diagnosis?

  30. ECG diagnosis of atrial hypertrophy?

  31. ECG diagnosis of atrial hypertrophy? • Lead II

  32. Conditions causing Atrial hypertophy on the ECG • RAH • LAH

  33. Murmur in a well four year oldNo. 6 • No. 6 What is this? • BP 130/90 • Soft ESM at upper RSE • ejection click • ECG- LVH with strain • CXR- unavailable

  34. Murmur in a well four year oldNo. 6 • No. 6 What is this? • BP 130/90 • Soft ESM at upper RSE • ejection click • ECG- LVH with strain • CXR- unavailable • What do you wish to examine now?

  35. Murmur in a well four year oldNo. 6 • No. 6 What is this? • BP 130/90 • Soft ESM at upper RSE • ejection click • ECG- LVH with strain • CXR- unavailable • What do you wish to examine now? • Diagnosis?- what might the CXR show?

  36. Normal blood pressure values in children Boys Girls Paediatrics (suppl) 59:797, 1977

  37. Murmur in a well four year old • No. 7 What is this? • Pulses normal, BP 90/65 • RV lift. • 2-3/6 ESM at upper LSE, fixed split of second sound • ECG- • CXR-

  38. Murmur in a well four year oldNo. 7

  39. Murmur in a well four year oldNo. 7

  40. Murmur in a well four year old • No. 7 What is this? • Pulses normal, BP 90/65 • RV lift. • 2-3/6 ESM at upper LSE, fixed split of second sound • ECG- LAD IRBBB • CXR- CM plethora • Diagnosis?

  41. Types of ASD

  42. What does this ECG show? 2 year old, loud systolic murmur, mild cyanosis (88%)

  43. What does this CXR show? 3 month cyanotic infant

  44. What does this CXR show?

  45. Topics we have covered (superficially!) • Murmur in a well four year old • ECG in diagnosis of CHD • chamber hypertrophy • QRS axis • RBBB in ASD • CXR in diagnosis of CHD • L-R shunts-> cardiomegally and plethora • oligaemia • chamber hypertrophy

  46. Useful texts • Essential paediatrics- Hull and Johnstone, Church Liv • Pediatric Cardiology for practitoners- Myung K Park, Mosby • How to Read Pediatric ECGs- Park and Guntheroth, Mosby • Heart Disease in Paediatrics- Jordan and Scott, Butterworths

  47. Paediatric ECGsthe rules Jon Skinner Green Lane Hospital

  48. Criteria for chamber enlargement • RA p wave amp >3mm • LA bifid p wave and prolonged >.10 secs - ie 2.5 squares (.08 secs in infants) • RV - use Davignon charts. R in V1>20v (4 squares) >25v in neonates or S in V6 >7v. OR upright T wave in V1 after 72 hours and up to 5 years. Severe RVH- ST and T wave now invert with ST depression, and small Q wave in lead V1. • LV R in V6 >25v (5 squares). Severe- ST depression and T wave inversion V6.

  49. Q- waves • Are allowed (usual) in 1,2, 3 and aVf, V5 and V6 and are narrow and up to 7mm deep in 2 and 3 • Are pathological in V1 (except occasional newborns) and indicate LTGA, single ventricle, severe RVH or anterior MI (deep and wide).

  50. QT interval • QTc = QT (ms)/ sq root R-R interval (ms) • is less than 0.45sec • Refer to Normal reference values • Measure in lead 2 and V5 (and particularly not in V2- V4)

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