Normal pediatric HR:
- Neonate: 150-180
- Infant: 145-150
Normal pediatric BP:
(In pediatrics, we worry more about hypotension than hypertension)
- Neonate -> anything below 60 is hypotensive
- Infant -> anything below 70 is hypotensive
- 1-9 yo -> Minimum SBP = 70 + (2 x age)
- > 9 yo -> like “adults”
Presentation of cardiac problems:
- ↓ feeding
- ↓ feeding
- ↓ activity
- SOB
Normal closure of PDA:
- Functional: 48 hrs
- Anatomical: 4-6 wks
Types of cardiac diseases in pediatrics:
- Congenital
- Acquired
- Electrophysiology
a. Congenital Heart Diseases
1) Cyanotic CHD:
- (present usually on the 2nd – 3rd week)
Tetralogy of fallot:Â (right -> left shunt)
- RVH
- Pulmonary\infundibular stenosis
- VSD
- Overriding aorta
- RV outflow obstruction
- Paroxysmal hyper-cyanotic attacks (tet spells)
- Auscultation: harsh systolic ejection murmur + thrill {upper sternal border}, single S2
- CXR: heart = boot, dark lungs bc ↓ pulmonary blood flow
- Tx: PGE, definitive surgery after 4 mo

Tricuspid atresia: (right -> left shunt)
- No blood flow from RA to RV -> flows through ASD, PDA, VSD
- Auscultation: no significant murmur, single S2
- Tx: PGE, surgery
- SE of PGE? Hypotension and apnea
Ebstein anomaly:
- Downward placement of tricuspid valve
- Auscultation: holocystolic murmur, gallop rhythm
- ECG: WPW
Transposition of the great arteries: (mixing)
- Aorta arises from RV, pulmonary A arises from LV -> 2 parallel circuits -> need ASD, VSD, PDA
- Seen in IODM
- Auscultation: single S2
- CXR: heart = egg on string
- Tx: PGE, definitive arterial switch in the first 2 wks of life

Truncus arteriosus:Â (mixing)
- Single arterial trunk + VSD (always)
- Seen in DiGeorge syndrome
- Auscultation: systolic murmur, loud single S2
Total anomalous pulmonary venous return:Â
- Usually pulmonary venous returns into the left atrium, if it goes to the right -> mix -> cyanosis
- CXR: heart = snowman

2) Stenotic CHD:
Pulmonary stenosis:Â
- Obstruction to RV outflow -> RVH
- Auscultation: ejection systolic murmur + thrill {left 2nd-3rd ICS}
- Tx: balloon valvulopolasty, surgery
Aortic stenosis:Â
- Mostly caused by bicuspid valve -> obstruction to LV outflow
- Auscultation: ejection systolic murmur + thrill {right 2nd-3rd ICS}
- Tx: balloon valvulopolasty, surgery
Coarctation of the aorta:
- Infantile: preductal
- Differential cyanosis
- Tx: PGE, surgery
- Adult: juxtaductal\just below
- Seen in Turner syndrome
- Presentation: lag of femoral pulses, BP of UL > LL
- CXR: rib-notching
- Tx: treat HTN, surgery

3) Non-cyanotic CHD:
VSD: (left -> right shunt)
- Most common congenital heart lesion
- Large defect -> ↑ pulmonary flow -> ↑ PVR -> medial hypertrophy -> Eisnmenger (when PVR > SVR)
- Subtypes: small\large, muscular\membranous (more common)
- Auscultation: pansystolic\holosystolic murmur + thrill {lower left sternal border}
- CXR: large heart
- Tx: most small muscular (less membranous) close in the first 1-2 yrs
- When to operate? FTT, failure of medical correction of HF, infants w\ large defects
- Complication: HF, pulmonary HTN, endocarditis
ASD: (left -> right shunt)
- Most commonly ostium secundum defect (region of fossa ovalis)
- Auscultation: systolic ejection murmur + fixed slit of S2
- Tx: usually close on their own, but if persists after 5 yrs -> close it surgically before puberty (why? If becomes pregnant -> increases the workload on the heart)
AVSD: (left -> right shunt)
- Defect in the endocardial cushion -> defective AV valves
- Seen in Down syndrome
PDA: (left -> right shunt)
- A duct still being present 1 mo after birth
- More in girls, preterm, maternal rubella infection
- Presentation: wide pulse pressure, bounding peripheral pulses
- Auscultation: continuous machinery murmur
- Tx: indomethacin (PG inhibitor) (better results w\ preterm), surgical ligation (better results w\ term)
b. Aquired Heart Disease:
Myocarditis:
- Organism: Coxsackie B virus
- Presentation: fever, HF, arrhythmias
- Dx: biopsy
- Tx:Â HF and arrhythmias
Pericarditis:
- Same presentation as myocarditis except + distant and muffled HS
- Organism: GAS (S. agalactiae), staph
- Tx: underlying cause, pericardiocentesis if effusion
- ECG:

Infective endocarditis:
- Organism: strept viridians, staph aureus
- High risk pts? On central line, high outflow CHD (VSD, aortic stenosis), cardiac surgery, dental procedure, artificial valve
- Presentation: prolonged fever, splenomegaly, new murmur, splinter hemorrhage, Osler nodes, Janeway lesions, Roth spots
- Dx: Duke’s criteria (2 major OR 1 major + 3 minor OR 5 minor)
- Tx: organism specific for 4-6 wks, HF meds, surgery (interactable failure, abscess, recurrent emboli, increased size of vegetations, worsening regurg)
- Prophylaxis: amoxicillin to high risk pts
- Complications: HF from valve lesions (aortic\mitral), emboli (bc of vegetation)
Acute rheumatic fever:
- Organism: GAS
- Associated w\ strept pharyngitis
- Dx: Jone’s criteria
- Tx:
- For GAS eradication: oral penicillin for 10 days (erythromycin if allergic)
- For the arthritis\carditis: anti-inflammatory (aspirin if no HF, prednisone if w\ HF)
- Phenobarbital (only if chorea)
- Prophylaxis: continuous abx (single IM benzathine penicillin G every mo)
Kawasaki:
- Medium vessels vasculitis (mainly coronary)
- Complications: aneurysm
- Tx: aspirin (to prevent MI) and immunoglobulin
c. Arrhythmias:
Sinus tachycardia:
- Caused by something external, either fever, crying, hypovolemia
SVT:
- If more than 1 yr > 180
- If less than 1 yr > 220
- ECG: no P wave (very close QRS), constant R-R (means the HR is constant regardless of the environment, bc the origin is in the heart, where in sinus tachycardia, the origin is from outside, so the R-R will change according to the causative agent either fever, crying, hypovolemia)
- Tx:
- Stable -> adenosine (first dose = 0.1 mg\kg, max is 6 mg\kg) -> not improving -> adenosine (second dose – 0.2 mg\kg, max is 12 mg\kg) -> not improving -> amiodarone -> not improving -> cardioversion
- If unstable (↓BP, perfusion, consciousness) -> cardioversion then adenosine
V tach: (wide complex)
- Pulse -> amiodarone -> cardioversion
- No pulse -> CPR -> epinephrine -> DC shock
V fib:
- CPR -> epinephrine -> DC shock
Asystole:
- CPR only!
Innocent murmur:
- Systolic
- Grade 2\6 or less
- Intensifies w\ increased cardiac output (exercise\fever)
- Change in intensity w\ posture or head position
- No thrill, no heave, no abnormal HS, no radiation, no Sx
- Types: peripheral pulmonic stenosis, still’s murmur, venous hum, aortic outflow murmur
Download the PDF version: here
References:
- Dr Alhammad’s clinical notes
- Kaplan step 2 lecture notes