Pediatric Intensive Review

Osama Naga, MD
Clinical Assistant Professor
Paul foster School of Medicine
Texas Tech University Health Sciences
El Paso, Texas, USA

left clavicular region

Cardiology Lecture PDF Preview

Chest Pain
Clinical Case Scenario
A 15-year-old adolescent boy is brought to you for evaluation of chest pain.
He had chest pain 2 days ago during succor game and had to leave the game.
He describes the pain as dull and points to the middle of his chest. It was
worse when he was running. The pain resolved with rest and fluids. He denied
rapid heartbeat sensation. No family history of sudden death or death under
the age of 30 years. Denied using illicit drugs.
Physical examination is normal. EKG showed. ST segment elevation in the
anterior and lateral leads (V1 through V6) with ST segment depression in the
inferior leads. What is the MOST likely diagnosis?
A. Musculoskeletal pain
B. Precordial catch
C. Anomalous coronary artery
D. Exercise induced asthma
A 15-year-old adolescent boy is brought to you for evaluation of chest pain.
He had chest pain 2 days ago during succor game and had to leave the game.
He describes the pain as dull and points to the middle of his chest. It was
worse when he was running. The pain resolved with rest and fluids. He denied
rapid heartbeat sensation. No family history of sudden death or death under
the age of 30 years. Denied using illicit drugs.
Physical examination is normal. EKG showed. ST segment elevation in the
anterior and lateral leads (V1 through V6) with ST segment depression in the
inferior leads. What is the MOST likely diagnosis?
A. Musculoskeletal pain
B. Precordial catch
C. Anomalous coronary artery
D. Exercise induced asthma
 Chest Pain
• Non-cardiac chest pain (most common)
• The history and physical examination can establish the diagnosis of pain in the
majority of cases.

• Cardiac chest pain (rare)

• Chest pain in children is rarely due to cardiac disease.
 Precordial Catch Syndrome
• Very common form of benign, musculoskeletal chest pain in older
children and young adults
Physical examination is typically normal
• Presented with severe and sudden chest pain
The cause is unknown
• Often over the left precordium Management: Reassurance
• Described as knife-like sharp pain

• During episode patients report clearly that they can not catch their
breath; especially deep breath makes the pain worse

• Patient has no pain or limitations during physical activities

• Lasts for 30s to one minute

 Chest Pain
• Red flags for cardiac chest pain
• Pain with exertion

• Syncope

• Fatigue

• Shortness of breath with exertion

• Pain preceded by tachycardia

• Family history of heritable conditions such as hypertrophic cardiomyopathy

 Chest Pain
• Non-Cardiac Chest pain
• Musculoskeletal pain
• Chest wall tenderness with palpation

• Asthma
• Pneumonia
• Anxiety
• Recent major stressful event
• Separation from friends

• Reflux
• Sickle cell disease
• Vaso-occlusive crises or acute chest syndrome.
A 13-year-female while standing and waiting for her turn in school during
lunch, she felt lightheaded, weak, nauseous and passed out for 5 seconds,
she looked pale, and had cold sweat, her friends called her and helped her to
laydown and felt better after, she has no history of seizure or any other
medical problem, her physical examination is normal. What is the best course
of action
A. EKG
B. Echocardiogram
C. Stress test
D. Reassurance
A 13 years female while standing and waiting for her turn in school during
lunch, she felt lightheaded, weak, nauseous and passed out for 5 seconds,
she looked pale, and had cold sweat, her friends called her and helped her to
laydown and felt better after, she has no history of seizure or any other
medical problem, her physical examination is normal. What is the best course
of action
A. EKG
B. Echocardiogram
C. Stress test
D. Reassurance
 Syncope

• Syncope is a temporary loss of consciousness

• may be due to generalized cerebral hypoperfusion

• or neurologic disorders.
 Syncope
• Causes of Syncope

• Vasovagal: impaired response of the autonomic nervous

system
• The most common form of syncope in children
 Syncope

• Initial evaluation

• Electrocardiography − Rhythm − Left or right ventricular hypertrophy

• Further evaluation

• 24-h Holter or 30-day event monitoring if history suggests tachyarrhythmia

• Echocardiogram if physical examination or electrocardiogram abnormal

CARDIAC ARRHYTHMIAS
10mm 0.2 sec 0.04 sec

Speed 25mm/s
 Electrocardiogram Interpretation
Step 1 Rhythm, Rate, Axis

Step 2 P wave, PR interval

Step 3 QRS complex

Step 4 QT, ST and T

 Electrocardiogram Interpretation

• Rhythm
• Regular or irregular rhythm

• P wave before each QRS

• P wave can be normally negative in AVR

• Rate
• 300/number of LARGE boxes between R
 Rate

Heart Rate

• Regular

• The heart rate is 300 divided by the number of large squares between the QRS
complexes. (1 minute = 300 large divisions)

• For example, if there are 4 large squares between regular QRS complexes, the heart
rate is 75 (300/4=75).

• 300 → 150 → 100 → 75 → 60→ 50

 PR interval
Rhythm Usually < 200 ms in older children,
< 130 ms in newborns
Rate
Axis
P wave
PR interval
Varies according to the age and
HR

Prolonged Normal Short PR

 Rhythm
Rate
Axis
P wave QRS complex
PR interval Usually, < 120 ms
QRS complex

Wide complex Narrow complex

Normal duration

QRS amplitude
R/S ratio
 QRS Complex

• Positive T wave in V1 1st week of life → Normal

• Positive T wave in V1 after the 1st week of life → Suggestive of RVH

• Positive T wave in V1 is not abnormal in children > 6 years of age

Right bundle branch block (RBBB)

• More common in children particularly after open heart surgery

• V1
• Wide QRS (> 120 ms)

• RSR’ (rabbit ears)

• Wide S wave in V6
 RSR (rabbit ears) in V1

16-year-old with Tetralogy of Fallot repaired in infancy

Normal sinus rhythm with right bundle branch block
15-year-old with irregular heartbeat. EKG shows premature, inverted, or oddly
shaped P-waves

What is the most likely diagnosis?

A. Premature atrial contraction

B. Premature ventricular contraction
C. Atrial flutter
D. Atrial fibrillation
15-year-old with irregular heartbeat. EKG shows premature, inverted, or oddly
shaped P-waves

What is the most likely diagnosis?

A. Premature atrial contraction

B. Premature ventricular contraction
C. Atrial flutter
D. Atrial fibrillation
 Uniform (PVC)

Multiform (PVC)

Premature Ventricular Contractions

Premature, wide QRS, no P waves
Maybe normal if uniform and decrease with exercise
 Rhythm
QT interval
Rate • QTc Should not exceed 0.44s except in infants

Axis • Qtc interval up to 0.49s may be normal in infants <

P wave 6 months

PR interval • QTc > 0.45 s may be abnormal

QRS complex
QT interval

Corrected QT (QTC): QTC = QT/√RR

 15-year-old boy loses consciousness while playing football. He regains
consciousness quickly. He was rushed to ER and EKG as shown in the figure.
Long QT Syndrome (LQTS)
What is the most likely diagnosis?

A. Long Q-T syndrome

B. Torsade de pointe
C. Complete heart block
D.2nd degree heart block
 15-year-old boy loses consciousness while playing football. He regains
consciousness quickly. She was rushed to ER and EKG as shown in the figure.
Long QT Syndrome (LQTS)
What is the most likely diagnosis?

A.Long Q-T syndrome

B. Torsade de pointe
C. Complete heart block
D.2nd degree heart block
 Prolonged Q–T Interval
• Causes
• Medications:
• Tricyclic antidepressant overdose e.g. Amitriptyline

• Ampicillin, erythromycin, Trimethoprim-sulf

• Electrolyte abnormalities
• Hypocalcemia, hypomagnesemia, hypokalemia

• Mutations of genes encoding for cardiac ion channel proteins

• Romano-Ward syndrome

• Jervell and Lange–Nielsen syndrome

 Long QT Syndrome (LQTS)
• Clinical presentation

• Family history of unexplained sudden death

• Congenital deafness in the family

• Hereditary LQTS (Jervell and Lange–Nielsen syndrome)

• Fainting spells while swimming, startling, or exercising.

• Syncope, seizures, palpitations, cardiac arrest

• As many as 10 % have episodes of sudden cardiac arrest

 Long QT syndrome
QTc > 0.50
Long QT Syndrome (LQTS)
RR: 0.2 x 5=1 s QTC = QT/√RR
0.52/1=0.52

QT time
Lead II 0.4 + 0.12= 0.52 s

25mm/s

15-year-old boy loses consciousness while playing football. He regains consciousness quickly.
Newborn fails hearing screen, electrocardiogram (EKG) shows a
very prolonged QT interval

What is the most likely cause?

A. Jervell and Lange-Nielsen syndrome

B. Alport syndrome
C. Romano-Ward syndrome
D. Treacher Collins syndrome
Newborn fails hearing screen, electrocardiogram (EKG) shows a
very prolonged QT interval

What is the most likely cause?

A. Jervell and Lange-Nielsen syndrome

B. Alport syndrome
C. Romano-Ward syndrome
D. Treacher Collins syndrome
Long QT Syndrome (LQTS)

• Treatment

• Beta blockers are effective in preventing cardiac events in 70 % of patients

(LQTS type 1)

• Implantable cardioverter-defibrillator (ICD) is highly effective in preventing

sudden cardiac death in high risk patients

• Patients should avoid QT prolonging medications.

8-year-old girl presented with chest discomfort with sudden onset of palpitations, she felt her
heart pounding, “beeping in the chest”. In ER her EKG shows, narrow complex ( <80 ms)
tachycardia with a fixed rapid rate, P-waves are often difficult to see but may be seen as sharp
deflections within the T-waves

What is the most likely diagnosis?

A. Atrial flutter
B. Atrial fibrillation
C. Ventricular tachycardia
D.Supraventricular tachycardia
8-year-old girl presented with chest discomfort with sudden onset of palpitations, she felt heart
her heart pounding, “beeping in the chest”. In ER her EKG shows, narrow complex ( <80 ms)
tachycardia with a fixed rapid rate, P-waves are often difficult to see but may be seen as sharp
deflections within the T-waves

What is the most likely diagnosis?

A. Atrial flutter
B. Atrial fibrillation
C. Ventricular tachycardia
D.Supraventricular tachycardia
 Supraventricular Tachycardia (SVT)

• Background
• SVT is defined as a rapid tachycardia originating above the bundle of His

• Pathogenesis
• Reentrant tachycardia using an accessory pathway (AP)

• Reentrant atrioventricular nodal tachycardia (AVNRT), typically seen in adolescents

• Ectopic atrial focus

 Supraventricular Tachycardia (SVT)
• Clinical presentation
• Infants
• Heart rates of 220–270 beats/min

• Poor feeding, pallor, irritability, and lethargy if prolonged

• Congestive heart failure with hemodynamic decompensation

• School-aged children
• Palpitation, heart pounding, “beeping in my chest”

• Chest pain or fullness, shortness of breath

• Heart rate: 180–240 beats/min

Supraventricular Tachycardia (SVT)

• Diagnosis
• ECG
• Narrow complex (< 80 ms) tachycardia with a non variable rapid heart
rate

• P waves often are difficult to see but may be seen as sharp deflections
within the T-waves.
25mm/s 12-year-old with palpitation
Supraventricular tachycardia (Narrow complex tachycardia regular)
 Supraventricular Tachycardia (SVT)
• Management
• Stable
• Vagal maneuvers; for example, place ice bag to the face for 10–20s

• Adenosine (Avoid verapamil in infant < 1 year because of risks of hypotension

and shock) Remember to administer
• Avoid digoxin in WPW (pre-excited baseline ECG)
adenosine quickly (via
push with a flush quickly
• Beta blockers (e.g., propranolol)
thereafter)
• Unstable
• D/C cardioversion

• Pediatric cardiology referral

• Electrophysiological study with ablation procedure is the definitive treatment
of choice (older children)
6-year-old presented with difficulty breathing,
then collapsed?

What is the most likely diagnosis?

A. Atrial flutter
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation
6-year-old presented with difficulty breathing,
then collapsed?

What is the most likely diagnosis?

A. Atrial flutter
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation
 Ventricular Tachycardia
• Background
• Ventricular tachycardia (VT) in children is defined as a tachycardia of at least three successive
ventricular beats

• Causes
• Causative factors include use of drugs, caffeine, and decongestants

• Electrolyte imbalance

• Underlying cardiac disease

• Prior cardiac surgery

• Cardiomyopathy
A 14-year-old with chest pain, the
pain is worse during inspiration,
when lying flat.

What is the EKG finding?

A. Prolonged QT duration
B. ST segment elevation
C. Prolonged PR interval
D. Right ventricular hypertrophy
A 14-year-old with chest pain, the
pain is worse during inspiration,
when lying flat.

What is the EKG finding?

A. Prolonged QT duration
B. ST segment elevation
C. Prolonged PR interval
D. Right ventricular hypertrophy
Heart Murmurs
 Aortic valve Mitral valve
Pulmonary valve Tricuspid valve

Regurgitation Stenosis Regurgitation Stenosis

Diastolic murmur Systolic murmur Systolic murmur Diastolic murmur

 Step 1 Step 2 Step 3

Auscultate Supine Auscultate sitting Auscultate the back

• Innocent murmurs
• Typically, quiet grade 1 or 2
• Loudness
• Systolic
• Timing • Located over left sternal border
• Location • Possibly radiate to left or right sternal border
• Radiation • Low-pitched
• Vibratory
• Pitch
• Decrease in intensity from supine to sitting position
A child routine physical exam, ejection systolic murmur with a vibratory
character, best heard in the lower sternal border towards the apex
What is the most likely diagnosis?

A.Still’s murmur
B.Venous hum
C.VSD
D.ASD
A child routine physical exam, ejection systolic murmur with a vibratory
character, best heard in the lower sternal border towards the apex
What is the most likely diagnosis?

A.Still’s murmur
B.Venous hum
C.VSD
D.ASD
A child routine physical exam, ejection systolic murmur with a vibratory character,
best heard in the lower sternal border towards the apex

Non-radiating Vibrating (or musical)

Early systolic ejection quality

Still’s murmur
Innocent murmur
Low intensity 1-2/6 Located at the left
Short duration lower sternal border
A child routine physical exam, ejection systolic murmur with a vibratory character,
best heard in the lower sternal border towards the apex

Non-radiating
Vibrating (or musical)
Early systolic ejection quality

Still’s murmur
Innocent murmur
Low intensity 1-2/6 Located at the left
Short duration lower sternal border
 Murmur
• Peripheral pulmonary artery stenosis of the newborn
• Murmur is related to the acute take-off angle of the branch pulmonary arteries in the
newborn

• Characteristics
• Systolic ejection murmur of low intensity

• Heard best at the left upper sternal border and radiates bilaterally to the axillae and back

• Louder in the axilla or back than anterior chest

• Split S2 of normal intensity

• Murmur disappears, usually in 3–6 months.

A 6-year-old with systolic-diastolic murmur, low-pitched sound, best
heard in the infraclavicular region, disappears when supine and with
gentle pressure on the jugular vein

A.Still’s murmur
B.Venous hum
C.VSD
D.ASD
A 6-year-old with systolic-diastolic murmur, low-pitched sound, best
heard in the infraclavicular region, disappears when supine and with
gentle pressure on the jugular vein

A.Still’s murmur
B.Venous hum
C.VSD
D.ASD
2-month-old infant, respiratory rate of 80 breaths/min, blood pressure of 90/60
mm Hg, heart rate of 170 beats/min, and an oxygen saturation of 90% on room air.

On physical examination, the infant has no stridor, wheezing, or other adventitious

sounds. Mild intercostal retractions are noted. His cardiac examination reveals a
regular rate and rhythm, with a 3/6 holosystolic murmur heard best at the left
midsternal border and throughout the precordium. The liver edge is palpable 4 cm
below the right costal margin.

What is the BEST next step in the management of this infant’s condition?
A. Lisinopril
B. Furosemide
C. Calcium channel blockers
D. Digitalis
2-month-old infant, respiratory rate of 80 breaths/min, blood pressure of 90/60
mm Hg, heart rate of 170 beats/min, and an oxygen saturation of 90% on room air.

On physical examination, the infant has no stridor, wheezing, or other adventitious

sounds. Mild intercostal retractions are noted. His cardiac examination reveals a
regular rate and rhythm, with a 3/6 holosystolic murmur heard best at the left
midsternal border and throughout the precordium. The liver edge is palpable 4 cm
below the right costal margin.

What is the BEST next step in the management of this infant’s condition?
A. Lisinopril
B. Furosemide
C. Calcium channel blockers
D. Digitalis
2-month-old infant, respiratory rate of 80 breaths/min, blood pressure of 90/60
mm Hg, heart rate of 170 beats/min, and an oxygen saturation of 90% on room air.

On physical examination, the infant has no stridor, wheezing, or other adventitious

sounds. Mild intercostal retractions are noted. His cardiac examination reveals a
regular rate and rhythm, with a 3/6 holosystolic murmur heard best at the left
midsternal border and throughout the precordium. The liver edge is palpable 4 cm
below the right costal margin.

The BEST next step in the management of this infant’s condition?

Furosemide to treat pulmonary edema
 Cyanotic CHD

Increased pulmonary vascularity Decreased pulmonary vascularity

• Tetralogy of Fallot
• Simple Transposition of great arteries • Tricuspid valve anomalies
• TAPVR • Tricuspid atresia
• Truncus arteriosus • Ebsteins anomaly
• Pulmonary atresia

Eisenmenger Syndrome
 CHD with R → L Shunt
Decreased pulmonary vascularity

Right Left
Chest radiograph of a neonate with
severe cyanosis shows cardiomegaly, but
clear lung fields and decreased
pulmonary vascular markings
 Clinical approach to a newborn with cyanosis

• Hyperoxia Test: Give 100% oxygen

• Non-cardiac
• Arterial PaO2 will increase to ≥ 100 mmHg on exposure to 100% oxygen →
Lung

• Cardiac
• Arterial PaO2 will remain below 100mmHg → Heart
Cyanotic Heart Defects
 2-month-old presents with cyanosis, poor feeding, and crying, palpable right
ventricular impulse, single 2nd heart sound, a harsh systolic ejection murmur is
heard over the pulmonic area on the left sternal border, EKG shows right axis
deviation, right ventricular hypertrophy, CXR shows boot-shaped heart, and
diminished pulmonary vascularity. What is the most likely diagnosis?

A.Tricuspid atresia
B.Transposition of great vessels
C. Tetralogy of Fallot
D.Aortic stenosis
 2-month-old presents with cyanosis, poor feeding, and crying, palpable right
ventricular impulse, single 2nd heart sound, a harsh systolic ejection murmur is
heard over the pulmonic area on the left sternal border, EKG shows right axis
deviation, right ventricular hypertrophy, CXR shows boot-shaped heart, and
diminished pulmonary vascularity. What is the most likely diagnosis?

A.Tricuspid atresia
B.Transposition of great vessels
C. Tetralogy of Fallot
D.Aortic stenosis
 Tetralogy of Fallot

• Perimembranous ventricular septal defect (VSD)

• Pulmonic stenosis
• Overriding aorta
• Right ventricular hypertrophy
A child with tetralogy of Fallot is crying, has
worsening cyanosis, progressive oxygen
desaturation, and tachypnea
What is best next step?

A.Knee chest position

B.Digitalis
C.Consult the pediatric cardiologist
D.Echocardiogram
A child with tetralogy of Fallot is crying, has
worsening cyanosis, progressive oxygen
desaturation, and tachypnea
What is best next step?

A.Knee Chest position

B.Digitalis
C.Consult the pediatric cardiologist
D.Echocardiogram
 Hypercyanotic spell

Best next step

1-Knee chest position

Tetralogy of Fallot
2- Administration of oxygen, with calming measures.
3-Placement of an intravenous line to give a fluid bolus.
4-Administration of morphine, either intramuscularly or subcutaneously
5-Sodium bicarbonate, phenylephrine, esmolol
 Tetralogy of Fallot
• Description
• RVOT obstruction, VSD, overriding aorta, and RVH

• Associated Syndrome
• 22q11.2 deletion (DiGeorge syndrome)

• Clinical Presentation
• Systolic ejection murmur at birth
• Cyanosis at birth if there’s severe RVOT obstruction
• Boot-shaped heart (cœur en
• Paroxysmal hypercyanotic attack (or “blue” or “tet” spell) sabot) due to upturned RV apex
• Older unrepaired children may squat to prevent a spell • Decreased pulmonary blood flow
 Tetralogy of Fallot
• Management
• Neonates with severe obstruction maintain on
prostaglandin E1 (PGE) infusion until intervention
• Surgical correction electively within the first year
of life
Boot-shaped heart (cœur en
sabot) due to upturned RV
apex
Decreased pulmonary blood
flow
 Tetralogy of Fallot
• Hypercyanotic spells
• Calming behavior (mother, pacifier, quiet room to decrease PVR)
• Knee-chest position, OR squatting if older child → increase SVR
• Oxygen → decrease PVR
• Fluid resuscitation → increase preload → increases SVR
• Morphine → decreases heart rate
• Sodium bicarbonate (to treat acidosis)
Boot-shaped heart (cœur en
• Phenylephrine → increases SVR sabot) due to upturned RV
apex
• Beta blockers e.g., esmolol or propranolol to decrease heart rate Decreased pulmonary blood
flow
and RVOT obstruction
High Yield Facts
 Prostaglandin E1

Cyanosis and increased Cyanosis and decreased pulmonary Cardiogenic shock, and metabolic
pulmonary vascular markings vascular markings acidosis

Severe form of tetralogy of

Fallot Hypoplastic left heart
Transposition of the great Critical pulmonary valve syndrome
vessels stenosis (PS) Coarctation of aorta
Pulmonary atresia with intact Interrupted aortic arch
ventricular septum
Ebstein anomaly
 Get Started

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