Pulse rate and volume; BP; Femoral pulses present? Any radio-femoral delay? Peripheral
Location apex beat. Heart sounds/ murmur
Respiratory rate and effort; added sounds on auscultation
Hepatomegaly and peripheral oedema
Bulging chest (usually the left hemithorax; mainly older children)
- polycythaemia may indicate longstanding cyanosis
Echocardiogram - if structural heart disease suspected
- if structural heart disease suspected
- useful in selected cases, if available
Hyperoxia test- - for cyanotic newborns- give 100% O2: if baby remains
blue or oxygen saturations fail to rise more than 10%, suggests CHD
Indications for admission
Cyanosis - in general any child with acute cyanosis must be admitted.(Exception if child has longstanding cyanosis and already been investigated)
Any evidence of acute cardiac failure or cardiovascular collapse.
An otherwise well child with a heart murmur may be referred to cardiac clinic.
NOTES FOR SPECIFIC SUBSETS OF CONGENITAL HEART DISEASE:
(a) Cyanotic congenital heart disease presenting as cyanosis in the newborn
Cyanosed term infant who does not pink-up with oxygen. He/she may or may not have other cardiac signs such as a cardiac murmur, and may appear otherwise well.
Examples of defects
Transposition of the great arteries, Pulmonary atresia, Tetralogy of Fallot, Tricuspid atresia, Ebsteins anomaly
Note: Cyanotic congenital heart disease may be difficult to distinguish from persistent pulmonary hypertension of the newborn (PPHN) due to persistent foetal circulation.
Suspect PPHN if there has been foetal distress, the need for resuscitation at birth, or neurological signs of birth asphyxia.
Investigate with chest X-ray and/or echocardiogram.
Parental counselling re: condition and prognosis (generally poor in Malawi)
Rx PPHN with oxygen, minimal handling, consider iv Magnesium infusion
Baby presents in shock/ state of collapse in the first 2 weeks after patent ductus shuts.
These babies are difficult to distinguish clinically from those with collapse from other causes eg. sepsis/ inborn errors of metabolism.
Prostaglandins to maintain the patency of the ductus arteriosus as a temporary measure are not available. The surgery that would be required following this is also unavailable in Malawi.
Treat for septic shock - correct hypoglycaemia and hypothermia until cardiac diagnosis established
If there is a clear deterioration with administration of oxygen, stop it.
Consider furosemide if clear signs of cardiac failure present (see chapter cardiac failure).
Counsel the parents
(c) Cyanotic congenital heart disease presenting as cyanosis in the older child
Usually Tetralogy of Fallot, associated with hypercyanotic spells.
Characteristic squatting behaviour relieves cyanosis and breathlessness during spell
Management of spell
Place the child in knee-chest position (or encourage squatting in older child)
Give i.v. or i.m. morphine 0.1mg/kg and p.o. propranolol 0.5mg/kg STAT
Give maintanance fluids to increase venous fill
Long-term Management of TOF
Propranolol 1mg/kg BD to prevent spells
Aspirin if polycythemic
Suitable for referral to South Africa if available (discuss with consultant cardiac clinic)