Congenital Heart Defects

Acyanotic vs. cyanotic, and what the nurse watches for

Pediatrics

Acyanotic (left-to-right shunt or obstruction)

VSD	Most common CHD. Loud holosystolic murmur; may close on its own; large ones cause HF
ASD	Often silent in childhood; soft murmur
PDA	"Machinery" murmur, bounding pulses; common in preterm infants
Coarctation of aorta	High BP and bounding pulses in the arms; weak or absent femoral pulses; low BP in the legs
Aortic / pulmonary stenosis	Murmur; exercise intolerance; HF if severe

ASD, VSD and PDA are acyanotic: extra blood goes to the lungs (risk of heart failure), not blue blood to the body.

Cyanotic (deoxygenated blood reaches the body)

Tetralogy of Fallot	Pulmonary stenosis, VSD, overriding aorta, right ventricular hypertrophy. "Tet spells"
Transposition of great arteries	Severe cyanosis at birth; needs a mixing site (PDA/ASD); arterial switch surgery
Tricuspid atresia	Cyanosis; staged surgery
Truncus arteriosus	Single great vessel; cyanosis and HF
Hypoplastic left heart	Underdeveloped left side; duct-dependent; staged surgery (Norwood, Glenn, Fontan)

Tet spell (hypercyanotic episode)

Knee-chest position (older children squat): ↑ systemic resistance, more blood to the lungs.
Keep calm; parent holds the child.
Oxygen.
Morphine, IV fluids, and other drugs as ordered.

Duct medicines

To close a PDA (preterm): indomethacin, ibuprofen, or acetaminophen.
To keep it open in duct-dependent defects: prostaglandin E1 (alprostadil) infusion. Watch for apnea, fever, flushing, low BP.

Heart failure in infants

Tachypnea and sweating during feeds, poor feeding, poor weight gain, tachycardia, hepatomegaly, irritability. (Peripheral edema is less common than in adults.)
Small frequent feeds; higher-calorie formula or fortified breast milk; tube feeds if tiring; rest; daily weight.
Digoxin: count the apical pulse for 1 full minute; hold and notify per parameters (commonly infant <90–110, child <70); vomiting or poor feeding can be early toxicity. Furosemide: watch K⁺.

Kawasaki disease (acquired)

Fever ≥5 days + features: red eyes without discharge, red cracked lips and "strawberry tongue", rash, swollen hands and feet then peeling, a large neck lymph node.
Danger: coronary artery aneurysms (echocardiograms).
Treatment: IVIG + aspirin (one of the few times aspirin is used in children).
Delay live vaccines (MMR, varicella) ~11 months after IVIG. Report flu or chickenpox exposure while on aspirin (Reye's syndrome).

Memory hook Cyanotic defects start with T: Tetralogy, Transposition, Tricuspid atresia, Truncus, Total anomalous pulmonary venous return. The most common congenital birth defect overall is a heart defect (about 1 in 100 births).