THE PEDIATRICS CLERKSHIP - PART 5 ppt

CYSTIC FIBROSIS (CF) DEFINITION Disease of exocrine glands that causes viscous secretions: Ⅲ Chronic respiratory infection Ⅲ Pancreatic insufficiency Ⅲ Increased electrolytes in sweat E TIOLOGY Ⅲ Defect of cyclic adenosine monophosphate (cAMP)-activated chloride channel of epithelial cells in pancreas, sweat glands, salivary glands, in- testines, respiratory tract, and reproductive system Ⅲ Autosomal recessive P ATHOPHYSIOLOGY Ⅲ Chloride does not exit from cells. Ⅲ Increased osmotic pressure inside cells attracts water and leads to thick secretions. E PIDEMIOLOGY Most common cause of severe, chronic lung disease in children. S IGNS AND SYMPTOMS Ⅲ Respiratory: Ⅲ Cough—most common pulmonary symptom Ⅲ Wheezing, dyspnea, exercise intolerance Ⅲ Bronchiectasis, recurrent pneumonia Ⅲ Sinusitis, nasal polyps Ⅲ Reactive airway disease, hemoptysis Ⅲ Increased AP chest diameter Ⅲ Hyperresonant lungs Ⅲ Clubbing of nails Ⅲ Gastrointestinal (GI): Ⅲ Failure to thrive Ⅲ Meconium ileus (10%) Ⅲ Constipation, rectal prolapse Ⅲ Intestinal obstruction Ⅲ Pancreatic insufficiency: Ⅲ Malabsorption Ⅲ Fat-soluble vitamin deficiencies Ⅲ Glucose intolerance Ⅲ Biliary cirrhosis (uncommon): jaundice, ascites, hematemesis from esophageal varices Ⅲ Reproductive tract: decreased/absent fertility—female, thick cervical secretions; male azoospermic Ⅲ Sweat glands: Ⅲ Salty skin Ⅲ Hypochloremic alkalosis in severe cases Ⅲ Complications may include pneumothorax, chronic pulmonary hyper- tension, cor pulmonale, atelectasis, allergic bronchopulmonary as- pergillosis, respiratory failure, GE reflux. D IAGNOSIS Ⅲ Sweat test—chloride concentration > 60 mEq/L. Ⅲ Hypoelectrolytemia with metabolic alkalosis. Ⅲ Chest x-ray—blebs. 170 HIGH-YIELD FACTSRespiratory Disease Cystic fibrosis is the most common lethal inherited disease of Caucasians. The gene for cystic fibrosis is CFTR; the mutation is delta F508. A patient with severe CF breathing room air can have an arterial blood gas (ABG) showing decreased chloride and increased bicarbonate. A 3-year-old has had six episodes of pneumonia, with Pseudomonas being isolated from sputum; loose stools; and is at the 20th percentile for growth. Think: CF. Typical Scenario False-positive sweat test (not CF): Ⅲ Nephrogenic diabetes insipidus Ⅲ Myxedema Ⅲ Mucopolysaccharidosis Ⅲ Adrenal insufficiency Ⅲ Ectodermal dysplasia Ⅲ Pulmonary function tests (PFTs)—obstructive and restrictive abnormal- ities. Ⅲ Prenatal diagnosis via gene proves CF mutations or linkage analysis. T REATMENT Ⅲ Multidisciplinary team approach—pediatrician, physiotherapist, dietit- ian, nursing staff, teacher, child, and parents Ⅲ Respiratory: Ⅲ Chest physical therapy Ⅲ Exercise Ⅲ Coughing to move secretions and mucous plugs Ⅲ Bronchodilators Ⅲ Normal saline aerosol Ⅲ Anti-inflammatory medications Ⅲ Dornase-alpha nebulizer (breaks down DNA in mucus) Ⅲ Pancreatic/digestive: Ⅲ Enteric coated pancreatic enzyme supplements (add to all meals) Ⅲ Fat-soluble vitamin supplements Ⅲ High-calorie, high-protein diet Ⅲ Antibiotics—tobramycin with cephalosporin or penicillin for bacterial infections. Pseudomonal infections are especially common. Ⅲ Lung transplant Ⅲ Gene therapy being aggressively studied P ROGNOSIS Ⅲ Advances in therapy have increased life expectancy into adulthood. TONSILS/ADENOIDS Tonsillitis/Adenoiditis D EFINITION Inflammation of: Ⅲ Tonsils—two faucial tonsils Ⅲ Adenoids—nasopharyngeal tonsils S IGNS AND SYMPTOMS Ⅲ Sore throat Ⅲ Pain with swallowing Ⅲ May have whitish exudate on tonsils Ⅲ Chronic tonsillitis: Ⅲ Seven in past year Ⅲ Five in each of the past 2 years Ⅲ Three in each of the past 3 years T REATMENT Ⅲ Less than 2 to 3 years old: Tonsillectomy is performed for obstructive sleep symptoms. Ⅲ Large size alone is not an indication to remove tonsils. Enlarged Adenoids D EFINITION Nasopharyngeal lymphoid tissue. S IGNS AND SYMPTOMS Ⅲ Mouth breathing Ⅲ Persistent rhinitis Ⅲ Snoring 171 HIGH-YIELD FACTS Respiratory Disease Features of CF: CF PANCREAS Ⅲ Chronic cough Ⅲ Failure to thrive Ⅲ Pancreatic insufficiency Ⅲ Alkalosis Ⅲ Nasal polyps Ⅲ Clubbing Ⅲ Rectal prolapse Ⅲ Electrolytes increased in sweat Ⅲ Absence of vas Ⅲ Sputum mucoid Ninety-nine percent of cases of meconium ileus are due to CF. Fat-soluble vitamin deficiencies: A—night blindness D—decreased bone density E—neurologic dysfunction K—bleeding DIAGNOSIS Ⅲ Digital palpation Ⅲ Indirect laryngoscopy T REATMENT Ⅲ Adenoidectomy: Ⅲ Persistent mouth breathing Ⅲ Hyponasal speech Ⅲ Adenoid facies Ⅲ Recurrent otitis media or nasopharyngitis Ⅲ Tonsillectomy should not be performed routinely unless separate indica- tion exists. Peritonsillar Abscess D EFINITION Walled-off infection occurring in the space between the superior pharyngeal constrictor muscle and tonsils. E TIOLOGY Ⅲ GABHS Ⅲ Anaerobes E PIDEMIOLOGY Usually preadolescent. S IGNS AND SYMPTOMS Ⅲ Preceded by acute tonsillopharyngitis Ⅲ Severe throat pain Ⅲ Trismus Ⅲ Refusal to swallow or speak Ⅲ “Hot potato voice” Ⅲ Markedly swollen and inflamed tonsils Ⅲ Uvula displaced to opposite side T REATMENT Ⅲ Antibiotics (penicillin) Ⅲ Incision and drainage 172 HIGH-YIELD FACTSRespiratory Disease Tonsils and adenoids are part of Waldeyer’s ring that circles the pharynx. It can be normal for tonsils to be relatively large during childhood. Trismus is limited opening of the mouth. FIGURE 12-6. Lateral radiograph of the soft tissue of the neck. Note the large amount of pre- vertebral edema (solid arrow) and the collection of air (dashed arrow). Findings are consis- tent with retropharyngeal abscess. (Photo courtesy of Dr. Gregory J. Schears.) RETROPHARYNGEAL ABSCESS DEFINITION Potential space between the posterior pharyngeal wall and the prevertebral fascia. E TIOLOGY Usually a complication of pharyngitis: Ⅲ GABHS Ⅲ Oral anaerobes Ⅲ S. aureus S IGNS AND SYMPTOMS Ⅲ Sudden onset of high fever with difficulty in swallowing Ⅲ Refusal of feeding Ⅲ Throat pain Ⅲ Hyperextension of the head Ⅲ Toxicity is common Ⅲ May cause meningismus D IAGNOSIS Lateral neck x-ray: normal retropharyngeal space should be less than one half of width of adjacent vertebra (see Figure 12–6). T REATMENT Ⅲ Clindamycin or Ampicillin–sulbactam ASTHMA DEFINITION Reversible airway obstruction characterized by airway narrowing. E TIOLOGY Hyperresponsiveness to a variety of stimuli: Ⅲ Respiratory infection Ⅲ Air pollutants Ⅲ Allergens Ⅲ Foods Ⅲ Exercise Ⅲ Emotions P ATHOPHYSIOLOGY Ⅲ Bronchospasm (acute) Ⅲ Mucus production (acute) Ⅲ Inflammation and edema of the airway mucosa (chronic) Ⅲ Two types: Ⅲ Extrinsic Ⅲ Immunologically mediated Ⅲ Develop in childhood Ⅲ Intrinsic Ⅲ No identifiable cause Ⅲ Late onset Ⅲ Worsen with age Ⅲ Underlying abnormalities in asthma include increased pulmonary vas- cular pressure, diffuse narrowing of airways, increased residual volume 173 HIGH-YIELD FACTS Respiratory Disease Usually lymph nodes in the retropharyngeal space disappear by third to fourth year of life. Asthma is the most common chronic lung disease in children. Asthma is the most common cause of cough in school-age children. The most important risk factor for development of asthma is the combination of RSV-related bronchiolitis and a genetic predisposition for atopic disease. and functional residual capacity, and increased total ventilation main- taining normal or reduced P CO 2 despite increased dead space. S IGNS AND SYMPTOMS Ⅲ Cough, wheezing, dyspnea. Ⅲ Increased work of breathing (retractions, use of accessory muscles, nasal flaring, abdominal breathing). Ⅲ Decreased breath sounds. Ⅲ Prolongation of expiratory phase. Ⅲ Acidosis and hypoxia may result from airway obstruction. Ⅲ See Table 12-4 for classification of severity. D IAGNOSIS Ⅲ Clinical diagnosis, usually. Ⅲ Peak expiratory flow rate (PEFR): Ⅲ Maximal rate of airflow during forced exhalation after a maximal in- halation Ⅲ Normal values depend on age and height: Ⅲ Mild (80% of predicted) Ⅲ Moderate (50–80% of predicted) Ⅲ Severe (< 50% of predicted) Ⅲ Chest x-ray will demonstrate hyperinflation and can be useful to look for pneumonia. Ⅲ Pulse oximetry may demonstrate hypoxia. Ⅲ Fever and focal lung exam—think pneumonia. Ⅲ Unresponsive to usual URI therapy. Ⅲ Complete blood count (CBC)—eosinophilia > 250 to 400 cells/mm 3 . Ⅲ ABG—hypoxia Ⅲ Bloodwork should not be routinely ordered in the evaluation of asthma. 174 HIGH-YIELD FACTSRespiratory Disease Classic trilogy of asthma: Ⅲ Bronchospasm Ⅲ Mucus production Ⅲ Inflammation and edema of the airway mucosa Respiratory drive is not inhibited in asthma. All wheezing is not caused by asthma; all asthmatics do not wheeze. TABLE 12-4. Asthma severity classification. Step Symptoms Pulmonary Function Tests (PFTs) 1—Mild intermittent Ⅲ Up to 2×/week Ⅲ PEFR variability not more than 20% Ⅲ Asymptomatic, normal PFTs between exacerbations Ⅲ PEFR or FEV 1 at least 80% predicted 2—Mild persistent Ⅲ > 2×/week, but < 1×/day Ⅲ PEFR variability 20–30% Ⅲ Exacerbations may affect activity Ⅲ PEFR or FEV 1 at least 80% predicted 3—Moderate persistent Ⅲ Daily symptoms Ⅲ PEFR variability > 30% Ⅲ Daily use of inhaled short acting β 2 agonist Ⅲ PEFR or FEV 1 60–80% predicted Ⅲ Exacerbations affect activity Ⅲ Exacerbations may last days and occur ≥ 2×/week 4—Severe persistent Ⅲ Continual symptoms Ⅲ PEFR or FEV 1 < 60% predicted Ⅲ Limited physical activity Ⅲ PEFR variability > 30% Ⅲ Frequent exacerbations PEFR, peak expiratory flow rate; FEV 1 , forced expiratory volume in one second. Reproduced from NHLBI guidelines, publication 97-4051, 1997. TREATMENT Goals: Improve bronchodilation, avoid allergens, decrease inflammation, edu- cate patient. First-Line Agents 1. Oxygen 2. Inhaled β 2 agonist Ⅲ Albuterol (2.5 mg) (nebulized) Ⅲ Short-acting/rescue medication—treats only symptoms, not underly- ing process Ⅲ Bronchial smooth muscle relaxant Ⅲ Side effects: tachycardia, tremors, hypokalemia 3. Corticosteroids (sooner is better) Ⅲ For treatment of chronic inflammation Ⅲ Oral prednisone (2 mg/kg, max 60 mg) or Ⅲ IV methylprednisolone 2 mg/kg max 125 mg) Ⅲ Contraindication: active varicella or herpes infection 4. Anticholinergic agents Ⅲ Ipratropium bromide (nebulized) Ⅲ Act synergistically with albuterol Ⅲ Bind to cholinergic receptors in the medium and large airways Second-Line Agents 1. Magnesium sulfate—bronchodilation via direct effect on smooth mus- cle 2. Epinephrine or terbutaline 3. No role in acute asthma for theophylline; not recommended Others 1. Heliox—mixture of 60–70% helium and 30–40% oxygen Ⅲ Decreases work of breathing by improving laminar gas flow (nonin- tubated patient) Ⅲ Improves oxygenation and decreases peak airway pressure (intubated patients) 2. Mechanical ventilation indications: Ⅲ Failure of maximal pharmacologic therapy Ⅲ Hypoxemia Ⅲ Hypercarbia Ⅲ Change in mental status Ⅲ Respiratory fatigue Ⅲ Respiratory failure 3. Leukotriene modifiers Ⅲ Inflammatory mediators Ⅲ Improve lung function Ⅲ No role in acute asthma 4. Cromolyn and nedocromil Ⅲ Effective in maintenance therapy Ⅲ Exercise-induced asthma Ⅲ May reduce dosage requirements of inhaled steroid Admit if: Ⅲ Respiratory failure requiring intubation Ⅲ Status asthmaticus Ⅲ Return ED visit in 24 hours Ⅲ Complete lobar atelectasis 175 HIGH-YIELD FACTS Respiratory Disease Asthmatic patient in severe respiratory distress may not wheeze. Spirometry is the most important study in asthma. A 5-year-old boy with a history of sleeping problems presents with a nonproductive nocturnal cough and shortness of breath and cough during exercise. Think: Asthma, and start on a trial of a bronchodilator. Typical Scenario O 2 is indicated for all asthmatics to keep O 2 saturation > 95%. Long-acting β 2 agonist (salmeterol) should not be used for acute asthma exacerbation. Ⅲ Pneumothorax/pneumomediastinum Ⅲ Underlying cardiopulmonary disease Status Asthmaticus D EFINITION Ⅲ Life-threatening form of asthma Ⅲ Condition in which a progressively worsening attack is unresponsive to usual therapy S IGNS AND SYMPTOMS Look for: Ⅲ Pulsus paradoxus > 20 mm Hg Ⅲ Hypotension, tachycardia Ⅲ Cyanosis Ⅲ One- to two-word dyspnea Ⅲ Lethargy Ⅲ Agitation Ⅲ Retractions Ⅲ Silent chest (no wheezes—poor air exchange) FOREIGN BODY ASPIRATION PATHOPHYSIOLOGY Cough reflex usually protects against aspiration. E PIDEMIOLOGY Twice as likely to occur in males, particularly 6-month-olds to 3-year-olds. S IGNS AND SYMPTOMS Ⅲ Determined by nature of object, location, and degree of obstruction. Ⅲ Initial respiratory symptoms may disappear for hours to weeks after inci- dent. Ⅲ Vegetal/arachidic bronchitis due to vegetable (usually peanut) aspira- tion causes cough, high fever, and dyspnea. Ⅲ Complications if object is not removed include pneumonitis/pneumo- nia, abscess, bronchiectasis, pulmonary hemorrhage, erosion, and perfo- ration. D IAGNOSIS/TREATMENT Larynx Ⅲ Croupy cough, may have wheezing, aphonia, hemoptysis, cyanosis Ⅲ Lateral x-ray Ⅲ Direct laryngoscopy—confirm diagnosis and remove object Trachea Ⅲ Wheezing, audible slap and palpable thud due to expiratory impaction Ⅲ Chest x-ray (see Figure 12-7), bronchoscopy Bronchi Ⅲ Initial choking, gagging, wheezing, coughing Ⅲ Latent period with some coughing, wheezing, possible hemoptysis, re- current lobar pneumonia, or intractable asthma Ⅲ Tracheal shift, decreased breath sounds Ⅲ Midline obstruction can cause severe dyspnea or asphyxia Ⅲ Leads to chronic bronchopulmonary disease if not treated 176 HIGH-YIELD FACTSRespiratory Disease Nedocromil is not Food and Drug Administration (FDA) approved for children under 12 years of age. Most important risk factor for morbidity is failure to diagnose asthma from recurrent wheezing. Increased white blood cell (WBC) count does not always signify infection in status asthmaticus. A young patient being treated as an inpatient for asthma exacerbation is anxious, has a flushed face, and is vomiting repeatedly. Think: Aminophylline toxicity. Typical Scenario Asthmatic child’s ability to use inhaler correctly should be regularly assessed. Ⅲ Direct bronchoscopic visualization (Figure 12-8) Ⅲ Lobectomy if vegetal foreign body for extended period of time Ⅲ Antibiotics for secondary infection Ⅲ Emergency treatment of local upper airway obstruction if necessary TRACHEOESOPHAGEAL FISTULA (TEF) DEFINITION Connection between the trachea and esophagus (see Figure 12-9). E TIOLOGY Ⅲ Congenital Ⅲ Acquired S IGNS AND SYMPTOMS Ⅲ Suspect esophageal atresia Ⅲ Maternal polyhydramnios Ⅲ Inability to pass catheter into stomach Ⅲ Increased oral secretions—drooling Ⅲ Choking, cyanosis, or coughing with an attempt to feed Ⅲ Tachypnea D IAGNOSIS Ⅲ X-ray: Radiopaque feeding tube passes no further than proximal esopha- gus. Ⅲ Barium swallow: Aspiration of barium into the tracheobronchial tree. T REATMENT Esophageal atresia is a surgical emergency. TRACHEOMALACIA/LARYNGOMALACIA DEFINITION Ⅲ Floppy epiglottis and supraglottic aperture Ⅲ Disproportionately small and soft larynx S IGNS AND SYMPTOMS Ⅲ Usually begins within first month Ⅲ Noisy breathing Ⅲ Stridor 177 HIGH-YIELD FACTS Respiratory Disease FIGURE 12-7. Radiograph of lateral soft tissue of the neck demonstrates a foreign body (nail) in the pharynx. (Photo courtesy of Dr. Gregory J. Schears.) Dehydration may be present in status asthmaticus, but overhydration should be avoided (risk for syndrome of inappropriate antidiuretic hormone secretion [SIADH]). Prevention is key! Keep small food and objects away from young children. Foreign Body Aspiration Ⅲ Toddlers: R = L mainstem Ⅲ Adults: R mainstem predominates Percussion of lung fields: Ⅲ Hyperresonant = overinflation Ⅲ Dull = atelectasis A 2-year-old boy is brought to the ED with the acute onset of audible wheezing. His respiratory rate is 24, and he has mild intercostal retractions. His babysitter found him playing in his room. Think: Foreign body aspiration. Typical Scenario Ⅲ Hoarseness or aphonia (laryngeal crow) Ⅲ Feeding difficulty Ⅲ Symptoms worse when crying or lying on back D IAGNOSIS Ⅲ Direct laryngoscopy Ⅲ Collapse of laryngeal structures during inspiration especially arytenoid cartilages T REATMENT Ⅲ Reassurance Ⅲ No specific therapy required Ⅲ Usually resolves spontaneously by 18 months CONGENITAL LOBAR EMPHYSEMA (INFANTILE LOBAR EMPHYSEMA) DEFINITION Overexpansion of the airspaces of a segment or lobe of the lung. P ATHOPHYSIOLOGY No significant parenchymal destruction. 178 HIGH-YIELD FACTSRespiratory Disease FIGURE 12-8. Foreign body (peanut) in the right mainstem bronchus visualized by bron- choscopy. Foreign bodies tend to lodge most commonly in the right mainstem bronchus due to the larger anatomic angle that makes traveling down right mainstem easier. (Photo cour- tesy of Dr. Gregory J. Schears.) FIGURE 12-9. Types of tracheoesophageal fistulas (TEFs). Type A, esophageal atresia (EA) with distal TEF (87%). Type B, iso- lated EA. Type C, isolated TEF. Type D, EA with proximal TEF. Type E, EA with double TEF. A previously healthy 12- year-old boy develops pneumonia with consolidation of the right lower lobe on three different occasions in 6 months. Think: Aspiration of a foreign body. Typical Scenario There is an association of tracheoesophageal fistulae with esophageal atresia. H-type tracheoesophageal fistula is the least common but the most likely to be seen in ED. SIGNS AND SYMPTOMS Ⅲ Normal at birth Ⅲ Cough, wheezing, dyspnea, and cyanosis within a few days D IAGNOSIS Ⅲ Chest x-ray Ⅲ Radiolucency Ⅲ Mediastinal shift to opposite side Ⅲ Flattened diaphragm T REATMENT Ⅲ Remove bronchial obstruction (foreign bodies, mucous plug) Ⅲ Lobectomy CYSTIC ADENOMATOID MALFORMATION DEFINITION Ⅲ Excessive overgrowth of bronchioles Ⅲ Increase in terminal respiratory structure S IGNS AND SYMPTOMS Ⅲ Neonatal respiratory distress Ⅲ Recurrent respiratory infection Ⅲ Pneumothorax D IAGNOSIS Ⅲ Chest x-ray (posteroanterior [PA], lateral, and decubitus) Ⅲ Cystic mass (multiple grape-like sacs) and mediastinal shift Ⅲ Air–fluid level Ⅲ CT scan T REATMENT Surgical excision of affected lobe. 179 HIGH-YIELD FACTS Respiratory Disease Laryngomalacia is the most frequent cause of stridor in infants. Symptoms of laryngomalacia can be intermittent. Congenital lobar emphysema is the most common congenital lung lesion. Cystic adenomatoid malformation is the second most common congenital lung lesion. Cystic adenomatoid malformation may be confused with diaphragmatic hernia in neonatal period. [...]... bottom right: these parasternal short-axis (P S Ax) views taken from the same normal subject are sequential scans through the heart from the top to the bottom (from the cranial-to-caudal direction) The top frame represents a short-axis view of the entire right heart In the center, the aortic valve (AO) cusps are seen in their open position, demonstrating a trileaflet aortic valve Posteriorly, the left atrium... view from the third intercostal space The sector subtends the right side of the heart as it winds around the aortic root (AO) in the center of image The right atrium (RA) is separated from the right ventricle (RV) by the tricuspid valve The pulmonary artery (PA) is separated from the right ventricle by the pulmonary valve The cusps of the aortic valve can also be identified in this figure The pulmonary... (LA), with the left atrial appendage (LAA) extending to the left side of the heart, are observed The interatrial septum separates the left atrium from the right atrium (RA) The tricuspid valve separates the right atrium from the right ventricle (RV) In the bottom frame with the caudal scan, the right (RV) and left (LV) ventricles are seen The ventricular septum is seen between the two ventricles The mitral... in its open position with the anterior cusp (arrow) at the top and the posterior cusp (arrow) at the bottom B This is a series of apical four-chamber views (A 4 Ch) from a normal subject, demonstrating the scan from the anterior to the posterior aspect of the heart (from the apex to base) The electrocardiogram shown on the bottom indicates the timing within the cardiac cycle The top frame is taken in... the crux of the heart The other labels are as for the previous panels The fourth frame shows the aortic arch from the suprasternal notch sagittal view (SSN, SAG) in a normal infant The scan comes from the suprasternal notch area, and the sector subtends the innominate vein (IV) superiorly, as it crosses in front of the ascending aorta (AAO) The whole arch is seen from the ascending aorta to the descending... entering the left atrium (LA) The right atrium (RA) is separated from the left atrium (LA) by the faint echo of the interatrial septum The aortic root (AO) can be seen to be arising out of the heart, and the left and right ventricles (LV, RV) can be seen separated from their respective atria by the tricuspid and mitral valves in the closed position, and from each other by the ventricular septum The second... (LV), and the left ventricular posterior wall Behind the ascending aortic root is the left atrium (LA) Posterior to the heart behind the pericardium, the descending aorta (DAO) can be seen running in its cross-section, indicating how far from the sagittal body plane this image is as the descending aorta runs on the left of the spine Bottom left: from the same normal subject in the parasternal short-axis... demonstrate the exit of the aorta (AO) and the pulmonary artery (PA) from their respective ventricles, the left ventricle (LV) and the right ventricle (RV) In the upper left panel, the aorta (AO) can be seen arising from the left ventricle (LV) and arching toward the left side over the main pulmonary artery (PA) In the bottom left panel, taken with an orthogonal view and more anterior angulation, the right-sided... demonstrates the descending aorta in cross-section, the pulmonary veins (PV) from the left and the right (arrows), the atria, and the ventricles This is an end-systolic frame, as seen from the electrocardiogram The third frame, taken with most caudal scanning, demonstrates the descending aorta (DAO) posteriorly, and a small portion of the left atrium (LA) with a coronary sinus (CS) running inferiorly at the. .. Define the rhythm (sinus, or other) 3 Measure the P-R interval, QRS duration, and Q-T interval 4 Measure the axes of the P waves, QRS complexes, and T waves 5 Look for abnormalities of wave patterns and voltages Cardiology consultation is indicated with any “noninnocent” murmur Rate Age-dependent—see Table 1 3-3 ECG PAPER Ⅲ Speed = 25 mm/s Ⅲ Small box = 0.04 sec = 1 mm Ⅲ Large box = 0.20 sec = 5 mm ATRIAL . ventricular rates. 2. Define the rhythm (sinus, or other). 3. Measure the P-R interval, QRS duration, and Q-T interval. 4. Measure the axes of the P waves, QRS complexes, and T waves. 5. Look for abnormalities. cross-sectional views taken of the heart with transtho- racic echocardiography: Ⅲ The parasternal (long and short axis) view Ⅲ The apical view Ⅲ The subcostal view (taken in the midline below the. above the baseline by the number of boxes (mm) and subtract all forces below baseline. If the total is +[+], the axis range is between ++90° and −90°. Ⅲ Do the same in aVF. If the total is +[+], the