Paediatric cardiac and endocrine

Pediatric cardiac and endocrine items ask for the position that breaks a tet spell, the pulse check after cath, and whether a shaky school-age child needs juice or glucagon.

Congenital heart and catheterization

Cyanotic congenital lesions with right-to-left shunt (tetralogy of Fallot is the exam favorite) can dump desaturated blood into the aorta when pulmonary flow drops or systemic resistance falls. A hypercyanotic “tet” spell is that shunt widening in real time: the infant deepens blue, often with crying or agitation. Knee-chest raises systemic vascular resistance and reduces venous return to the right heart, which steers more blood toward the lungs. Calm the child, give oxygen, and escalate; the position is a physiology move, not a comfort pose.

The distractor that looks gentle is laying the spell infant flat “to rest” or starting a casual bottle while they are deep blue. Flat positioning can drop SVR relative to the right-sided obstruction and worsen the right-to-left dump. Treat the spell first; feeding waits until color and work of breathing improve.

Cardiac catheterization accesses a vessel; usually femoral; so the puncture can bleed or clot. After the sheath comes out, hold firm pressure as ordered, keep the limb still, and check the distal limb for color, warmth, capillary refill, and pulse. A wet dressing, expanding hematoma, or a cold pale foot with a weak or absent pulse is escalate-now, not “watch through the next snack.”

Coarctation of the aorta narrows the descending aorta, so upper-body flow is relatively preserved while lower-body flow is reduced. That is why arm blood pressures and pulses can read stronger than those in the legs. Finding that gradient is a report cue for evaluation; do not chalk weak femoral pulses up to “a fussy exam” when the arm-leg difference is clear.

Infant heart failure and Kawasaki

Infants with heart failure have limited cardiac reserve. Feeding is aerobic work for them, so poor intake, sweating with feeds, tachypnea, and failure to thrive are cardiac signs, not “picky eating.” Small, frequent feeds and calorie density as ordered reduce the workload per session; upright positioning after feeds can help respiratory effort. The bedside decision is protect calories without exhausting the pump.

• HF infants tire at the breast/bottle; small frequent feeds, calorie density as ordered, upright after.
• Digoxin: apical pulse first; hold for bradycardia per the pediatric order; teach toxicity cues (vomiting, bradycardia).
• Kawasaki: treat as ordered; watch for coronary complications in teaching and follow-up.

Digoxin slows conduction and strengthens contraction; in infants the safety gate is the apical heart rate before the dose. Hold for bradycardia using the pediatric parameter on the order; do not invent an adult hold number. Toxicity often announces with vomiting and progressive bradycardia; a “just give it, they’ll settle” distractor ignores that cue. Double-check the dose math; pediatric digoxin errors are classic high-alert traps.

Kawasaki disease is a medium-vessel vasculitis. Prolonged fever with mucocutaneous signs (strawberry tongue, rash, red cracked lips, extremity swelling or peeling) matters because coronary arteries can aneurysm. IVIG and aspirin as ordered are the exam treatment frame; the nursing watch is cardiac follow-up and recognizing that this is not ordinary viral fever reassurance. Skipping coronary teaching because the fever broke is the distractor that under-triages risk. Aspirin here is a specific ordered indication; it does not cancel Reye teaching for viral fever in otherwise well children (see Paediatric neurology).

Acute rheumatic fever is an immune follow-through after group A strep pharyngitis that was missed or undertreated. Jones-type findings on stems include carditis (new murmur, heart-failure signs), migratory arthritis, chorea, erythema marginatum, and subcutaneous nodules, plus evidence of prior strep. The valve, especially mitral, can scar for life; that is why secondary antibiotic prophylaxis as ordered is not optional paperwork. Bed rest during carditis, aspirin or anti-inflammatories as ordered, and treating the strep. Do not call chorea “behavioral” and send them home without a cardiac exam. Adult valvular maps sit in Acute coronary syndromes.

Diabetes, hypoglycemia, metabolic disorders

Pediatric hypoglycemia is a brain-glucose emergency with a simple airway gate. If the child is awake and can swallow, give about 15 g of fast-acting carbohydrate and recheck per protocol; juice, glucose tabs, or gel the child can take themselves. If they are unresponsive or seizing, the gut is not a safe route: protect the airway and give glucagon / activate emergency services per plan. Forcing juice into a limp mouth looks helpful and risks aspiration.

1. Recognize hypo: shakiness, sweat, hunger, confusion, behavior change.
2. If awake and able to swallow: fast-acting carbohydrate (~15 g), recheck per protocol.
3. If unresponsive or seizing: glucagon / emergency services; protect airway.
4. Sick days: continue insulin plan, check ketones, hydrate, call for persistent vomiting.

On sick days, illness raises stress hormones and can drive ketones even when the child is eating poorly. Stopping insulin “because they aren’t eating” is the classic wrong move; the plan usually continues basal or sick-day insulin while you check glucose and ketones, push fluids as tolerated, and call for persistent vomiting or rising ketones. The decision is monitor and adjust with a plan, not a holiday from insulin.

Phenylketonuria (PKU) is an enzyme block: phenylalanine builds up and injures the developing brain if the diet is not controlled. Lifelong low-phenylalanine intake with special formula is the teaching core; not a toddler phase that ends at school age. Congenital hypothyroidism lacks thyroid hormone needed for growth and neurodevelopment; daily replacement started early protects that trajectory. Both disorders are “start early, stay consistent”; delaying treatment while waiting for symptoms is the distractor that costs development.

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