Pediatric Murmurs Flashcards
Changes in circulation at birth
Foramen ovale closes
Ductus arteriosus closes—> forms ligamentum arteriosum
Ductus venosus closes —> forms ligamentum venosum
Umbilical vein becomes ligamentum teres
In pediatrics, who should receive a complete cardiac exam?
Any child who has a heart murmur
Any child who has historical features suggestive of cardiac disease or abnormal cardiac function
Infants with: feeding intolerance (sweating, head-bobbing), failure to thrive, respiratory symptoms, cyanosis
Older children with: chest pain, syncope, exercise intolerance, FAMILY HISTORY OF SUDDEN DEATH IN YOUNG PEOPLE
6 components of documenting a murmur
Grade (1-6, grade 4 = thrill)
Timing (early, middle, late, holosystolic)
Location of highest intensity
Character (harsh, whooping, blowing, etc.)
Changes with position
Radiation
What are you checking for on an exam of the precordium?
Increased precordial activity
THRILL — caused by blood flowing from high pressure to lower pressure; must be designated as grade IV murmur and above! — needs cardiology eval
The later closing of the tricuspid valve and pulmonic valve can occur during inspiration because of increased filling of the right side of the heart. Split S1 is usually normal (in 40-70% of individuals).
A split S2 with inspiration is normal, but a FIXED SPLIT S2 is indicative of _______________
Atrial septal defect (ASD)
[constant overfilling of the right ventricle due to the left to right shunt with subsequent delayed closure of the pulmonic valve]
In VSD, S1 and S2 are obscured, it is called a ______ murmur
Holosystolic
A _____ murmur is usually lower pitched, rumbling, and NEVER NORMAL ON ITS OWN
Diastolic
The only sound in diastole that does not warrant a referral to cardiology
Venous hum (this is a functional/innocent murmur caused by flow of venous blood from the head and neck into the thorax, heard continuously while the child is sitting and should disappear when pressure is placed on jugular vein, when childs head is turned, when child is supine)
Most pathologic murmurs do not change significantly with standing. What is the exception?
Hypertrophic cardiomyopathy — harsh crescendo-decrescendo systolic murmur heard best at the apex and left sternal border
Increases in intensity when patient stands
Increases in intensity with valsalva
[essentially a left ventricular outflow tract obstruction; rare but one of the leading causes of death in athletes; also called idiopathic hypertrophic subaortic stenosis (IHSS)]
The 7 S’s of innocent murmurs
Sensitive (changes with position or respiration)
Short duration (not holosystolic)
Single (no associated clicks or gallops)
Small (murmur limited to small area and nonradiating)
Soft (low amplitude)
Sweet (not harsh sounding)
Systolic (occurs during and is limited to systole)
What are some PE findings that warrant referral to a cardiologist?
Grade 4 murmur or above Diastolic murmur Increased intensity on standing Symptomatic murmur Obscured heart sounds Weak femoral pulses Clicks Hyperactive precordium FamHx of sudden death at young age Abnormal or extra heart sounds (except S3 in kids) Predisposing conditions (congenital or prenatal)
Innocent murmur best heart at apex of heart and LL sternal border; best heard with bell of stethoscope
Still’s murmur
18/10,000 infants are born with Critical Congenital Heart Disease (CCHD); this can be diagnosed in the nursery using O2 saturation.
What lesions do we look for?
Hypoplastic left heart syndrome Pulmonary atresia Tetralogy of fallot Total anomalous venous return Transposition of great arteries Tricuspid atresia Truncus arteriosus
[other critical CHDs — coarctation of aorta, double outlet right ventricle, ebstein anomaly, single ventricle]
If you have a patient with _______, get a cardiology referral even if you don’t hear a murmur, because they have a high incidence of ASD. The study of choice is ____________
Trisomy 21; echocardiogram with doppler
