Module 5: (a) Pediatric Murmurs

Question 1

Murmurs

-Stats

Answer 1

1. Nearly all children have murmurs at some time
2. More likely to be heard during sick visits
3. Usually benign
4. May indicate structural heart disease

Question 2

Evaluation of Murmurs

Answer 2

1. Hx — Exercise tolerance, chestp pain, syncope, FH
2. General PE — Growth, respirations, perfusion
3. Palpation — Thrill, precordial activity
4. Auscultation — S1, S2, clicks, murmurs
5. Exercise tolerance in an infant — Trouble feeding, gets SOB when feeding **

Question 3

Characteristics of Murmurs

Answer 3

1. Timing — If you hear a murmur in only ONE part of the cardiac cycle it is almost always a SYSTOLIC murmur
   - If pulse is consistent with murmur, it is during systole **
   - Systolic + Diastolic Murmur — Aortic stenosis — two seperate components w/ silence between the two
   - Continuous murmur — PDA is example of continuous
2. Character
   - Regurgitant murmur — VSD
   - Ejection
   - Pitch is determined by pressure.
   - Harsh, musical — Harsh has the sound of “sh” — Stills murmur has a musical character
3. Location
   - Upper left sternal border — Pulmonary flow murmurs — Radiates to back
   - URSB — Aortic outflow murmurs — Radiate to carotids
   - LLSB — Ventricular septal defects
   - Apex — Mitral murmurs

Question 4

Clicks

Answer 4

1. Short, high-pitched sounds
2. Usually indicate valvar abnormalities
3. More similar to first and second heart sounds than they are different
4. Two major types
   - Ejection clicks
   - Midsystolic clicks

Question 5

Ejection Clicks

Answer 5

1. Immediately after S1 — May be mistaken for split S1
2. Aortic Clicks
   - Usually heard at apex
   - Constant throughout respiratory cycle
3. Pulmonary clicks — Left sternal border and Louder w/ expiration
4. Ventricular septal aneurysm — Left sternal border

Question 6

Midsystolic Clicks

Answer 6

1. Midway between S1 and S2
2. Mitral Vlave Prolapse
   - Click heard best at apex
   - Accentuated by standing
   - Decreased by lying supine
   - Click is followed by regurgitant murmur

Question 7

Normal Murmurs Stats

Answer 7

1. Usually Systolic
2. Less than grade 4/6 (NO THRILL)
3. Generally increased w/ fever, anemia, anxiety, excitement
4. Several specific types

Question 8

Normal Murmurs

-Still’s Murmur

Answer 8

1. Short, systolic murmur
2. Vibratory, buzzing, honking
3. Lower left sternal border
4. Most common 3-8 years of age
5. Louder supine and decreases w/ valsalva
6. Typically resolve by adolescents

Question 9

Normal Murmurs

-Pulmonary Flow Murmur

Answer 9

1. Short, systolic ejection murmurs
2. Upper left sternal borner
3. All ages but RARE in infants
4. Increases with supine position
5. Increases w/ fever, anemia

Question 10

Normal Murmurs

-Peripheral Pulmonic Stenosis

Answer 10

1. Systolic Ejection murmur heard LOUDEST in axillae (especially right axilae)**
2. Commonly heard in premature NEONATES
3. Usually resolve by 1 year of age

Question 11

Normal Murmurs

-Sypraclavicular Bruit

Answer 11

1. Systolic Ejection murmur
2. Supraclavicular region and neck — Sometimes heard below clavicles
3. Not affected by sitting or lying
4. Decreased by hyperextension of shoulders

Question 12

Normal Murmurs

-Venous Hum

Answer 12

1. Continuous (Louder in diastole)
2. Supraclavicular — Right more common than left
3. Disappears with changes in head position, digital pressure, lying supine
4. Loudest when sitting or standing
5. Caused by blood flow in jugular vein

Question 13

Murmurs Needing Evaluation

-Info

Answer 13

1. Murmurs in symptomatic kids
2. Loud murmurs
3. Diastolic murmurs
4. Murmurs that don’t fit into categories of innocent murmurs

Question 14

Congenital Heart Disease

-Presenting as an Asymptomatic Murmur

Answer 14

1. Spetal defects — ASD, VSD
2. Obsturciton to ventricular outflow
   - Valvar, subvalvar, or supravalvar Aortic or pulmonic stenosis
   - Coarctation of Aorta
3. Patent ductus Arteriosus (PDA)

Question 15

What causes Systolic Murmur

Answer 15

1. Turbulence in ventricular outflow
   - Narrowing of aortic or pulmonary valve, aorta or pulmonary artery
   - Increased flow
2. AV valve regurgitation
3. Abnormal ventricular or acterial communications — VSD, PDA

Question 16

Aortic Stenosis

Answer 16

1. May be valvar, subvalvar or supravalvar
2. Systolic ejection murmur — Upper right sternal border — Radiates to the neck
3. May have thrill in suprasternal notch
4. Valvar AS usually causes a systolic ejection click at apex

Question 17

Pulmonic Stenosis

Answer 17

1. Systolic ejection murmur — Upper Left sternal border — Radiates to back
2. Systolic ejection click at Lower left sternal border varies w/ respiration
3. May have thrill in suprasternal notch

Question 18

Coarctation of the Aorta

Answer 18

1. Narrowing of aortic arch adjacent to site of ductus
2. Systolic ejection murmur below left scapula
3. Decreased pulses and BP in lower extremities **
4. If severe, causes shock

• THINK OF COACTATION OF THE AORTA W/ ANY NEWBORN **
• ANY BABY IN SHOCK, THINK COARCTATION AS WELL **

-THESE CHILDREN NEED INTUBATION **

Question 19

Ventricular Septal Defect

Answer 19

1. Holosystolic Murmur — Harsh and high pitched if VSD is small
2. Diastolic rumble at apex - Low pitched rumble — After S2 before S1 and check for sounds — Louder with bell
3. If VSD is large it will lead to CHF
   - Increased LA pressure
   - Pulmonary edema
   - Increased WOB
   - Poor growth
   - Usually have Hepatomegaly from increased right atrial pressure

Question 20

Atrioventricular Septal Defect

Answer 20

1. Left to right shunt (atrial and ventricular)
2. Increased pulmonary blood flow
3. Common AV valve
4. Increased PA pressure
5. Normal saturations
6. High incidence with Down’s syndrome

Question 21

Posterior Rib Fractures

Answer 21

1. Always a sign of NAT - Abuse

Question 22

Atrial Septal Defect

Answer 22

1. Systolic Ejection murmur
2. Upper left sternal border
3. Wide fixed split S2
4. Diastolic rumble at lower left sternal border
5. CHF not generally seen
6. Subtle exercise intolerance

Question 23

Normal Splitting of S2

-Inspiration

Answer 23

1. Negative intrathoracic pressures increases systemic venous return
2. Increases filling of RV and prolonged RV ejection
3. Delays pulmonary valve closure making S2 split
4. No change in pulmonary venous return
5. No effect on LV filling

Question 24

Normal Splitting of S2

-Expiration

Answer 24

1. Positive intrathoracic pressure decreases systemic venous return
2. Decreases filling of RV and shortened RV ejection
3. Pulmonary valve closure is earlier, making S2 single
4. No change in pulmonary venous return
5. No effect on LV filling

Question 25

ASD - Wide, fixed splitting of S2

Answer 25

1. Left-to-right ASD flow increases RV filling, delays P2 causing wide splitting 2. Inspiration increases systemic venous return, but decreases ASD flow 3. Expiration decreases systemic venous return, but increases ASD flow 4. Splitting does not vary with respiration

Question 26

What Causes Diastolic Murmurs?

Answer 26

1. Turbulence in ventricular inflow - Narrowing and increased flow 2. Semilunar valve regurgitation

Question 27

What Causes Continuous Murmurs?

Answer 27

1. Abnormal connection between systemic to artery and a pulmonary artery — Ex: PDA 2. Abnormal AV communications - AV Fistula & Coronary artery fistulae

Question 28

Common Murmurs in the First Few days of Life | -NORMAL

Answer 28

1. Peripheral pulmonic stenosis 2. Pulmonary flow murmur 3. Transitional murmurs - Closing PDA - Transient tricuspid regurgitation

Question 29

Common Murmurs in the First Few days of Life | -Abnormal

Answer 29

1. Outflow obstruction - Aortic stenosis - Pulmonary stenosis - Coarctation 2. Abnormal Communications - Ventricular Septal defect - Patent ductus arteriosus

Question 30

Common Murmurs in the First Few days of Life | -NORMAL transitional Murmur — Closing PDA

Answer 30

1. ULSB or left infraclavicular area 2. Systolic or continuous 3. Often louder as PDA gets smaller 4. Typically 12-48 hrs of age

Question 31

Common Murmurs in the First Few days of Life | -Normal Transient Tricuspid Regurgitation

Answer 31

1. LLSB 2. Regurgitant, systolic 3. Often seen in asphyxiated infants or infants w/ pulmonary hypertension 4. Resolves over several days

Question 32

Common Murmurs in the First 6 months of Life | -Normal?

Answer 32

1. Peripheral pulmonic stenosis | 2. Pulmonary flow murmur

Question 33

Common Murmurs in the First 6 months of Life | -Abnormal

Answer 33

1. Outflow obstruction - Aortic Stenosis - Pulmonary stenosis - Coarctation 2. Abnormal communications - Ventricular septal defect - Patent ductus arteriosus

Question 34

Common Murmurs in the First few years of Life | -Normal

Answer 34

1. Pulmonary Flow murmur 2. Stills Murmur 3. Venous hum

Question 35

Common Murmurs in the First few years of Life | -Abnormal

Answer 35

1. Outflow obstructions - Aortic stenosis, pulmonary stenosis, coarctation 2. Abnormal communications - VSD, ASD, PDA

Question 36

Common Murmurs in school aged children | -Normal & Abnormal

Answer 36

1. Normal = All previous + Supraclavicular bruit | 2. Abnormal = All previous + Hypertrophic cardiomyopathy

Question 37

Endocarditis Prophylaxis 2007

Answer 37

1. Many fewer patients require prophylaxis than under previous recommendations 2. Prophylaxis no longer recommended for GI or GU procedures 3. Prophylaxis for oral procedures limited to selected high-risk patients

Question 38

Indications for Prophylaxis

Answer 38

1. Prosthetic cardiac valve or previous endocarditis 2. Congenial heart disease only in the following cateogories - Unrepaired cyanotic congenital HD - Completely repaired congenital HD w/ prostehtic material or device - Repaired congenital heart disease w/ residual defects 3. Cardiac transplantation reciepts w/ cardiac valvular disease