Direction of heart sounds for clicks and murmurs - URSB
aortic vale clicks of aortic stenosis, venous hum
Direction of heart sounds for clicks and murmurs - ULSB
pulmonary valve clicks of pulmonary stenosis
pulmonary flow murmurs
ASD
PDA, venous hum
Direction of heart sounds for clicks and murmurs - LLSB
VSD, still murmur, tricuspid valve regurg, hypertrophic cardiomyopathy, subaortic stenosis
Direction of heart sounds for clicks and murmurs - Apex
aortic or mitral valve regurgitation
Direction of heart sounds for clicks and murmurs - Erb point (left sternal border between 2nd and 3rd intercostal space)
aortic ejection click or aortic stenosis or dilated aortic root
Innocent murmur - auscultatory findings
- grade 1 -III/IV in intensity and localized
- changes with position
- may vary in loudness
- may increase in loudness with illness or exercise
- musical or vibratory in quality (sometimes blowing)
- systolic in timing (except for venous hum - continuous)
- duration is short
- best heard in LLSB
- may disappear with Valsalva maneuver
- VS and ECG normal
possible pathologic murmur -auscultatory findings
- in a child with a syndrome
- any diastolic murmur
- systolic murmur with a thrill
- pan-systolic murmur
- continuous that can’t be suppressed
- systolic clicks
- opening snaps
- fixed splitting of 2nd HS
- accentuated S2
- S4 gallop
- not positional
- grade IV or higher
- harsh quality
Stills Murmur
- innocent
- heard 3-6 yo
- systolic ejection murmur
- LLSB or between LLSB and apex
- grade 1-III
- vibratory/musical
- decreases in upright position
Venous hum
- innocent
- heard 3-6 yo
- grade I-III
- louder in upright position
- changes with compression of jugular vein or turning head
carotid bruit
- innocent
- any age
- Systolic ejection murmur
- neck, over carotid artery
- grade I-III
Adolescent ejection murmur
- innocent
- 8-14 yo
- LUSB
- softer in upright position
- does not radiate to back
Normal Peripheral Pulm stenosis murmur
- innocent
- newborn- 6mo
- systolic ejection murmur
- axilla and back, LUSB/RUSB
- harsh, short, high frequency
CHF - S&S in infants
- Tachypnea
- tachycardia
- rales or wheezing
- cardiomegaly or hepatomegaly
- periorbital edema
- poor feeding/tires easily
- poor weight gain
- diaphoresis
CHF - S&S in kids and teens
- tachypnea
- tachycardia
- rales or wheezing
- cardiomegaly or hepatomegaly
- orthopnea
- SOB or dyspnea with exertion
- peripheral edema
- poor G&D
Heart condition for premature infant
PDA
Heart condition for birth - 1 wk old
Hypoplastic left heart coarction of aorta critical aortic stenosis interrupted aortic arch AV malformations tachy cardiomyapathy
Heart condition for 1wk - 3mo
VSD truncus arteriosis AV defect coarction tachy PDA aortic stenosis tricuspid atresia
Heart condition for older than 1 yr
bacterial endocarditis
rheumatic fever
myocarditis
Aortic Stenosis History
- G&D may be normal
- Activity intolerance/fatigue can develop with any age or increase with age
- CHF, low Cardiac output, and shock may be evident in newborns
- sudden death
Aortic Stenosis PE
- BP narrow pulse pressure
- A grade III to IV/VI, loud harsh systolic crescendo-decrescendo murmur is best heard at the upper right sternal border with radiation to the neck, LLSB, and apex
- With a valvular lesion, a faint early systolic click at the LLSB may be heard
- With aortic insufficiency, an early diastolic blowing murmur is heard at the LLSB to apex
- In the most severe lesions, S2 is single or closely split; S3 or S4 heart sound also be heard
- A thrill may be present at the suprasternal notch
Aortic Stenosis - Dx
Chest radiographs are usually normal or may show LVH. Adults frequently develop radiographic evidence of calcification on the aortic valve over time
ECG can be normal of reveal LVH and inverted T waves
A 24 hour Holter monitor or 30 day event monitor demonstrates ventricular arrhythmia
Echo is the diagnostic examination of choice
Aortic Stenosis MGMT
- Type and timing of treatment depend on the severity of the obstruction
- Children with mild aortic stenosis can participate in all sports but should have annual cardiac examinations.
- Those with moderate aortic stenosis should choose low-intensity sports as guided by their cardiologist.
- Children with severe aortic stenosis or moderate with symptoms should avoid competitive or intensive sports because of the risk of sudden death from ventricular arrhythmias
When to refer to cardiologist
Oxygen saturation less than 95%
Symptoms of CHF
A pathological murmur or a murmur that is difficult to differentiate in the presence of poor growth and development
A child with a murmur who is otherwise doing well should be referred to a pediatric cardiologist for further evaluation in a timely but not urgent manner
Newborns should be evaluated within 1-2 days of noticeable signs or immediately (change in breathing pattern, increases irritability and poor feeding, and/or cyanosis), depending on severity of symptoms
An older child with dizziness, chest pain with exertion, arrhythmia, dyspnea, syncope, signs of CHF, or abnormal vital signs should be referred ASAP
Syncope Diagnostics
- Orthostatic vital signs: more than a 30mm Hg drop in BP after standing for 5-10 seconds, or a baseline systolic pressure of less than 80mm Hg in an adolescent
- Hemoglobin, if anemia is suspected: CBC, random glucose, and glucose tolerance tests for syncope.
- 12 lead EKG
- ECHO
