18. Child murmurs

Question 1

What is an innocent heart murmur?

What does it sound like?

Answer 1

Murmur not associated with pathology, detected in 30-70% of normal children.
Early/ejection systolic in nature - never diastolic, varies with position and respiration, normal heart sounds (physiological splitting S2)

Question 2

What are the 4 classically described innocent heart murmurs?

Answer 2

• Still’s murmur
• Pulmonary flow murmur
• Branch pulmonary stenosis
• Venous hum

Question 3

What is the most common innocent murmur? What does is sound like?

Answer 3

Still’s:

• typically heard 2-6y.os
• low to medium pitched
• early to mid systolic
• crescendo then decrescendo

Question 4

What age group does pulm flow murmur typically occur in? What does it sound like?

Answer 4

• Children to adolescents
• ejection to mid systolic peak
• medium to high pitch
• beware can sound like ASD, pulm valve stenosis

Question 5

Branch pulm stenosis - commonly heard in which group? sounds like?

Answer 5

< 6mth old

murmur sounds like pulm flow murmur, radiates to axilla and back

Question 6

Venous hum sounds like?

Answer 6

• low pitch continuous murmur
• most audible low anterior neck
• louder when erect
• quieter when hed turned away.
  But continuous murmur needs to be assumed pathological until otherwise proved

Question 7

Dynamics of all innocent murmurs?

Answer 7

• variation with respiration: increase with inspiration

- variation with posture - audible when supine, disappears when erect, increases with squatting

Question 8

murmur is probably innocent if?

Answer 8

• hx and exam otherwise normal
• soft early to mid systolic murmur
• left sternal edge with minimal radiation
• softer when erect and varies with respiration
• normal physiological split of S2
• no additional sounds
• normal ECG and O2 sats

Question 9

when to call a cardiologist

Answer 9

• harsh murmur
• pansystolic
• additional heart sounds
• abnormal S2
• high intensity

Question 10

most common congenital heart diseases

Answer 10

1. Ventricular septal defect - 25-30%
2. atrial septal defect
3. patent ductus arteriosus
4. coarctation of aorta
   5 tetralogy of fallot
   6 pulm valve stenosis

Question 11

Which congenital heart diseases are associated with high pulm blood flow/significant left to right shunt?

Answer 11

Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus

Question 12

What results in significant left to right shunt?

Answer 12

Increased volume of blood in lungs decreases pulmonary compliance and increases WOB:

• tachypnoea
• FTT
• increased catecholatmines> sweating, irritablility, tachycardia

Question 13

When do symptoms of VSD arise?

Answer 13

as pulm vascular resistance falls - usually 1-3 wks

Question 14

VSD txs

Answer 14

medical:
- diuretics
- afterload reduction - ACEi
Surgery: 
- closure- open or catheter

Question 15

Does ASD give rise to symptoms in infancy?

Answer 15

Very uncommon - will eventually lead to pulm hypertension, heart failure and arrhythmias

Question 16

tx of ASD

Answer 16

• 80% of small lesions close by themselves in first 2 yrs

- large defects: close before school age

Question 17

When does the patent ductus arteriosus usually close?

Answer 17

10-14 days

Question 18

What are 2 examples of cyanotic lesions?

Answer 18

• Tetralogy of Fallot - decreased pulm blood flow

- Transposition of great arteries- increased/normal pulm flow

Question 19

tetralogy of fallot?

Answer 19

VSD, overriding aorta, pulmonary stenosis, right ventric hypertrophy

Question 20

What is tetralogy of fallot associated with

Answer 20

trisomy 21

Question 21

Which heart thing accounts for majority of cyanosis presentation in babies?

Answer 21

Transposition of the great arteries.

lethal condition if not treated - balloon atrial septostomy