24 - Pediatric Cardiovascular, Thorax and Lung Exam

Question 1

Chest wall in infants and children

Answer 1

Rib cage is more circular than adult

AP diameter to lateral diameter decreases significantly during the first three years

Question 2

Diaphragm in the infant and child

Answer 2

Horizontal, decreased contraction efficiency

Muscles of inspiration become less fatigued as a child ages

Question 3

Lungs in infants and children

Answer 3

Alveolar multiplication after birth continues up to two years old
Alveolar size continues to increase until thoracic growth is complete

Question 4

Where do you start for a pediatric lung exam?

Answer 4

ABCs

Airway

Breathing

Circulation

Question 5

Respiratory rate for a newborn

Answer 5

40-60 bpm

Question 6

Infant breathing patterns

Answer 6

Obligate nasal breathers
Periodic breathing

When assessing respiratory rate, must take it for one full minute

Question 7

Periodic breathing

Answer 7

Breathing pattern for infants within the first month of life, where they will breathe rapidly for several seconds, then not breath for up to 20 seconds afterwards
Anything longer than 20 seconds is APNEA

Question 8

Things to monitor in lung exam

Answer 8

Respiratory rate and effort

Retractions

Question 9

Types of retractions

Answer 9

Suprasternal
Subcostal
Intercostal

Question 10

Auscultation of the infant lungs

Answer 10

Differentiated lung sounds from heart sounds can be a challenge

Sounds transmit easier in the infant than they do in an adult

Question 11

How do you get a quiet infant?

Answer 11

Feed them
Pacify them

Have parent hold them

Get them to fall asleep

Question 12

What is included in the cardiac exam?

Answer 12

Heart auscultation
Lung exam
Liver exam
Skin
Pulses

Question 13

Acrocyanosis

Answer 13

Peripheral cyanosis

Normal finding in a neonate and is not worrisome

Question 14

Central cyanosis

Answer 14

Abnormal at any age

Can be pulmonary or cardiovascular in etiology

Question 15

How can you differentiate between cardiac and pulmonic causes of central cyanosis?

Answer 15

Hyperoxitest:
Check ABG, provide 100% O2 for 10 minutes, recheck ABG

If pO2 rises > 100 mmHg, the cause is likely pulmonary

Question 16

Where is the newborn apical impulse?

Answer 16

In the 4th or 5th intercostal space just medial to the midclavicular line

Question 17

What would cause the apical impulse to shift?

Answer 17

Pneumothorax (collapsed lung)
Dextrocardia (heart on the wrong side)
Diaphragmatic hernia (hole it diaphragm)

Question 18

Normal newborn heart rate

Answer 18

120-160 bpm

Question 19

If a baby has a “machinery murmur”, what does this indicate?

Answer 19

Patent ductus arteriosis

Sound harsh, lout continuous murmur heard at the first to third intercostal spaces and the lower sternal border

Question 20

What blood pressure would indicate a hypertensive infant?

Answer 20

> 80/50

Question 21

Innocent murmurs

Answer 21

Common from 3-7 years old
Maximally audible at mid left sternal border

Midsystolic

Heard better when supine and least when standing/holding breath

More common with a fever

Question 22

Pathologic murmur

Answer 22

Abnormal cardiac size or ECG

Diastolic murmur

Cyanosis

Abnormally weak or strong pulses

Loud, with thrill, or transmits through thorax

Question 23

Normal capillary refill time

Answer 23

1-2 seconds

Question 24

Pulses in infants that are readily palpable

Answer 24

Brachial
Radial
Femoral

Question 25

Bounding pulse in an infant

Answer 25

May be significant for a left to right shunt characteristic of a PDA

Question 26

Deminished femoral pulse

Answer 26

May be due to a coarctation of the aorta

Question 27

Patent ductus arteriosus

Answer 27

A Ductus Arteriosus is a minor vessel, sometimes persisting from the fetal structure of the heart in a newborn baby, which connects the aorta to the pulmonary artery

Allows blood to flow from the aorta into the pulmonary artery

Allows the mixing of oxygen-poor blood being carried to the lungs by the pulmonary artery with oxygen-rich blood being carried by the aorta to the body

Question 28

PDA treatmetn

Answer 28

If the Patent Ductus Arteriosus remains open in a newborn, pharmaceutical treatment with indomethacin or ibuprofen may be used to encourage its closure. If the PDA still does not close, it is recommended that it be closed either by a cardiac catheterization procedure or surgery

Question 29

Coarctation of the aorta

Answer 29

Coarctation of the Aorta is characterized by a blockage (coarctation) in the aorta itself. This may consist of a narrowing of the vessel or a shelf-like obstruction within it

Question 30

Where do we see coarctation of the aorta?

Answer 30

The coarctation is located on the descending aorta near the heart, usually immediately past the point (further from the heart) where the subclavian artery (SA in the diagram) exits the aorta on its way to the upper body.

In some cases, the aortic valve (AV), through which blood enters the aorta from the left ventricle, is abnormally formed in this defect, with only two valve leaflets rather than the usual three (Bicuspid Aortic Valve).

Question 31

What does coarctation of the aorta cause?

Answer 31

The obstruction to blood flow caused by the coarcation causes high blood pressure in the left ventricle (which pumps blood into the aorta) and the part of the aorta between the heart and the blockage (the aortic arch - AA in diagram).

While the blood pressure in the upper body becomes high, the blood pressure in the lower body is low because of the reduced blood flow through the aorta. If the obstruction in the aorta is severe, infants will develop severe heart failure after the patent ductus arteriosus (PDA) closes in the first several days after birth. If the problem is not diagnosed promptly, the infant may die.