52b. Paeds murmur Flashcards by Ailsa Jones

Examination of a murmur

Measure pulse at same time as listening to heart, pulse coincides with s1

SCRIPT

S – Site: where is the murmur loudest?
C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
R – Radiation: can you hear the murmur over the carotids (aortic stenosis) or left axilla (mitral regurgitation)?
I – Intensity: what grade is the murmur?
P – Pitch: is it high-pitched or low and rumbling? Pitch indicates velocity.
T – Timing: is it systolic or diastolic?

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Cardio history and examination paeds

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grades of murmurs

Grade I: Difficult to hear
Grade II: Quiet
Grade III: Easy to hear
Grade IV: Easy to hear with a palpable thrill
Grade V: Audible with stethoscope barely touching the chest
Grade VI: Audible with stethoscope off the chest

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where are each of the positions to listen to?

APT-M 2245

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What is S1? what systolic murmurs do you get?

systole

LUB - dub

mitral and tricuspid valves are closed, this allows blood to be ejected out of the heart and into the aorta and pulmonary artery.

If the blood backflows through open vessels = mitral and tricuspid regurgiatation.

If the blood can’t be ejected properly = aortic stenosis and pulmonary stenosis

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what is S2? what diastolic murmurs do you get?

diastole

lub - DUB

aortic and pulmonary valves are closed, this allows the ventricles to fill

If the aortic and pulmonary valves don’t close properly, you get aortic and pulmoanry regurgitation

If the mitral and tricuspid valves don’t allow the blood past, you get mitral stenosis and tricuspid stenosis

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What is S3?

lub-dub-DE

rapid ventricular filling, chordae tendinae twang as they are stretched quickly

may be normal in young people

may be a sign of heart failure in older people

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what is S4?

LE-lub-dub

heard just before S1

Sound of a stiff ventricle trying to work

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Way to remember murmurs quickly

Ard fall - aortic regurgitation - diastolic - collapsing pulse

Ass bump - aortic stenosis - systolic - crescendo-decrescendo murmur - “ejection systolic”

Msd you - mitral stenosis - diastolic -

Mrs through - mitral regurgitation - stenosis - “pan-systolic” - radiates to axilla

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what is the ductus arteriosus?

fetal shunt that allows blood to pass from pulmonary artery into aorta in order to bypass pulmonary circulation

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what is the foramen ovale?

fetal physiological hole in the heart which allows blood to pass from the right atrium into the left atrium to bypass pulmonary circulation

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what is the ductus venosus

fetal shunt which allows blood to pass from the umbilical vein into the inferior vena cava in order to bypass the fetal liver which doesn’t function properly yet

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what is the umbilical vein

carries oxygenated blood towards the baby’s heart and away from placenta

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what is the umbilical arteries

2 umbilical arteries

carry deoxygenated blood away from the babys heart towards placenta

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what is the cause of innocent mumurs

They are caused by fast blood flow through various areas of the heart during systole.

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features of innocent murmurs

Soft
Short
Systolic
Symptomless
Situation dependent, particularly if the murmur gets quieter with standing or only appears when the child is unwell or feverish

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what features of a murmur would prompt further investigations and referral to a paediatric cardiologist

Murmur louder than 2/6
Diastolic murmurs
Louder on standing
Other symptoms such as failure to thrive, feeding difficulty, cyanosis or shortness of breath

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what are the key invetsigations to establish the cause and rule out abnormalities in a child with a murmur

ECG
Chest Xray
Echocardiography

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causes of continuous murmurs

venous hum
stills murmur
Patent ductus arteriosus (PDA)

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Causes of ejection systolic murmur

Congenital pulmonary stenosis
Atrial Septal Defect (relative PS)
Tetralogy of Fallot (PS)
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Coarctation of the aorrta
Bicuspid aortic valve

Causes of diastolic murmurs

Early diastolic
- aortic regurgitation
- pulmonary regurgitation

Late diastolic
- mitral stenosis

cause of gallop rhythm

ebsteins anomaly

Presentation venous hum

Continuous blowing noise heard just below the clavicles

Due to the turbulent blood flow in the great veins returning to the heart.

Presentation stills murmur

Low-pitched sound heard at the lower left sternal edge

when does the ductus arteriosus usually close

The ductus arteriosus normally stops functioning within 1-3 days of birth, and closes completely within the first 2-3 weeks of life. When it fails to close, this is called a “patent ductus arteriosus” (PDA).

why does PDA cause a continuous murmur

since there is a constant pressure gradient in both systole and diastole forcing blood from the aorta into the pulmonary artery. The normal aortic systolic/diastolic pressure is 120/80 mmHg and the normal pulmonary arterial pressure is 25/5 mmHg.

Presentation PDA

newborn examination - murmur normal first heart sound with a continuous crescendo-decrescendo “machinery” murmur that may continue during the second heart sound Large volume, bounding, collapsing pulse left subclavicular thrill wide pulse pressure heaving apex beat or Shortness of breath Difficulty feeding Poor weight gain Lower respiratory tract infections

most important invetsigation murmur

Echocardiogram

management of PDA

- indomethacin or ibruprofen if open at 1 year - trans-catheter closure

causes PDA

genetic maternal rubella prematurity

pulse character in PDA

large volume, bounding, collapsing pulse

How does a PDA cause pulmonary hypertension

The pressure in the aorta is higher than that in the pulmonary vessels, so blood flows from the aorta to the pulmonary artery. This creates a left to right shunt where blood from the left side of the heart crosses to the circulation from the right side. This increases the pressure in the pulmonary vessels causing pulmonary hypertension, leading to right sided heart strain as the right ventricle struggles to contract against the increased resistance. Pulmonary hypertension and right sided heart strain lead to right ventricular hypertrophy. The increased blood flowing through the pulmonary vessels and returning to the left side of the heart leads to left ventricular hypertrophy.

In what conditions may you want to keep PDA open?

coarctation tetralogy of fallot transposition of the great arteries

how do you keep PDA open?

prostaglandin E1

continuous blowing noise heard just below the clavicles

venous hum

Low-pitched sound heard at the lower left sternal edge

stills murmur

normal first heart sound with a continuous crescendo-decrescendo “machinery” murmur that may continue during the second heart sound Large volume, bounding, collapsing pulse left subclavicular thrill wide pulse pressure heaving apex beat

PDA

how to use inspiration and expiration to hear murmurs better

RILE Right-sided murmur → heard best on Inspiration Left-sided murmur → heard best on Expiration

management congenital pulmoanry stenosis

w&w balloon valvuloplasty via a venous catheter

associations with congenital pulmonary stenosis

Tetralogy of Fallot William syndrome Noonan syndrome Congenital rubella syndrome

Fixed splitting of second heart sound indicates?

atrial septal defect (ASD)

mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border with a fixed split second heart sound.

ASD

Presentation ASD

mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border with a fixed split second heart sound. In childhood: Shortness of breath Difficulty feeding Poor weight gain Lower respiratory tract infections In adulthood: dyspnoea heart failure stroke

What symptoms often come alongside a pathological murmur

Shortness of breath Difficulty feeding Poor weight gain Lower respiratory tract infections

why does congenital heart disease cause LRTI?

left -->right shunts = pulmonary over circulation - pulmonary oedema - becomes infected - LRTI

Management ASD

1. rf to paeds cardiologist 2. If small w&W 3. Surgical correction (transvenous catheter closure via femoral vein) or open heart surgery + anticoagulants are used to reduce the risk of clots and stroke in adults

most common ASD

Ostium secondum

mumur heard AVSD

Mid systolic Pulmonary flow murmur due to increased flow through the pulmonary valve Mid diastolic flow murmur due to increased flow through the tricuspid valve S3 gallop