52b. Paeds murmur Flashcards
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?
Cardio history and examination paeds
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
where are each of the positions to listen to?
APT-M 2245
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
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
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
what is S4?
LE-lub-dub
heard just before S1
Sound of a stiff ventricle trying to work
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
what is the ductus arteriosus?
fetal shunt that allows blood to pass from pulmonary artery into aorta in order to bypass pulmonary circulation
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
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
what is the umbilical vein
carries oxygenated blood towards the baby’s heart and away from placenta
what is the umbilical arteries
2 umbilical arteries
carry deoxygenated blood away from the babys heart towards placenta
what is the cause of innocent mumurs
They are caused by fast blood flow through various areas of the heart during systole.
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
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
what are the key invetsigations to establish the cause and rule out abnormalities in a child with a murmur
ECG
Chest Xray
Echocardiography
causes of continuous murmurs
venous hum
stills murmur
Patent ductus arteriosus (PDA)
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
- rf to paeds cardiologist
- If small w&W
- 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
