Cardio Flashcards
Cardiac History
Exercise tolerance, chest pain, syncope, family hx
Feeding difficulty
Hx of dizziness and syncope
Diaphoresis, congested cough, tachypnea
Perinatal hx
Maternal hx
Maternal use of NSAID and ASA
Increased risk of pulmonary hypertension of the newborn
Increased risk of premature closure of ductus
Maternal use of Lithium
Increased risk of Ebstein’s anomaly of the tricuspid valve
SLE
neonatal heart block
Diabetes
Cardiomyopathy
Transposition of the great arteries
Ventricular septal defect
PDA
Age Appropriate Hx
Infant
Growth
Check feeding
Color
Congested cough
Rapid deep breathing with SOB in a colicky baby suggests heart failure
School Aged Hx
Growth pattern
Chest deformity
Activity level
Difficulty in keeping up with activity
Hx of dizziness or syncope
Tires after activity
Family Hx
Maternal diabetes
Medications
Prenatal infection
Maternal diabetes: ASD, coarctation, cardiomyopathy
Prenatal Hx of medication use: Dilantin, coumadin, psychotherapeutics, antiepileptics
Prenatal infection: CMV, Coxsackie, Herpes
Family Hx
Prenatal Substance abuse
Physical Assessment Order
Inspection
Palpation
Auscultation
Percussion
General Physical Assessment
- Vital Signs
- Temperature
- HR (sinus arrythmia)
- RR (look for retractions, grunting, and nasal flaring)
- BP
- Pressure differential b/w right arm and lower leg
- BP is HIGHER in leg
- Activity level
Oxygen Saturation
75-85 is normal for children with right to left shunt
Faces
Central Cyanosis
Peripheral cyanosis
Acrocyanosis
Cardiac Evaluation Continued
Overall growth and appearance
Lungs – clear wheezing, grunting and rales
Peripheral perfusion/abdominal pain
Hepatosplenomegaly (1-2cm soft liver edge is normal, evaluate for position and size, critical indicator of cardiac output)
Extracardial anomalies
SACRAL EDEMA*****
Inspection (7)
Close observation of growth and development
Cyanosis
Look for precordial bulging, sign of right sided enlargement
Clubbing
VS
Jugular venous pulsation
Pallor, cyanosis, peripheral lymphedema
Pulse rate is increased by ______ for each centigrade of fever
10-15 bpm
Waterhammer or Corrigan’s pulse
pulse that is bounding and forceful, rapidly increasing and subsequently collapsing, as if it were the sound of a waterhammer that was causing the pulse.
PDA
Quincke Pulse
With a light held on the pad of the finger, gentle pressure is applied to the distal nail, if the pulse pressure (PP) is wide, alternating filling and blanching of the capillary bed can be seen
Aortic insufficiency
Premature Pulses
may have bounding pulses due to lack of subcutaneous fat and higher incidence of PDA
Assessment of pulses
- Assessment of femoral and radial pulse
- Palpate for thrill
- Turn child to the left and feel the apex
- Basal thrills are felt with child sitting up
- Look for thrills at PMI and suprasternal notch
- Pericardial friction rubs can be palpated
High frequency thrills along the LBD
Ventricular septal defect
Low frequency thrill in 2nd ICS suggests
Aortic stenosis
Diastolic thrill at the apex
mitral stenosis
Point of Max Impulse
- Normal position of apex beat
- 5th ICS space MCL after 7
- Before this age, the apex best is in the 4th ICS to the left of the MCL
- Determine ventricular overload
- Cardiomegaly
- Presence or absence of thrill
- Turbulent blood flow
AUSCULTATE
Aortic
Mitral
Erb’s point
Tricuspid
Pulmonic
Infraclavicular – carotid and axillary
Posterior aspect under scapula
Listen for low pitched sounds of the diastolic murmur by listening for
the absence of silence during diastole
Age specific hits
Infants
Listen during feeding
Age specific hints
4months to 1 year
Listen while baby is being brough to sitting: Strain to sit up
Age specifc
TODDLER
Play with them once they have confidence in you
Give them time to warm up
7 S’s of innocent murmurs
Systolic
Short duration (not holosystolic)
Single (no clicks or gallops)
Small (do not radiate)
Sensitive (tend to change with position or respiratory effort – louder supine)
Soft
Sweet (no harsh sounds)
S1
Split S1
- Due to closure of the tricuspid and mitral valve
- Best heard at the left lower sternal border or at the apex
- Split s1 can be normal in children but if wide can be right bundle branch block or Ebstein anomaly
S2
Due to closure of pulmonic and aortic valve
Aortic valve closes first
Distinguishing between Splitting and S3
Intensity
Quality
- Split s2 of equal intensity and quality
- Hear at base
- Occur with very interval between sounds
- Splitting at base is absence in pulmonic stenosis, tetralogy of fallot, pulmonic atresia or truncus
Position Heard
Distance between sound
Murmurs
Murmurs are produced when the blood velocity becomes critically high in the presence of an irregularity or narrowing of the surface over which the blood flows.
The loss of laminarity
Results in turbulence which in turn produces a sound.
Etiology of Murmurs
- The frequency of the sound from the turbulence varies directly with velocity of the blood flow.
- High sound frequencies are associated with high velocity jets as in mitral regurgitation with the flow from the high pressure left ventricle to the low pressure left atrium
Aids to Auscultation
Quiet patient
Quiet room
No distractions
Good Stethoscope
Good hearing
Types of murmurs
Systolic – ejection, holosystolic or regurgitant
Diastolic – early decrescendo, mid-diastolic
Continuous = PDA
Characteristics of Murmurs
Timing – systolic, diastolic, continuous
Intensity – standard scale
Quality – frequency and pitch
Intensity of the murmur
The velocity of the blood
The volume of blood causing the murmur
The distance from the site of the origin of the murmur to the stethoscope
Grading of the murmur
- 1/6 Faint, not easily heard
- 2/6 Faint but heard immediately
- 3/6 Loud but no thrill
- 4/6 Loud with a thrill
- 5/6 Loud with a thrill and heard with the edge of the stethoscope on the chest
- 6/6 Heard with the stethoscope 1 cm. off of the chest wall
Third Heart Sound
- Associated with ventricular filling
- Louder in the non-compliant left ventricle
- Louder with increased blood flow/cardiac output
- Intermittent S3 may be a normal variant
Extra Cardiac Sounds
Friction rubs
Bronchial sounds
Rales
Pleural rubs
Wheezes
Radiation of the murmur
Direction of blood flow
Site of Origin
Intensity of murmur
Chest X-ray and Cardiac Anomalies
Tetralogy of Fallot
Boot sign
Chest X-ray and Cardiac Anomalies
Transposition of great arteries
Egg on a string sign
Chest X-ray and Cardiac Anomalies
Total Anomalous Pulmonary Venous Connection
Snowman sign
Chest X-ray and Cardiac Anomalies
Partial anomalous pulmonary venous return
Scimitar sign
Innocent murmur
Systolic
Less than 4/6 (no thrill)
Generally increased with fever, anemia, anxiety, excitement
Sitting or standing decreases murmur due to venous pooling
Several specific types
5 innocent murmurs of childhood
Still’s murmur
Pulmonary flow murmur
Peripheral pulmonic stenosis murmur
Supraclavicular bruit
Venous hum
Still’s murmur
Caused by uniform periodic vibration of the left heart structure
First heard during sick visit in preschooler and usually disappears in puberty
Most common innocent murmur
Still’s murmur characteristics
Short, systolic
Vibratory, buzzing hocking
Lower left sternal border
Most common 3-7 years
Louder supine
Decreases significantly or disappears with Valsalva
Pulmonary ejection murmur
- Probably from mildly turbulent flow in right side of heart
- Short, systolic ejection
- Upper left sternal
- All ages (rare in infants) Much more common in late childhood and early adolescents
- Louder with expiration
- Normal S2 split
Pulmonic ejection murmur characteristics
- Thin body habitus
- Straight back syndrome
- Increase cardiac output
- Increases with supine position
- Increased with fever, anemia
- Varies from I-III/VI
- Left and right sternal border, transmit to back
- Best heard in supine position with exhalation
- Intensifies with exercise
Peripheral pulmonic branch stenosis
- Turbulence arising the acute angle at which the relatively small branch pulmonary arteries take off from the main pulmonary artery
- Systolic, ejection which disappears by six months
- If it does not disappear by six month, severe branch pulmonary artery stenosis is associated with Williams syndrome and congenital rubella
- Chest and axillae (often loudest in axillary
- New born infants and early well child check
Supraclavicular carotid bruit Cause
Caused by turbulence at the take off area of the brachiocephalic and carotid arteries from the aortic arch
Supraclavicular Carotid Bruit Characteristics
- Systolic and ejection, high pitched, harsh
- Best heard in supraclavicular fossa on the right more than left
- Does not radiate far
- Supraclavicular region and neck
- Not heard below clavicle
- Not affected by sitting or lying
- Decreased by hyperextension of shoulder
Venous Hum
- Continuous (lounder in diastole)
- Supraclavicular
- Right more common than left
- Disappears with change in head position, digital pressure, lying spine
- Loudest when sitting or standing
When to refer: Neonate
- Murmurs are common in neonates
- Absence of murmur does not mean no heart disease
- Loud or long murmur
- Murmurs radiating to back
- Appears ill
- Any diastolic murmur
- Abnormal CXR or EKG
- Dysmorphic features
- Abnormal cardiac sounds
- Clicks, rubs, abnormally split S2 or single S2
Clues to Cardiac Disease in Neonates
Cyanosis
Tachypnea
Tachycardia
Diaphoresis
Gallop
Abnormal splitting of S2
Abnormal precordial activity
Hepatomegaly
Abnormal pulses
BP lower in lower extremities
Mottled extremities
Significant Hx
- Tachypnea
- Feeding intolerance
- Poor weight gain
- Exercise intolerance
- Excessive fatigue
- Frequent respiratory infections
- Syncope
- Persistent cough, wheezing (not associated with asthma
- Chest pain with exertion
- Cyanosis
- Palpitations
When to refer over 6 weeks
Abnormal pulse or BP
Abnormal S1 or S2
Displaced apical impulse
Click, gallop, rumble
Murmur – diastolic, continuous (if not venous hum), loud
Murmurs needing Eval
Murmurs in symptomatic kids
Loud murmur
Diastolic murmurs
Murmurs that don’t fit into categories of innocent murmur
Congenital heart disease
Presenting as an asymptomatic murmur
Septal
ASD, VSD
Obstruction to ventricular outflow
Valvar, subvalvular or supravalvar aortic or pulmonic stenosis
Coarctation of aorta
PDA
What causes systolic murmur
- Turbulence in ventricular outflow
- Narrowing of aortic or pulmonary valve, aorta or pulmonary artery
- Increased flow
- AV valve regurgitation
- Abnormal ventricular or arterial communications
- VSD or PDA
Aortic Valve Stenosis
Intro
Occurs in 5% of children with CHD
May have associated defect such as coarct, VSD or PDA
Non obstructive isolated bicuspid aortic valve is most common congenital defect which occurs in 1% of the population
Presentation of Aortic Stenosis
Most common is just a murmur
If very narrow valvular opening, needs the right to left shunting available through the PDA and may present acutely with shock or CHF if ductus closes
Can progress over months
Aortic Stenosis Presentation cont. (4)
- May be valvar, subvalvar or supravalvar
- Systolic ejection murmur begins early in systole after the click
- Medium to high pitched
- Upper right sternal border to apex
- Radiation to neck
- Click helps distinguish it from pulmonary flow murmur
- May have a thrill in suprasternal notch or in carotid arteries area
- Valvar AS usually cases a systolic ejection click at the apex
- Click is not present in the most severe cases
Pulmonic Stenosis
- Systolic ejection murmur
- Upper left sternal border
- Radiation to back
- Systolic ejection click at lower left sternal border which varies with respiration
- May have thrill in suprasternal notch
- Harsh loud murmur
Patient Ductus Arteriosus
- Blood from right ventricle into descending aorta, bypasses the lungs
- PDA normally closes by 48 hours after birth
- Direction of shunt depends upon the differential resistance between the aorta and pulmonary artery
- Right to left ductal shunting occurs with severe left heart obstructive lesions
- Severe coarctation
- Hypoplastic left heart
- Normally left to right shunting
Patent ductus arteriosus
Presentation
- Prematurity
- May have pulmonary overcirculation and will present early
- Infants and children tend be completely asymptomatic
- If infant is going to present with pulmonary overcirculation, does so when the pulmonary resistance falls at 4 to 6 weeks.
- Single S2 = pulmonary hypertension
Patent ductus arteriosus
2
Wide pulse pressure
Bounding pulses – waterhammer pulse
Quincke pulse on finger tips
Coarctation of Aorta
- Narrowing of aortic arch adjacent to the site of ductus
- Systolic ejection murmur below left scapula
- Decreases pulse and BP in lower extremities
- If severe, causes shock
- Often associated with bicuspid aortic valve
Ventricular Septal Defect
- Holosystolic murmur
- Harsh, high pitched if VSD is small
- Diastolic rumble at Apex
- CHF is VSD is large
- Increased LA pressure
- Pulmonary edema
- Increased work of breathing
- Poor growth
- Can lead to pulmonary hypertension if not found
Ventricular Septal Defect (2)
- At birth PVR is greater than SVR and shunt is right to left or bidirectional
- As PVR falls, then left to right shunt and murmur appears
- Pitch depends on whether right to left or left to right
- Diastolic rumble
- Caused by vibration of the mitral valve as the large volume of flow from the lungs goes into the left ventricle
- Much more likely to be moderate in intensity
VSD (3)
Can have a normal to wide split S2 which will vary with respirations
Increase volume traversing the pulmonary valve causes it to close later
Loudness of murmur does not correlate with size of the defect
Plateau shaped murmur with the same intensity throughout.
Atrial Septal Defect
- Systolic ejection murmur
- Upper left sternal border
- Wide fixed split S2
- Right ventricular impulse
- Diastolic rumble at lower left sternal border
- CHF not seen
- Subtle exercise intolerance
What causes diastolic murmurs?
- Turbulence in ventricular inflow
- Narrowing
- Increased flow
- Semilunar valve regurgitation
What causes continuous murmurs
- Abnormal systemic to pulmonary artery communications
- PDA
- Abnormal arteriovenous communications
- AV fistula
- Coronary artery fistula
Common murmurs in first days of life
NORMAL
- PPS
- Pulmonary flow murmur
- Transitional murmurs
- Closing PDA
- Transient tricuspid regurgitation
Common murmurs in first days of life
ABNORMAL
- Outflow obstruction
- AS
- PS
- Coarctation
- Abnormal communications
- VSD
- PDA
Transitional murmurs
ULSB or left infraclavicular area
Systolic or continuous
Often louder as PDA gets smaller
Occasional vibratory
Typically 12 to 48 hours of age
Transient Tricuspid Regurgitation
- LLSB
- Regurgitant, systolic
- Often seen with asphyxiated infants or infants with pulmonary hypertension
- Takes several days to resolve
Complex Congenital Heart disease
- Ebstein anomaly
- Common AV canal (truncus)
- Tetralogy of Fallot
- Hypoplastic left heart
- Transposition of the great vessels
CHF History Child
Decreased exercise capacity
Fatigability
SOB
Weight gain or loss
CHF History – infant
Poor weight gain
Cachexia
Malnutrition
Sweating when feeding
CHF Hx
Adolescent
Fatigue
Cold intolerance
Exercise intolerance
Syncope
Dizziness
CHF physical Exam
First sign = TACHYCARDIA
- Infant heart is stiffer and less distensbile so they increase rate as they cannot increase stroke volume
- Tachypnea
- Hepatomegaly
- Edema
- Ascites
- Diminish perfusion
- Pedal edma and neck veing distention are rare
- Listen for gallop
Hypertrophic Cardiomyopathy
- May have biventricular outflow tract obstruction in infancy
- Older children asymptomatic
- May have murmur
- Pulse may be diminished as ventricular ejection is impeded
- Listen to murmur squatting and then have the patient stand.
- MURMUR WILL greatly INCREASE IN INTENSITY as child stands
Hypertrophic cardiomyopathy
POSITIONS
- Maneuvers that increase the intensity and duration of the murmur
- Decrease preload
- Strain of Valsalva
- Increase contractility
- Exercise
- Decrease afterload
- Stand suddenly
- Decrease preload
- Maneuvers that will decrease the intensity and duration of the murmur (this is the opposite of what you would expect)
- Increase afterload
- Squat or hand grasp
- Increase preload
- Raise legs
- Increase afterload
