Child with a Murmur

Question 1

What proportion of children are found to have a murmur compared to those that actually have congenital heart disease?

Answer 1

• 30-70%
• 0.8% have congenital heart disease

Question 2

What are the features of an innocent paediatric murmur?

Answer 2

• Early/ejection systolic
• Never limited to diastole
• Vary with position and respiration
  
  • Increase on inspiration
  • Audible supine, disappears or softer when erect, increase with squatting
• Normal heart sounds and normal physiological S2 split
• No clicks or thrills associated

Question 3

What are the features of a Still’s murmur?

Answer 3

• Most common innocent murmur
• Peaks at 2-6 years
• Early/mid systolic crescendo-decrescendo murmur at a low/medium pitch.
• Heard best at the lower-left sternal edge

Question 4

What are the features of a pulmonary flow murmur?

Answer 4

• Peaks in children/adolescence
• Early/mid systolic peak, medium-high pitch
• Heard best at left-upper sternal edge
• Red flags - ejection click, thrill (pulmonary stenosis), atrial septal defect

Question 5

How is a branch pulmonary stenosis murmur clinically distinguished from a pulmonary flow murmur?

Answer 5

• Same features
  
  • Early/mid systolic peak, medium-high pitch
  • Heard best at left-upper sternal edge
• Generally heard in infants < 6 months while the main PA forms a more acute angle with a branch.
• Radiates to axilla and back

Question 6

What are the features of a venous hum murmur?

Answer 6

• Low pitch continuous murmur
• Loudest in the low anterior neck and infraclavicular area R>L
• Quieter when head turned away or jugular vein compressed

Question 7

What are some red flags when listening to a paediatric murmur?

Answer 7

• Loud murmur > grade 3
• Diastolic/continuous murmurs
• Obvious or fixed S2 splitting

Question 8

What are the features of the murmur arising from a ventricular septal defect? How is this condition managed?

Answer 8

• Pansystolic murmur heard best at the lower left sternal edge (septum)
• Louder can mean a smaller defect
• Mx - reduce preload/afterload (ACEIs, diuretics), consider surgery

Question 9

What are some features of the murmur caused by an atrial septal defect? How is it managed? What are the complications if it isn’t?

Answer 9

• Ejection systolic murmur with S2 splitting
• Surgical closure
• Pulmonary hypertension, arrhythmias, heart failure

Question 10

What are the features of a murmur caused by a patent ductus arteriosus? How is it treated?

Answer 10

• Continuous machine-like murmur heard best over the ULSE
• Treatment - indomethacin (prems - closes PDA), surgery/device (term)

Question 11

List some causes of acyanotic heart disease. What is the underlying pathophysiology?

Answer 11

• VSD, ASD, PDA, coarctation, pulmonary or aortic stenosis
• Left -> right shunt or obstruction

Question 12

List some causes of cyanotic heart disease. What is the underlying pathophysiology?

Answer 12

• Tetralogy of Fallot, transposition of the great arteries, total anomalous pulmonary venous connection
• Right to left shunt

Question 13

What are the 4 features of the tetralogy of Fallot?

Answer 13

• Stenosis of the pulmonary artery
• Intraventricular communication (VSD)
• Deviation of the origin of the aorta to the right
• Concentric right ventricular hypertrophy

Question 14

Outline the treatment of transposition of the great arteries

Answer 14

• Echo diagnosis
• Prostaglandin to maintain PDA patency
• Balloon atrial septostomy
• Arterial switch operation