Child with a Murmur Flashcards
What terms are used to describe locations on the precordium?
Upper right sternal border
Upper left sternal border
Lower left sternal border
Apex
How common are innocent murmurs?
30-70%
What do all innocent heart murmur have in common?
Early/ejection systolic in nature Never heard in diastole Vary with position and respiration Normal heart sounds No click or thrills
What is the most common type of innocent murmur?
Still’s vibratory murmur
What are the features of a Still’s murmur?
In preschool age
Musical
Early or mid systolic
Maximal at LLSE
What are the features of a pulmonary flow murmur?
– Typically children to adolescents – Ejection to mid systolic peak
– 2nd-3rd interspace LUSE
– Medium to high pitch
– Beware DDx
What are the features of branch pulmonary stenosis?
Infants - typically under 6 months
Murmur same as pulmonary flow murmur
Radiate to both axilla and back
What are the features of venous hum?
Low pitch, continuous Turbulence in superior cava and right atria Loudest on right side of neck Louder when standing up Quieter when lying and head turned
What maneuvors be performed to confirm innocence of a murmur?
Louder on inspiration
Disappears when erect
Audible when supine
Louder on squatting
Why does splitting increase in inspiration?
Increased negative pressure - increased preload - takes longer for blood to flow out of right ventricular - pulmonary valve close later
What are some exam findings that are predictive of a pathological murmur?
Pansystolic
Additional heart sound
Intensity more than grade 3
Max point of intensity left upper sternal border
What are the most common congenital heart defects?
VSD - 25-30%
ASD - 6-8%
PDA - 6-8%
Which lesions cause high pulmonary blood flow?
Shunt lesions
ASD
VSD
PDA
How do high pulmonary blood flow states present?
Tachypnoea, recession, FTT
Sweat, irritability, tachycardia due to increased catecholamines
What is the murmur in VSD?
Pansystolic murmur
When do symptoms occur in VSD?
When pulmonary vascular resistance drops at 6 weeks - allows more left to right shunting
How are VSD treated medically? How does it work?
Diuretics - reduce volume overload
ACEi - Afterload reduction
Physiologically, what is the major difference between VSD and ASD?
VSD causes left heart overloading
ASD causes right heart overloading
How do ASD present?
Uncommonly give rise to symptoms in infancy
Some mild increase WOB
Eventually causes pulmonary HTN, heart failure, arrhythmias
How does ASD present on exam?
Ejection systolic pulmonary flow murmur
Fixed splitting of S2
How are ASD treated?
80% of small lesions close in first 2 years
Large defects closed before school age
- Percutaneous closure
What are the features of TOF?
Pulmonary outflow tract obstruction
VSD
Right ventricular hypertrophy
Overriding aorta
What causes cyanotic newborns?
Transposition of the great arteries
