CVS- PED Flashcards
The examination of the heart and the vascular systems in infants and children is similar to that in adults. T or F
True
To make the examination easier and more productive, a good clinician must recognize:
- the fear/s of their patient
- their inability to cooperate
- (in many instances), their desire to play
USE YOUR KNOWLEDGE OF THE DEVELOPMENTAL STAGE OF EACH CHILD
A ____________may be easiest to examine while standing or sitting on mother’s lap, facing her shoulder, or being held
2 yr old
USE YOUR KNOWLEDGE OF THE DEVELOPMENTAL STAGE OF EACH CHILD
Give young children___________they cannot figure out how to drop the objectà no free hand to push you away
something t-o hold in each handà
__________-to small childrenà will hold their attention à they may forget your examining them
Endless chatter
USE YOUR KNOWLEDGE OF THE DEVELOPMENTAL STAGE OF EACH CHILD
Let children move the stethoscope themselves, going back to listen properly. true or false
True
General abnormalities may suggest_____________-, as exemplified by Down syndrome or Turner’s syndrome
** increased likelihood of congenital cardiac disease**
Around age________
Measure blood pressure in both arms and one leg at one time around this age
This is to check for possible _____________
Thereafter, the right arm blood pressure needs to be measured.
3 to 4
*coarctation of the aorta
*in_______________, the blood pressure is lower in the legs than in the arms
coarctation of the aorta
_____________children often have benign murmurs.
Preschool and school-‐aged
Most common
Grade I-II/VI
Musical and vibratory
Early and midsystolic murmur with multiple overtones
Located over the mid or lower left sternal border
CAN also be heard over the carotid arteries
Still’s murmur
__________- à disappearance of the precordial murmur
Carotid artery compression
This murmur may be extremely variable and may be accentuated when cardiac output is increased, as occurs with__________________
Note: The murmur will diminish as the child goes from supine to sitting to standing
fever or exercise.
Usually heard in preschool and school-aged children
Soft, hollow, continuous sound
Louder in diastole
Heard just below the right clavicle
Can be completely eliminated by maneuvers that affect venous return (lying supine, changing head position, jugular venous compression)
Same quality as breath sounds (frequently overlooked)
Venous hum
Murmur heard in the carotid area or just above the clavicles
Early and midsystolic
Slightly harsh quality
Louder on the left
May be heard alone or in combination with the Still’s murmur
May be completely eradicated by carotid artery compression.
Carotid bruit
*Among young children, murmurs without the recognizable features of the three common benign murmurs may_______– and should be evaluated thoroughly by pediatric cardiologists
signify underlying heart disease
Pathologic murmurs that signify
cardiac disease can first appear
_______________
Examples include aortic stenosis
and mitral valve disease.
after infancy and during childhood.
The murmur heard in
the carotid area or just
above the clavicles is
known as a ______________
It is early and
midsystolic, with a
slightly harsh quality. It
is usually louder on the
leftandmay be heard
aloneor in combination with the Still’s murmur. It may be completely
eradicated by carotid artery compression.
carotid
bruit.
Location and Characteristics of Benign Heart Murmurs in Children*
Preschool or early
school age
description:
Grade I–II/VI, musical, vibratory
Multiple overtones
Early and midsystolic
Mid/lower left sternal border
Frequently also a carotid bruit
Still’s murmur
Preschool or early
school age
Venous hum
Soft, hollow, continuous
Louder in diastole
Under clavicle
Can be eliminated by maneuvers
Venous hum
Preschool and later
Early and midsystolic
Usually louder on left
Eliminated by carotid compression
Carotid bruit
Older child, adolescence and later
Grade I–II/VI soft, non-harsh
Ejection in timing
Upper left sternal border
Normal P2
Pulmonary flow murmur
The_____________is a grade I–II/VI soft, non-harsh
murmur with the timing characteristics of an ejection murmur, beginning
after the** first sound and ending before the second sound** but without the
marked crescendo–decrescendo quality of an organic ejection murmur.
If you hear this murmur,** evaluate whether the pulmonary closure sound is of
normal intensity** and** whether splitting of the second heart sound is eliminated**
during expiration.
benign pulmonary flow murmur
An _______________
murmur will have normal intensity and normally split second heart sounds.
This pulmonary flow murmur may also be heard in the presence of volume
overload from any cause such as chronic anemia, and following exercise. It
may persist into adulthood.
adolescent with a benign pulmonary ejection
A pulmonary flow murmur accompanied
by a fixed split second heart
sound suggests right-heart volume
load such as an__________
atrial septal defect.
The patient:
Should have their shirt/s off, or wear an examination gown
Females _____________ and older should wear a gown with the opening infront
Should be calm and quiet.
9 yo and above
The stethoscope:
It should be your own!!!!
This part of the stet is useed for high pitched ( primarily systolic)sounds and press firmly
diaphragm
This is a part of the stet that is low pitched ( primarily diastolic ) sounds, and press lightly
BELL
Diapragm should be small enough to fit on the chest of the patient
it should have a tubing which is ______________ and has a size of ___________
It should have earpiecesthat are comfortable and snug
short ( 16- 18 inches)
Should be quiet ( patient, family, exam room, surrounding areas)
- may briefly disconnect ventilator or occlude suction devices
- BRIEF bilateral occlusion of infant nares ( warn the parents first))
- should be well lit
environment
the order of CVS examination ins pedia is :
Inspection
Palpation
Auscultation
**** Percussion is ommitted)
chest observation gives clues to cardiopulmonary diseases
can be insensitive
INSPECTION
in the inspection, an asymmetry is an indicative of:
RVE
INSPECTION:
Increased A-P chest diameter indicates ____________
chronic air trapping/ hyperinflation
INSPECTION
___________- can cause displacement of the heart
PECTUS EXCATUM
Note :
a Latin term meaning hollowed chest)[1] is the most common congenital deformity of the anterior wall of the chest, in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest.[2] It can either be present at birth or not develop until puberty.
Pectus excavatum is sometimes referred to as cobbler’s chest, sunken chest, the crevasse, or funnel chest.
The hallmark of the condition is a sunken appearance of the sternum. The heart can be displaced and/or rotate**d.Mitral valve prolapse **may also be present. Base lung capacity is decreased
INPECTION:
is a horizontal groove along the lower border of the thorax corresponding to the costal insertion of the diaphragm; It is usually caused by chronic asthma or obstructive respiratory disease. It may also appear in ricketsbecause the patients lack the mineralized calcium in their bones necessary to harden them; thus the diaphragm, which is always in tension, pulls the softened bone inward. During rickets it is due to the indentation of lower ribs at the point of attachment of diaphragm.
It is named after Edwin Harrison
Harrison’s groove, also known as Harrison’s sulcus
Sometimes overlooked
Use the most sensitive portion of the hand
Lay the heel of R hand at Left sternal border with fingertips pointing to left of the axilla
PALPATION
Found the fingertips during palpation
note interspace location, relatioo the midclavicular / anterior axillary line, amplitude
Apical impulse/ apex bear/ PMI
The strong impulse in apical impulse / apex bear/ PMI is due to ____________________
increased CO or LVH
The Downward/ leftward displace in PMI is ____________________________
LVH
This disease can shift PMI posterior ( making it difficult to palpate)
RVH
Palpation of loud murmur/ felling or rumbling
Thrills
Forceful, systolic thurst that moves the palpating hand up a little
Heave
A heave is an vindicative of
RVH
This is usually not performed for cardiac borders, but for lung fields
percussion
The bread and butter of the business
Where to listen in auscultaion?
Mitral area
tricusp and secondary aortic area
aortic area
pulmonary area
APEX/ 5 LICS ( mitral area)
Left lower sternal border/ 4 LICS: ( tricuspid and secondary aortic area)
upper Right sternal border/ 2RICS ( aortic area)
Upper left sternal border/ 2LICS: pulmonary area
lWhere else to listen?
Left and right infraclavivular areas
Left anterior axillary line
R and L axillae
R and L interscapular areas of back ( for pulmonary / aortic collaterals)
AUSCULTATION:
How to listen ?
Have a system, e.g. method of inching
Listen systematically: s1, s2, systolic sounds, systolic murmurs, diastolic sounds , diastolic murmurs
(real) Normal heart sound
LUB DUP
Closing of the mitral and tricuspid valves
S1
s1 is best heard at the ____________
apex and LLSB
Tends to be more low- pitched and long as compared to S2
S1
Occurs with high cfever, exercise, ardiac output such as thyrotoxicosis
LOUD S1
A soft S1 occurs with the following __________________
- impaired myocardial contraction
- CHF
- mitral regurgitation
- slowed venricular ejection rate
- mitral insufficiency
- increased chest wall thickness
- pericardial effusion
- hypothyroidism
- cardiomyopathy
- aortic insufficiency
11.
how to differential S1 from S2 ?
by palpating carotid pulse
Note: S1 comes before and S2 comes after carotid upstroke
From closure vibrations of aortic and pulmonary valves
often ignored, but it can tell much
S2
S2 is divided into :
A2 and P2
Note: A2 : aortic
P2 : pulmonary closure sounds
Aortic closes before pulmonic
This is best heard at LMSB/ 2LICS
Higher pitched than S1– better heard with diaphragm
S2
Normally split is due to different impedance of sytemic and pukmonary vascular beds
audible splut with > 20msec difference
Split in 2/3 of NB by 16 hrs of age, 80 % by 48 hrs
hard to discer in heart rates > 100 bpm
S2 splitting ( normal)
Respiratory variation causes increase splitting on inspiration: decrease pulmonary vascular resistance , increase pulmonary blood flow
When supine, slight splitting can occur in expiration
when upright S2 usually become single with expiration
S2 splitting ( normal, cont)
Single S2 occurs with greater impedance to pukmonary fow,P2 closer to A2
single S2
Single and loud A2 :
TGA,
extreme ToF
Truncus arteriosus
Single and loud P2:
Pulmo HPN
Single and soft
ToP
Loud ( not single ) A2:
CoA or Ai
What are extra heart sounds?
- S3
- S4
- Clicks
- Friction rub
Usually physiologic in infants and children
low pitched sound, occurs with rapid filling of ventricles in earlly diastole
Due to sudden intrinsic limitation of longitudinal expansion of ventricular wall
Makes Ken- tuck- y- thytm on auscultation
S3
S3 + tachycardia
Gallop ( galloping horse)
best heard with patient supine or in left lateral decubitus
increases by exercise, abdominal pressure or lifting legs
S3
LV S3 is heard at ___________
RV S3 is hear at ____________
apex
LLSB
Nearly always pathologic
Can be normal in elderly or athletes
low pitched sound in late diastole
Due to poor compliance causing vibration in stiff ventricular myocardium as it fills
Makes “ Ten-nes-see” rhythm
Better heard at the apex or LLSB in the supine or left lateral decubitus position
S4 gallop
S4 associiations are:
CHF
HCM
severe systemic HTN
Pulmonary HTN
myocarditis
tricuspid atresis
TAPVR
CoA
AS with severe LV disease
Kawasaki;s disease
Usually pathologic
Snappy, high pitched sound usually in early sytole
Due to vibration in the artery distal to a stenotic valve
Click
Click can be associated with:
valvar aortic stenosis or pulmonary stenosis
Truncus arteriosis
Pulmonary atresia/ VSD
Bicuspid aortic valve
Mitral Valve prolaps
Ebstein’s anomaly
Creaking sound hear with pericardial imflammation
changes with position, louder with inspiration
caused by pericardial effusion, and can be heard in a limted area in the left left parasternal space
Friction rub
Sounds made by turbulsence in the heart of blood stream
Described as wooshing sound
** can be benign ( Innocent, flow, functional) or pathologic**
murmur are the leading cause for referral for further evaluation
Dont let murmurs distract youffrom the rest of the exam
Murmur
When do murmurs occur?
They occur when blood makes a:
- Forward flow through a constrict/ stenosed valve
- ( i.e systole = pulmonic valve stenosis and Aortic valve stenosis.
- Diastole = Tricuspid valve stenosis, Mitral valve stenosis.
- backwarflow/ regurgitation through a prolapsing valve ( ie mitral valve prolapse, through which the blood flows from the left ventricular back into the left atrium
- Backward flow of the blood through a septal defect
- (ASD/ atrial septal defect = communication between the left and right ventricles;
- VSD = communication between the left and right venricles
- Flow of blood through “ persistent” fetal structure
- ( ie. Patent foramen ovale and patent ductus arteriosus
What is the first step in investigating a murmur
Identify the normal heart sounds ( S1 and S2 )
►
analyze the murmur
Grading of intensity or loudness
graded on a 6 point scale:
grade 1: very FAINT
grade 2: quiet but heard immediately
grade 3: moderately loud
grade 4: loud
grade 5: heard with stethoscope partyly off the chest
Grade 6: no stethosopce needed
Note: THRILSS ARE ASSOCIATED WITH MURMURS of GRADES 4-6
Murmurs are longer than heart sounds
HS can be distinguised by simultaneous palpation of the carotid arterial pulse
systolic, diastolic, continuos
Timing
LOCATION
Area: UPPER RIGHT STERNAL BORDER ( 2nd RICS)
aortic stenosis, venous hum
Upper left sternal border ( 2nd LICS)
Piulmonary stenosis
Pulmonary flow murmurs
Atrial septal defect
PDA
Lower left sternal border ( 5th LICS)
Stiff’s murmur
ventricula septal defect
tricuspid valve regurgitation
hypertrophic cardiomyopathy
subaortic stenosis
Apex ( 5th ICS LMCIS)
Mitral valve regurgiitation
RAdiation:
To the neck?
axilla?
upper or lower sternal border
back
General rule of thumb: is that the sound radiates in the direction of the blood flow
A murmur can radiate to different locationss from its origin, and this can be an important clue because it correlates with the direction of __________________
blood flow
Systolic ejection murmur ( AS vs MR vs VSD)
the murmur of aortic stenosis tends to radiate to the common carotid arteies, wheres mitral regurgitaion classically radiates to the left axiilla.
A VSD does not radiate to those areas
Other characteristics:
shape
crescendo
decrescendo
up-down
plateau
other charac:
pitch
high
mild
low
other charac of murmurs
quality
blowing
harsh
rumbling
musical
What are the variations in murmurs?
Variation with respiration ( R- sided murmurs change more tha n L- sided)
Variation with position of patient
variation with special maneuvers
Definition:
contractio of ventricles
SYSTOLE
contraction of atrium / relaxzaiton of ventricles
diastole
the valvels are hard/ stiff such that they make a snapping sound when they are open.
stenosis
Notes: this happens in pulmonary valve stenosisenosis a, mitral valve stenosis ic and aortic valve stenosis. Sometimes the valves become too “stenosed/ hardened” such that there may be a tendency for a forward flow to be interrupted. If such happens in aortic valve stenosis, there will be lack of oxygenized blood pumped into the systemic circulation, thus causing sudden fainting of an otherwise seemingly normal patient.
backward flow thorugh the blood
regurgitation
What are the types of murmurs
I. systolic
- Ejection
- innocent murmur
- aortic stenosis
- pulmonic stenosis
- atrial septal defect
- Holosystolic/ pansystolic
- mitral regurgitation
- mitral valve prolapse
- tricuspid valve regurgitation
- ventral septal defect
II. ** diastolic**
- A. Aortic regurgitaion
- B. Mitral stenosis
- C. pulmonic regurgitation
III. Combined
- A. PDA
- B. Severe coarctation of the aorta
Begins after the first heart sound, increases in intensity immediately after, but wanes before it reaches the second heart sound
Systolic ejection murmur
- Always systolic
- Without evidence of any physiologic or antomic abnon and rmalities
- grade 5/ 6
- Varies considerably in position and level of activity
- Does not radiate to the carotids nor axillae
- Seen in up to 50 % of children, ussually 3-8 yrs old, then disappears by puberty
- Low to medium pitched, best heard in 3rd- 4th ICS
- Due to high cardiac output states and flow-related ( thyrotoxicosis, anemia, fever, exercise, pregnancy)
Systolic ejection murmur
What are the pathological systolic ejcetion murmur
B. Pathological
- ASD
- PS
- AS
- Begins with 1st heart sound and continues through systole in a plateau like fashion beyond the 2nd heart sound
- Terminates when the pressure in the left ventricle drops to the level of the left atrium during isovolimic relaxation
- Little variation with respiration
- flow from a high pressure chamber to a low- pressure chamber
- May be absent in large lesions or in EISENMENGER SYNDROMES
- seen in MR, TR, VSD
Holosystolic/ pansystolic Murmur
- Occurs in diastole beginning with the 2nd heart sound and ending just before the 1st heart sound
- Low- pitched “ rumbling” - mitral stenosis: occurs early in diastole and presystole; has an associated “ opening snap”
- high - pitched “ regurgitaion” - aortic insufficiency
holosystolic / pandiastolic murmur
- Begins in systole ( or the 1st heart sound) , and extends through the 2nd ho part or all oear sound, into part or all of the diastole
- PDA- from high pressure vessel ( aorta) to low- pressue vessel ( pulmonary artery
continuos murmur
What are the rechniques in enhancing auscultaion?
- inspiration- normally you should hear splitting of s2 with inspiration. P2 occurs later and moves farther away from A2
- Exhalation- can be used to evaluate right-sided heart murmurs. R-sided murmurs decrease with inhalation, while L-sided murmurs remain unchanged
- Muller’s maneuvers
this is a technique where in you ha patient pinch the nostrils shut with one hand and suck on a finger with the other ( creates prolonged negative intrathoracic pressure; shifts blood from systemic to pulmonary circulation
Muller’s maneuver
standing to squatting- squattin increases stroke volume, and standing decreases it again
- _________________ - as patient squats,this murmur should be decreased
Hypertrophic obstructive cardioyopathy
occasionally decreases in standing to squatting
mitral regurgitation
in squatting to standing this murmur increases
hypertrophic obstructive cardiomyopathy
Note: mitral regurgitation ocassionally increases
mumur should decrease, as vLV increases and Lv enlarges
place blood pressure cuff on both arms and occlude blood flow for 20 secs
Note: increases intensity : MR, VSD, other mumur unaffected
transient arterial occlusion
- Normal pulses; radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis
- Rhtym abnormalities
- Sinus arrrhytmia: pulse accelerates with inspiration
- pulse deficit: with atrial affibrilation + tachycardia, the radial pulse is notconsecuiequal to the cardia apical pulse
- Bigeminal pulse: 2 consecutive beats closely couples, with susbsequent pause after the next beat
Arterial pulse
Volume abnormalities:
quick upstroke and full voliume —> seen in HPN and anxxiety
hyperkinetic pulse
Vvolime abnormalities:
- a brisk pulse with large volume, collapsing pulse ( in aortic regurgitation)
Corrigans pulse
Volume abnormalities:
This is a bifid oulse, 2 distinct impulses with each heartbeat, seen in aortic regurgitation, hypertrophic cardiomyopathy
pulse bisfiriens
volume abnormalities:
This is a one pulse feels larger, the next one small = due to decreased cardiac contractility ( poor prognosis)
pulse alterans
Volume abnormalities:
this is a weakening of pulse with inspiration more than normal (pericardial effusion, constrictive percarditis
pulse parodoxus
How is pulse being graded?
0= no pulse
3= normal pulse
4= bounding pulse
this is a temporary weakening of lower extremities due to arterial insuffficiency
intermittent claudication
atherosclerosis of abdomina aorta, reducing flow to lower exremities, leading to impotence
Leriche’s syndrome
this is a pulseless disease -no pulse in arms due to progressiv obliterative arteritis
takayasus’s arteritis
What vein is used in Cenral venous pressure
Right internal jugular Vein is used
