Murmur

Question 1

On your review of a 1-year-old child with an upper respiratory tract infection you note a grade 2-3/6 pansystolic murmur at the left sternal edge with an active praecordium. On further history the child has poor growth over the last 12 months.

Answer 1

Impression
Cardiac murmur’s are common examination findings, and can represent a wide range of normal physiological findings and pathology.

Whilst this may represent a physiologial or innocent murmur, or a flow murmur. However, given the child has a hyperdynamic precordium and has had poor growth in the past 12 months, I would be concerned about acynotic cardiac pathology including;
PDx - AVSD (commonly associated with Down syndrome)
- septal defects (ASD, VSD - more likely given it is pan-systolic)
- PDA
With these there is a risk of progression to Eisenmenger’s syndrome and subsequent cyanotic presentation.
- other valvular lesions (stenosis, regurgitation)

Less likely but would want to rule out cyanotic cardiac pathology including;

• Tetralogy of Fallot
• Transposition of great vessels
• Tricuspid atresia
• Truncus arteriosus
• total arterial pulmonary venous connection
• Ebstein’s anomaly (risk in lithium during pregnancy)\

Goals

• ensure haemodynamic stability in the patient
• targeted Hx/Ex/Ix, determine likely underlying pathology
• initiate appropriate referral and management

Question 2

Murmur - History

Answer 2

History

• sx: poor feeding, irritability, difficulties breathing, recurrent respiratory infections, abdominal pain, developmental delay, diaphoresis, facial oedema
• HPI: recent changes or present since birth, skin colour at birth, recent illnesses (flow murmur)
• Family history of CHD, cardiovascular disease
• Details of pregnancy and birth, blue book assessment findings
• Rest of paediatric history (vaccinations, medications, milestones, etc)

Question 3

Murmur - Examination

Answer 3

Examination

• General observation + vitals (agitation, cyanosis, SOB/dyspnoea, use of accessories, birth defects, signs of Trisomy 21)
• Cardiac examination: auscultate for murmurs (location - Left sternal edge more likely flow), palpate for thrills/heaves, peripheral stigmata (clubbing). Assess the murmur in different positions (lying to sitting is different)
• Respiratory exam: signs of pulmonary oedema secondary to heart failure: bibasal crackles
• Abdominal examination: hepatomegaly

Question 4

Murmur - Investigations

Answer 4

Investigations
Key/diagnostic:
- Echocardiogram

• Bedside: ECG, vital signs, VBG if acute concern
• Bloods: Not indicated
• Imaging: ECHO, CXR for cardiac/pulmonary complications

Question 5

Murmur - Management

Answer 5

Management
Depends on the degree of acute concern;

if HD stable;
- Timely referral to paediatric cardiologist

If HD unstable

• immediate referral to ED for stabilising measures
• paediatric cardiology referral; likely surgical management with repair of any congenital heart disease found

If innocent heart murmur;
- appropriate to do nothing and just have follow up review in 1-2 weeks to assess for any changes