Paediatric Cardiology - Murmurs and Blue Baby

Question 1

What are most heart murmurs in children like?

Answer 1

“innocent” - not associated with pathology

Question 2

What features of a murmur should you comment on?

Answer 2

Timing - systolic or diastolic
Character - pan systolic or ejection systolic?
Loudness - out of 6, >=4 is palpable (thrill)
Radiation

Question 3

What are the main types of innocent murmurs?

Answer 3

Ejection murmur

Venous hum

Question 4

What are the hallmarks of an innocent murmur?

Answer 4

Asymptomatic
Normal CVS exam
Systolic or continuous
No radiation
Variation with posture

Question 5

What are ejection murmurs caused by?

Answer 5

Outflow tract either side of the heart

Question 6

How do ejection murmurs sound?

Answer 6

Soft blowing systolic murmurs

Second and fourth left intercostal spaces

Question 7

How are venous hums generated?

Answer 7

By head and neck veins

Question 8

How do venous hums sound?

Answer 8

Continuous low pitched tumble

Heard beneath clavicle

Disappear on lying flat

Question 9

When is an innocent murmur more likely to be noted?

Answer 9

During tachycardia e.g:

With fever
Anaemia
Exercise

Question 10

What features if associated with a murmur make it significant?

Answer 10

Syncope
Episodic cyanosis
Abnormal pulses, heart sounds, BP or cardiac impulse
Diastolic murmur
Pan systolic murmur
Murmur radiate to back
Thrill

Question 11

What murmurs are most likely to be heard at the upper right sternal border?

Answer 11

Aortic stenosis

Question 12

How does aortic stenosis sound?

Answer 12

Ejection systolic
Preceding ejection click
Radiate to neck

Question 13

What is aortic stenosis associated with?

Answer 13

Williams syndrome

Question 14

What murmurs are most likely to be heard at the upper left sternal border?

Answer 14

PDA
ASD
Pulmonary stenosis
Coarctation of the aorta

Question 15

How does a Patent Ductus Arteriosus sound on auscultation?

Answer 15

Continuous machinery like murmur
Radiate to back
Bounding/collapsing pulse
Wide pulse pressure

Question 16

How does an Atrial Septal Defect sound? What is it associated with?

Answer 16

Ejection systolic murmur
Wide fixed (doesn't change with inspiration) splitting of S2

Associated with Down’s

Question 17

How does pulmonary stenosis sound on auscultation? What is it associated with?

Answer 17

Ejection systolic murmur
Preceding ejection click
Radiate to back

Associated with Noonan’s syndrome

Question 18

How does coarctation of the aorta sound on auscultation?

Answer 18

Systolic crescendo-descrendo murmur

Radiate to back

Question 19

What other clinical features does coarctation present with and what condition is it associated with?

Answer 19

Radio-femoral delay
BP Difference in upper and lower limbs

Associated with Turners syndrome

Question 20

What murmurs are heard at the left lower sternal border?

Answer 20

Innocent murmurs
VSD
Tricuspid regurgitation

Question 21

How does a Ventricular Septal Defect sound and what is it associated with?

Answer 21

Harsh pan systolic murmur
Radiate all over chest

Associated with Down’s, Patau’s and Edwards

Question 22

How does tricuspid regurgitation sound?

Answer 22

Loud pansystolic murmur

Louder on inspiration

Question 23

What murmurs are heard best at the apex?

Answer 23

Mitral regurgitation

Mitral valve prolapse

Question 24

Describe the mitral regurgitation murmur

Answer 24

Pansystolic murmur

Radiate to axilla

Question 25

Describe the mitral valve prolapse murmur

Answer 25

Late systolic murmur | Preceding systolic click

Question 26

What causes central cyanosis?

Answer 26

Desaturation of central arterial blood

Question 27

How does central cyanosis appear?

Answer 27

Blue colouration of mucous membranes of lips, tongue and extremities

Question 28

What causes peripheral cyanosis and how does it appear?

Answer 28

Decreased local circulation and increased extraction of O2 from tissues Blue skin around lips and extremities (NOT MUCOUS MEMBRANES)

Question 29

What are the categories of causes of cyanosis?

Answer 29

Cardiac Respiratory Other

Question 30

What are the cardiac causes of cyanosis?

Answer 30

Transient cyanosis - can be central or peripheral (central much shorter) Cyanotic congenital heart defects (ToF, transposition etc.) Total anomalous pulmonary venous return Truncus arteriosus

Question 31

What are the respiratory causes of cyanosis?

Answer 31

``` Resp distress syndrome Birth asphyxia Transient tachypnoea of newborn Meconium aspiration Pneumothorax ```

Question 32

What are the other causes of cyanosis?

Answer 32

Infection Seizures Metabolic abnormalities

Question 33

What are some causes for cyanosis in an older child?

Answer 33

``` Infection Seizure Metabolic disturbance Pneumonia Asthma PE CHD Raynauds ```

Question 34

How do children with Duct Dependent Congenital Heart Disease's present?

Answer 34

Acutely unwell within first 2-4 days of life due to ductus arteriosus closing

Question 35

What circulation can be dependent on the ductus arteriosus staying open?

Answer 35

Pulmonary and Systemic circulation

Question 36

How does a patient with duct dependent systemic circulation present?

Answer 36

``` Hypoxic Resp distress Heart failure No femorals Metabolic acidosis ```

Question 37

How does a patient with duct dependent pulmonary circulation present?

Answer 37

Cyanosed Tachypneic Normal pulses

Question 38

How do you treat duct dependent Congenital Heart Disease's?

Answer 38

IV Prostaglandin E2 - Dinoprostone

Question 39

What does Dinoprostone (prostaglandin E2) do?

Answer 39

Smooth muscle relaxant - keep DA patent

Question 40

What are the Adverse Drug Reaction's associated with Dinoprostone?

Answer 40

``` Hypotension Bradycardia Apnoea Fever Jittery ```

Question 41

What investigations should you do if a child is cyanosed?

Answer 41

``` ABG Hb Infection markers, sputum and blood cultures Echo - CHD CXR ```

Question 42

What is the hyperoxia test?

Answer 42

Used to determine whether cyanosis is due to a R --> L shunt or another illness

Question 43

How is the hyperoxia test carried out and interpreted?

Answer 43

Give 100% O2 for 10 mins If sats remain low --> CHD

Question 44

Why do sats not improve when giving a cyanosed child with Congenital Heart Disease oxygen?

Answer 44

Lungs are healthy and already fully saturated