Paediatric Cardiology - Murmurs and Blue Baby Flashcards
What are most heart murmurs in children like?
“innocent” - not associated with pathology
What features of a murmur should you comment on?
Timing - systolic or diastolic
Character - pan systolic or ejection systolic?
Loudness - out of 6, >=4 is palpable (thrill)
Radiation
What are the main types of innocent murmurs?
Ejection murmur
Venous hum
What are the hallmarks of an innocent murmur?
Asymptomatic Normal CVS exam Systolic or continuous No radiation Variation with posture
What are ejection murmurs caused by?
Outflow tract either side of the heart
How do ejection murmurs sound?
Soft blowing systolic murmurs
Second and fourth left intercostal spaces
How are venous hums generated?
By head and neck veins
How do venous hums sound?
Continuous low pitched tumble
Heard beneath clavicle
Disappear on lying flat
When is an innocent murmur more likely to be noted?
During tachycardia e.g:
With fever
Anaemia
Exercise
What features if associated with a murmur make it significant?
Syncope Episodic cyanosis Abnormal pulses, heart sounds, BP or cardiac impulse Diastolic murmur Pan systolic murmur Murmur radiate to back Thrill
What murmurs are most likely to be heard at the upper right sternal border?
Aortic stenosis
How does aortic stenosis sound?
Ejection systolic
Preceding ejection click
Radiate to neck
What is aortic stenosis associated with?
Williams syndrome
What murmurs are most likely to be heard at the upper left sternal border?
PDA
ASD
Pulmonary stenosis
Coarctation of the aorta
How does a Patent Ductus Arteriosus sound on auscultation?
Continuous machinery like murmur
Radiate to back
Bounding/collapsing pulse
Wide pulse pressure
How does an Atrial Septal Defect sound? What is it associated with?
Ejection systolic murmur Wide fixed (doesn't change with inspiration) splitting of S2
Associated with Down’s
How does pulmonary stenosis sound on auscultation? What is it associated with?
Ejection systolic murmur
Preceding ejection click
Radiate to back
Associated with Noonan’s syndrome
How does coarctation of the aorta sound on auscultation?
Systolic crescendo-descrendo murmur
Radiate to back
What other clinical features does coarctation present with and what condition is it associated with?
Radio-femoral delay
BP Difference in upper and lower limbs
Associated with Turners syndrome
What murmurs are heard at the left lower sternal border?
Innocent murmurs
VSD
Tricuspid regurgitation
How does a Ventricular Septal Defect sound and what is it associated with?
Harsh pan systolic murmur
Radiate all over chest
Associated with Down’s, Patau’s and Edwards
How does tricuspid regurgitation sound?
Loud pansystolic murmur
Louder on inspiration
What murmurs are heard best at the apex?
Mitral regurgitation
Mitral valve prolapse
Describe the mitral regurgitation murmur
Pansystolic murmur
Radiate to axilla
Describe the mitral valve prolapse murmur
Late systolic murmur
Preceding systolic click
What causes central cyanosis?
Desaturation of central arterial blood
How does central cyanosis appear?
Blue colouration of mucous membranes of lips, tongue and extremities
What causes peripheral cyanosis and how does it appear?
Decreased local circulation and increased extraction of O2 from tissues
Blue skin around lips and extremities (NOT MUCOUS MEMBRANES)
What are the categories of causes of cyanosis?
Cardiac
Respiratory
Other
What are the cardiac causes of cyanosis?
Transient cyanosis - can be central or peripheral (central much shorter)
Cyanotic congenital heart defects (ToF, transposition etc.)
Total anomalous pulmonary venous return
Truncus arteriosus
What are the respiratory causes of cyanosis?
Resp distress syndrome Birth asphyxia Transient tachypnoea of newborn Meconium aspiration Pneumothorax
What are the other causes of cyanosis?
Infection
Seizures
Metabolic abnormalities
What are some causes for cyanosis in an older child?
Infection Seizure Metabolic disturbance Pneumonia Asthma PE CHD Raynauds
How do children with Duct Dependent Congenital Heart Disease’s present?
Acutely unwell within first 2-4 days of life due to ductus arteriosus closing
What circulation can be dependent on the ductus arteriosus staying open?
Pulmonary and Systemic circulation
How does a patient with duct dependent systemic circulation present?
Hypoxic Resp distress Heart failure No femorals Metabolic acidosis
How does a patient with duct dependent pulmonary circulation present?
Cyanosed
Tachypneic
Normal pulses
How do you treat duct dependent Congenital Heart Disease’s?
IV Prostaglandin E2 - Dinoprostone
What does Dinoprostone (prostaglandin E2) do?
Smooth muscle relaxant - keep DA patent
What are the Adverse Drug Reaction’s associated with Dinoprostone?
Hypotension Bradycardia Apnoea Fever Jittery
What investigations should you do if a child is cyanosed?
ABG Hb Infection markers, sputum and blood cultures Echo - CHD CXR
What is the hyperoxia test?
Used to determine whether cyanosis is due to a R –> L shunt or another illness
How is the hyperoxia test carried out and interpreted?
Give 100% O2 for 10 mins
If sats remain low –> CHD
Why do sats not improve when giving a cyanosed child with Congenital Heart Disease oxygen?
Lungs are healthy and already fully saturated
