Paediatrics - Cardiovascular Examination Flashcards
Paediatric examination of the cardiovascular system
Inspection
J
A number of dysmorphic syndromes are closely associated with specific heart lesions, and their presence lends a strong clue:
From here the hands are inspected:
- is there clubbing - first seen in the thumbs
- cyanosis may be apparent from the nail beds, as may anaemia
Inspection of face:
- central cyanosis may be seen in the lips, or more convincingly the tongue
- the teeth should be inspected for caries, which are a risk factor for infective endocarditis
Inspection of the chest:
a careful examination should be made for scars:
- lateral thoracotomy scars might imply Blalock Taussig shunting in tetralogy of Fallot, or on the left might imply pulmonary artery banding.
- midline scars are usually associated with intracardiac surgery
Harrison’s sulcus is rarely a cardiological sign, but may be seen in chronic pulmonary hypertension with reduced lung compliance.
Paediatric examination of the cardiovascular system
Palpation (1)
Pulses:
- radial pulses, except in an infant where it may be easier to feel the brachial pulses. From these rate, rhythm and character should be noted.
- although they should never be forgotten, the femoral pulses are usually best left until the end of the examination, as palpation will make most infants cry.
- in the older child the carotid pulse may be felt; a thrill may be noted.
Paediatric examination of the cardiovascular system
Palpation (2)
Palpation of the apex beat is next.
- To avoid missing the examiner’s favourite - dextrocardia - a two handed approach may be used.
- The apex beat can usually be felt in the 5th, left intercostal space in the mid-clavicular line; the character of the beat should be noted.
Right ventricular heave should be examined for with the hand on the sternum.
During palpation of the chest any palpable heart sounds or thrills should be noted.
Palpation of the cardiovascular system is completed by examining for the liver.
Paediatric examination of the cardiovascular system
Auscultation (1)
- The examination of infants and toddlers should take place with the patient on the mother’s knee, only later moving the child on to the couch.
- An initial attempt at auscultation through the clothing enables the child to get used to the stethoscope, and a count of the resting heart rate to be obtained.
- Giving the child a toy to hold may help.
- Timing of systole by palpation of the carotid pulse, it is wise to begin auscultation in the second left intercostal space where the two components of the normal second sound are best heard.
Paediatric examination of the cardiovascular system
Auscultation (2)
- A split first sound is often heard, and is normal at the lower left sternal border.
- Physiological splitting of the second sound (P2 after A2) is most significant on inspiration.
- A2 is louder than P2 in pulmonary stenosis (P2 is soft and delayed), but P2 is as loud or louder than A2 in a secundum ASD or pulmonary hypertension.
- Splitting of A2 and P2 excludes truncus arteriosus or pulmonary atresia, but a single sound may be heard in a VSD with pulmonary hypertension, or tetralogy of Fallot.
Paediatric examination of the cardiovascular system
Auscultation (3)
- A venous hum increases on inspiration and disappears in the head down posture, and is thereby differentiated from the continuous murmur of a ductus.
- The child should not only be listened to in the prone position, but rolled onto his left side for the appreciation of a mid-diastolic murmur at the apex, and sat up and leaned forward for the blowing early murmur of aortic incompetence.
Paediatric examination of the cardiovascular system
Blood Pressure
- The blood pressure is usually recorded at the end of the examination in the hope that the patient will be more relaxed and lying comfortably.
- Errors in cuff selection can be minimised by selecting the longest cuff that will fit snugly around the child’s arm or leg. It is important to record the width of the cuff used.
