Download The Child With A Murmur - Faculty of Medicine

Mini-Medical School 2015
Pediatric Cardiology
The Child With A Murmur
Andrew Warren, MD, MSc, FRCPC
Division Head, Pediatric Cardiology, IWK Health Centre
Associate Professor, Department of Pediatrics,
Dalhousie University
At the end of this presentation you will be
able to…




Describe normal cardiac anatomy and physiology
Describe how heart sounds are generated
Define the term heart murmur
Name and describe the three most common causes
of murmurs in a school-aged child
 Describe the treatment approach to patients with
atrial septal defects
Wong KK, Barker AP, Warren AE. Paediatricians’ validation of learning
objectives in paediatric cardiology. Peds Child Health. 2005 Feb; 10(2):
95 – 99.
Assessment for…
Murmurs 55%
F/U CHD 10%
Syndrome 9%
Palpitations 8%
Syncope 6%
Cardiac Anatomy and Physiology
V. Filling = diastole
V. Emptying = systole
Texas Heart Institute. Heart anatomy [Internet].
Houston: Texas Heart Institute; 2015 Jul [cited
2016 Jan 5]. Available from:
http://www.texasheart.org/HIC/Anatomy/anato
my2.cfm
Electrocardiogram - ECG
Atrial
stimulation
Ventricular
“reset”
Ventricular stimulation
Atkielski A. Schematic diagram of normal sinus rhythm for a human heart as seen on ECG (with English labels)
[Internet]. [Unknown place]: Wikimedia Commons; 2007 Jan 13 [cited 2016 Jan 5]. Available from:
https://commons.wikimedia.org/wiki/File:SinusRhythmLabels.svg
S2 varies with respiration
 Normal S2 splits on inspiration and comes together
on expiration
 Related to “hangout interval”
 Hangout interval is the time from when pressure in
RV initially falls below PA pressure to the time the
valve closes
S2 Splitting
Lower impedence on inspiration
Blood moves forward longer in PA on inspiration
Pulmonary valve closes later on inspiration
S2 split widens on inspiration
Murmurs
 “Swishy” heart sounds caused by
• turbulent flow of blood within the heart or central
vessels
• vibration of cardiac tissue
 May occur during ventricular filling (diastole) or
emptying (systole)
Approach to physical examination
I – Inspection
P – Palpation
P – Percussion
A – Auscultation
C - Cogitation
Inspection – Vital signs





Heart Rate
Blood pressure
Respiratory Rate
Temperature
(Saturation)
Inspection
 Cyanosis - Blueness
•
•
•
•
Central – lips, tongue, mucous membranes
Peripheral – hands, feet, (around eyes, around lips)
Central cyanosis = probable hypoxemia
Peripheral cyanosis (isolated) = slow perfusion
Inspection
 Swelling
 Wasting
Inspection
 Dysmorphic features
Palpation
 Pulses
 Precordium
 “Heaves” or “Thrills”
• Suprasternal notch
• Left parasternal area
Palpation
 Apex = lowest most
lateral cardiac impulse
• Location

4th-5th intercostal
space,
midclavicular line
• Size, quality
Auscultation - The stethoscope
Bell (lowpitched
sounds)
Diaphragm
(higher-pitched
sounds)
Listening Areas
http://www.physiopedia.com/Auscultation
+ Back
Description of Murmurs
 Timing
• Which phase of the cardiac
cycle – systole or diastole?
 Location
• Eg. Best heard at the left
upper sternal border
 Effect of position change
• Eg. Disappears on standing
 Loudness (grade)
1-barely audible
4-associated with a thrill
2-audible with
concentration
5 - heard with stethoscope
partly off chest
3-easily audible
6-heard with stethoscope
entirely off chest
 Pitch
• Eg. High, medium, low
 Quality
• Eg. Blowing, coarse, vibratory
Case
 4 year old boy presents for preschool health check.
He is asymptomatic. On examination, you note his
chest in front of his heart (the precordium) is very
active. You listen with your stethoscope and hear a
normal S1, an S2 that sounds like it always has 2
components (is never single) and a grade 2/6, lowpitched, systolic murmur. It is loudest at the left
upper sternal border.
 What is the most likely cause of his murmur? What
helps us decide?
AGE when murmur first heard?
 Older, well children
• Innocent murmurs
• Mild obstructive lesions
(mild aortic or pulmonary
stenosis)
(stenosis=narrowing)
• Small or low pressure left
to right shunts (Atrial
septal defects)
Innocent murmurs
 Come from vibrations of the normal heart and
blood vessels
 Are louder lying than sitting or standing
 Are louder in high flow states (eg fever, activity,
anxiety)
 Are not associated with other examination
abnormalities (eg abnormal pulses, etc)
 Occur in healthy children
 Do not require treatment or follow-up
Obstructive Lesions
Aortic Stenosis
Pulmonary Stenosis
Please visit:
http://www.pted.org/?id=pul
monarystenosis1
Bicuspid Aortic Valve
Stanford Health Care. About aortic stenosis [Internet].
Standord: Stanford Health Care; [Date unknown; cited 2016 Jan
5]. Available from: https://stanfordhealthcare.org/medicalconditions/blood-heart-circulation/aortic-stenosis/causes.html
Atrial Septal Defects
• Active precordium
• Fixed split S2
• Systolic murmur
best at left upper
sternal border
• No change with
position
Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities.
Facts about atrial septal defect [Internet]. Atlanta: Centers for Disease Control and Prevention; 2014 Jul 9
[cited 2016 Jan 5]. Available from: http://www.cdc.gov/ncbddd/heartdefects/atrialseptaldefect.html
At the end of this presentation you will be
able to…
Describe normal cardiac anatomy and physiology
Describe how heart sounds are generated
Define the term heart murmur
Name and describe the three most common causes
of murmurs in a school-aged child
Describe the treatment approach to patients with
atrial septal defects