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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