The Cardiovascular Exam in Infants and Children

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The Cardiovascular Exam in Infants and Children
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Heart Rate

• Most labile of the vital signs
• Wide variations are normal
• Sensitive to multiple stimuli

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Blood Pressure

• Blood pressure increases with age
• Use appropriate cuff
• Repeat if abnormal

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Respiratory Rate

• Sensitive but non-specific for CHF
• Most reliable while asleep
• Minimal dyspnea with heart failure

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Inspection

• Growth (linear growth is spared)
• Color (cyanosis, pallor)
• Respiratory effort
• Precordial bulge
• Apical impulse

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Palpation

• Pulses (upper and lower)
• Precordial activity
• Thrills
• Liver edge
• Perfusion
• Skin temperature

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Pulses
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Auscultation

• Use your own stethoscope
• Insist on quiet surroundings
• Be methodical
• Be patient
• Come back and listen again
• Dont get discouraged

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Heart Sounds

• S1- closure of AV valves
• Increased in ASDs
• Obscured by holosystolic murmurs
• Variable in complete heart block

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Heart Sounds

• S2- closure of semilunar valves
• Increased P2 if increased pulmonary artery
  pressure
• Fixed splitting in ASDs

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Heart Sounds

• S3- rapid filling of ventricles
• Normal sound in children
• Usually in ages 3 to 16

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Heart Sounds

• S4- atrial contraction
• Uncommon in children, even in CHF
• Usually indicates a cardiomyopthy

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Ejection Clicks

• Early systolic, high frequency sounds
• Occur shortly after S1
• Signify semilunar stenosis
• Variable (louder on expiration) if pulmonary
• Constant (dont vary with respiration) if aortic

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Holosystolic Murmurs

• Begin with or obliterate the first heart sound
• Typical examples are VSD and MR

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Murmurs
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Systolic Ejection Murmurs

• Most common of all murmurs
• Begin after S1
• Originate in outflow tracts

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Decrescendo Diastolic

• Loudest in early diastole
• High pitch typical of aortic regurgitation
• Low pitch typical of pulmonary regurgitation

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Diastolic Rumble

• Usually increased flow across a normal mitral or
  tricuspid valve
• Very low frequency and intensity
• Generally the result of VSDs and ASDs

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Continuous Murmurs

• Any murmur which continues through S2
• Vascular in origin
• Patent ductus arteriosus and venous hum are the
  most common source

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Characteristics of Murmurs

• Loudness (Grade 1 to 6)
• Location
• Radiation
• Changes with respiration, position, valsalva
• Pitch or frequency
• Length

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Radiation of Murmurs

• Aortic -RUSB to neck
• Pulm-LUSB to lungs
• VSD-LLSB
• MR-Apex to axilla

Ao
Pa
VSD
MR
M
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Innocent Murmurs

• Grade I-II/VI (rarely III/VI)
• Systolic (except venous hum)
• Often vibratory
• Change with respiration and position
• Short
• Unassociated with abnormal heart sounds
• Characteristic age 3 to 12 years

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Congestive Heart Failure

• IS
• Tachypnea
• Tachycardia
• Hepatomegaly
• Cardiomegaly

• IS NOT
• Rales
• Peripheral edema
• Gallops
• Venous distension