The Cardiovascular Exam in Infants and Children

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

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

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

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

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

Pulses

Auscultation Use your own stethoscope Insist on quiet surroundings Be methodical Be patient Come back and listen again Don’t get discouraged

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

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

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

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

Ejection Clicks Early systolic, high frequency sounds Occur shortly after S1 Signify semilunar stenosis Variable (louder on expiration) if pulmonary Constant (don’t vary with respiration) if aortic

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

Murmurs

Systolic Ejection Murmurs Most common of all murmurs Begin after S1 Originate in outflow tracts

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

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

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

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

Radiation of Murmurs Aortic -RUSB to neck Pulm-LUSB to lungs VSD-LLSB MR-Apex to axilla Ao Pa VSD MR M

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

Congestive Heart Failure IS Tachypnea Tachycardia Hepatomegaly Cardiomegaly IS NOT Rales Peripheral edema Gallops Venous distension