Approach to murmur in Paediatrics.pptx

Approach to A child with murmur

1. Approach to murmur in Paediatrics By:- Jwan Ali Ahmed AlSofi

2. Murmur Murmurs   are heart sounds  that are produced as a result of turbulent blood flow across a defect or heart valve (either it has a defect like stenosis or regurgitation or there is overflow) that is sufficient to produce audible noise that can only be heard with the assistance of a  stethoscope or  “ auscultation ” . Can be present at birth (congenital) or develop later in life . A murmur can be appreciated in:- two thirds of all normal children three quarters of normal newborns . Murmurs are a clinical finding , not a disease , but they may indicate an underlying heart problem . Most heart murmurs are harmless (innocent) and don't need treatment . Murmurs are the most common presentation of ( CHD) .

3. Murmur Pathological Symptomatic Non-symptomatic Non-pathological Innocent Functional flow murmur SOB, Feeding difficulty Cyanosis Systolic murmur that is loud, long, and harsh Diastolic murmur Abnormal heart sound Click Abnormal pulse Abnormal investigation Not affected by position change ASD, mild form AS, PS, MVP HOCM Symptom free Short systolic murmur that is soft, musical, and localized (no radiation) Normal investigations Disappears (on movement and later on in life) Anemia Thyrotoxicosis Fever

4. Clinical Features of murmurs:- Timing Duration Character and pitch Intensity Location Radiation

5. Innocent Murmurs (benign , vibratory functional)

6. Occurs in the absence of any pathological or structural changes of heart , Does not indicate organic disease of the heart , During a febrile illness or anaemia , innocent or flow murmurs are often heard because of increased cardiac output. Usually disappears later . They usually disappears by 6 years of age but may persist up to 12-14 years of age .

7. Criteria of innocent murmur:- Systolic murmur only, not diastolic the quality of the sound - Soft blowing a lack of significant radiation, Left Sternal edge a significant alteration in the intensity of the murmur with positional changes the cardiovascular history and examination are otherwise normal.

8. Pulmonary flow murmur of newborn (or Peripheral pulmonary stenosis or Pulmonary branch murmur) (newborn-6months) . Consequence of flow turbulence made by normal blood flowing from (RV) to (PA) Mechanisms:- the pulmonary arteries that had limited blood flow in the uterus, and are therefore small. increasing cardiac output associated with declining haemoglobin level after birth. Features of the murmur of peripheral pulmonary stenosis:- heard best in the pulmonary area, radiates along the pulmonary arteries (so the murmur can be heard along the axillae and back- posterior lung fields). What this means is that because the pulmonary arteries go to each lung, the murmur is often heard in the right and left lateral chest .

9. A soft systolic at the upper left sternal border may be because of normal flow across small pulmonary arteries (the peripheral pulmonary flow murmur) increased blood flow across normal pulmonary arteries.- e,g , as in ASD. Pulmonic stenosis

10. Still's murmur or Vibratory murmur ( 3 - 6 years ):- is the most common one . Due to vibrations in either the right or left ventricle, or ‘‘tendons’’ often seen in the left ventricle. Best heard at the left middle-lower sternal border Are loudest when the patient is supine Get softer when the patient stands. (the murmur in HCM, behaves just the opposite of a Still’s murmur- When any patient stands, gravity takes blood to the lower extremities, and therefore less blood is in the heart. With less blood filling the ventricle, the walls of the ventricles get closer together, and in the case of hypertrophic cardiomyopathy, the obstruction within the cavity of the left ventricle worsens)

11. Venous hum ( 3 – 6 years ) . Is caused by blood flow returning from the child’s head and flowing from the superior vena cava to the right atrium. It is a blowing, continuous murmur, sounding like a soft hum during both systole and diastole. heard at the base of the heart just below the clavicles, mainly on the right side, Best heard while standing Disappears while the chest is flat. Changes with:- Moving the child’s head to either side child is lying down Light pressure to the right side of the neck, which temporarily stops blood flow through the right jugular venous system.

12. Carotid bruit ( any age) . Occurs due to normal passing of blood from the aorta to the carotid, heard best above the clavicle Hyperextend the shoulders  murmur disappears

13. The Aortic Outflow Murmur Heard in adolescents and young adults The murmur is usually grade one or two in intensity It is different from valvar aortic stenosis in that the patients do not have an ejection click . The murmur is often heard in athletes, who typically have a low resting heart rate and therefore a large stroke volume of blood flowing in the left ventricular outflow tract in systole. Standing a patient with hypertrophic cardiomyopathy should increase the murmur, whereas standing the patient with the aortic outflow murmur should result in either a decrease in the murmur, or no significant change.

14. Pathological Murmurs Are sounds produced by turbulent flow due to abnormal intra cardiac or intravascular obstructions or connections. When one or more of the following are present, the murmur is more likely pathologic and requires cardiac consultation : Abnormal heart sounds S12 A systolic murmur that is loud ( grade 3/6 or with a thrill ) long in duration and transmits well to other parts of the body, of harsh quality holosystolic , late systolic, Diastolic, continuous ( except for the venous hum ) murmurs presence of a thrill are not normal. Active precordium Abnormal cardiac size or silhouette or abnormal pulmonary vascularity on chest radiography Abnormal ECG The presence of symptoms, including failure to thrive or dysmorphic features, Associated Cyanosis

15. Innocent Pathological Symptom free Symptomatic Short systolic Pansystolic or diastolic Short, soft, and musical Harsh quality and intensity >grade 3 Localized with no radiation Radiation and posterior propagation Disappears with changing position Does not disappear No thrill May be associated with thrill Normal Investigations Often abnormal

16. Typically – no change with standing/positional changes ATRIAL SEPTAL DEFECT: systolic ejection murmur radiating to axilla & back fixed split second heart sound (S2) AORTIC VALVE/ PULMONARY VALVE STENOSIS: harsh, higher pitched, systolic ejection murmur systolic “ click ” AS – radiation RUSB carotids, suprasternal notch thrill PS – radiation to axilla and back Am I missing …

17. VENTRICULAR SEPTAL DEFECT: holosystolic murmur systolic regurgitant murmur (TR) harsh , higher pitched large VSDs may not have a loud murmur PATENT DUCTUS ARTERIOSUS: continuous murmur left upper sternal border, left infraclavicular area murmur does not decrease with head position changes Am I missing…

18. HYPERTROPHIC CARDIOMYOPATHY: systolic ejection murmur at left sternal border does NOT decrease in intensity with standing (innocent murmur should decrease with standing) may increase in intensity with standing may decrease in intensity with squatting Am I missing …

19. Diastolic Murmur Pathologic, if present Timing with pulse Causes: Aortic Valve regurgitation Pulmonary valve regurgitation Am I missing…

20. History: Pregnancy and birth history I ntermittent nature Normal growth and development N egative family history Physical Examination: C haracteristic qualities of innocent murmur - practice S econd heart sound: “ physiologic splitting ” inspiration- splits… expiration- single no increased intensity, pounding or loud N o click, no thrill (grade IV/VI murmur) N o suprasternal notch thrill P ositional changes - supine and standing Innocent Murmurs What You Can Do

21. Greater than grade III/VI (thrill) Holosystolic D iastolic H arsh C lick P ulse abnormality F ailure to thrive S ignificant family history Murmurs - When to be concerned?

22. EVALUATION of a child with murmur

23. 1. History: Feeding history, exercise intolerance. [HF. In <1-year exercise level is obtained during feeding (an infant with HF can only take small volumes of milk, develops SOB on sucking, and often perspires)] Heavy sweating with minimal or no exertion. Poor appetite and failure to grow normally (in infants). [indicates heart failure (HF)] Chronic cough. [indicates lung congestion] Swelling or sudden weight gain. [Edema] Cyanosis or cyanotic spells ± squatting posture (indicates cyanotic CHD, classically seen in tetralogy of Fallot ) . Chest pain, prolonged fever. [Endocarditis ] Dizziness, fainting episodes.

24. Feeding difficulty: When the mother complains that the baby is not able to take feeds properly (either breast feed or bottle feed), becomes breathless and has excessive sweating during feeding, the physician should think of congestive heart failure (CHF) of any cause. If the parents complain that the baby starts crying each time while taking feed s and if the feed is stopped, feels comfortable , one should think of a rare possibility of vascular ring malformation . Repeated respiratory infection: History of repeated cold and cough requiring admission to the hospital should be noted. If the infant is having repeated attacks of breathlessness, rapid breathing, cough, grunting sounds and restlessness (indicating repeated lower respiratory tract infection ) more than six times per year, indicates high pulmonary flow due to significant left to right shunt .

25. History of blue discoloration of lips, nails especially on crying indicates the possibility of cyanotic heart disease with decreased pulmonary blood flow and right to left shunt. When the cyanotic infant lies calm and listless having less physical activity it indicates cyanotic spell or low output state. History of squatting after exertion in a cyanosed child indicates:- tetralogy of Fallot (TOF) TOF like physiology and tricuspid atresia (TA). History of frequent palpitations in a cyanotic child, one should think of Ebstein anomaly. History of syncope on mild to moderate exertion in an acyanotic child indicates:- severe aortic stenosis (AS), hypertrophic cardiomyopathy, severe pulmonary hypertension congenitally corrected transposition of great arteries producing significant bradycardia.

26. Birth History . Was the baby term or preterm (structural abnormalities)? Was there asphyxia? (caused by a type of C.M., low O2 to the heart), ask for prolonged labor, history of convulsion, and SGA Maternal complications: DM leads to HOCM. HTN leads to TGA. SLE lead to COMPLETE HEART BLOCK. TORCH : rubella leads to PDA. Drug history: Isotretinoin is teratogenic. Anti- convulsants . Aspirin. Is there a family history of congenital heart disease? [There is a higher risk of heart defects in siblings of children with congenital heart disease.]

27. 2. Examination Appearance Posture . Color . Dysmorphic features . Respiratory distress . Nutritional assessment . Edema . Clubbing . Vital signs : Tachycardia is a sign of cardiac failure . The character of the pulse can also give a clue to cardiac pathology. Palpate the femoral pulses , as in coarctation of the aorta they are absent or weak and delayed compared with the radial pulse . Take the blood pressure , and if you suspect coarctation you need to do this in both arms and legs . Normally it is 10-20mmHg higher in the legs .

28. Other signs of heart failure : Tachypnoea , hepatomegaly , and crepitations in the lungs are the major clinical manifestations of cardiac failure in childhood . Peripheral oedema is rare . Cyanosis if present suggests reversal of shunt , urgent investigation is required . Raised JVP . Growth parameters : Failure to thrive and poor growth are important signs of cardiac failure in childhood and are also important in monitoring medical management.

29. 3. Precordium examination Precordial bulge : cardiomegaly Substernal thrust, parasternal heave : right ventricular (RV) enlargement Hyper dynamic precordium : volume overload ( large L  R shunt / severe valvular regurgitation ) Apex beat position quality : Thrill . Auscultation : S1. S2, added sounds, murmur.

30. 4. Investigations Chest X-ray: size: is not reliable at all in <1-year-olds, so send for echo. Because of thymus shadow and the heart is initially horizontal then moves down . Cardiothoracic ratio of up to 55% is normal in infants. shape : Boot shape: TOF Truncus arteriosus Egg shape: TGA Snowman silhouette (double contour of the heart ) : TAPVR vascularity : vascular markings should not exceed 1/3 of the thoracic diameter normally: Increased: plethoric Decreased : oligemic lung, thoracic abnormalities : rib notching → COA TAPVR= Total anomalous pulmonary venous return. Oxygen-rich blood from the lungs goes to the right atrium instead of the left atrium.

31. Oligemic Plethoric

32. Rib notching

33. Boot-shaped heart

34. Snowman sign Egg-shaped

35. ECG : Rate, Rhythm, axis, (P, QRS, T). gives further information about ventricular and atrial hypertrophy. Echo is important in evaluating cardiac structure and performance, gradients across stenotic valves and the direction of flow across a shunt: M-mode 2-dimensional Doppler transesophageal Cardiac Catheterization : is now rarely required for diagnosis. Angiography ( Angiocadiography ) . MRI . CT .

36. MCQS

37. Which one of the followings is not characteristic of innocent murmur: Symptom free The murmur is soft in character There is cardiomegaly on chest X-ray film The murmur is a grade I systolic murmur The murmur is heard at the left sternal edge C. There is cardiomegaly on chest X-ray film

38. Alan, a 4-month-old boy, sees his general practitioner for an ear infection. On listening to his chest a heart murmur is heard. Which one of the following features most suggests that it requires further investigation? Select one answer only. A. A thrill B. Disappearance of murmur on lying flat C. Murmur maximal at the left sternal edge D. Sinus arrhythmia E. Systolic murmur A. A thrill

39. Nada, a 5 month old female infant has a fever and runny nose for 2 days. On examination she has a fever of 38.3° C and a runny nose. Her tongue is pink. Her breathing is normal. Pulse is 160 beats/min. Her heart sounds are normal but she has a soft systolic murmur at the left sternal edge. Pulses are normal. Diagnosis??? Innocent murmur

40. Thanks