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EXAMINATION OF CARDIOVASCULAR SYSTEM

About half of congenital heart disorders may be detected in the neonatal period; the remaining will not present until later, hence the importance of routine examination at various ages.

‒–   Left-right shunts (potentially cyanotic CHDs: •   Atrial septal defect •   Ventricular septal defect •   Patent ductus arteriosus

‒–   Cyanotic CHDs: •   Transposition of the great vessels •   Fallot’s tetralogy •   Pulmonary atresia ‒–   Obstructive CHDs: •   Coarctation of aorta •   Pulmonary stenosis •   Aortic stenosis.

The symptoms and signs suggesting congestive cardiac failure at neonatal period associated with CHDs are:

•   Tachypnoea (respiratory rate > 50–60 breaths/min at rest). •   Look for respiratory difficulty or dyspnea at rest or following a feed – inability to

finish a feed due to dyspnea is characteristic. •   Tachycardia (heart rate >140–160 beats/min at rest. •   Sweating – some refer to the circle of sweat on the sheet around the infant’s head as

the ‘halo sign’ •   Unusual weight gain (indicating generalized edema). •   Hepatomegaly. •   Gallop rhythm. •   Cyanosis, especially central – nursing the infant in 100% oxygen may help to

distinguish cardiac from respiratory cyanosis. Although, high prevalence of CHDs, still rheumatic fever, cardiomyopathies and pericardial diseases are encountered among children. Remember :

•   Use your eyes and hands before your ears. Leave the heart to last; and when you come to it leave auscultation to the last.

•   Start at the periphery and work towards the heart

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Position & Exposure:

The infants are preferred to be examined in the parents ‘lap, meanwhile older children could be examined in bed supine or semi-sitting position 45, undressed till the waist photo (1)

CVC Examination:

I-  General Examination; Look for; •   Anthropometrics measures; normal or stunted •   Vital signs: pulsations*, respiratory rate, blood pressure** and Temperature •   Skin: rash, erythema marginatum photo (2), subcutaneous nodules. •   Face:

o   Dysmorphic features,; Dawn syndrome, William or Edwards Syndrome. o   Color: central cyanosis, pallor, jaundice. o   Sweating and oral hygiene as dental caries.

•   Mouth: follicular tonsillitis. photo (3) •   Neck: jugular venous pulse & cervical lymphadenopathy. •   Hands:

Clubbing, splinter hemorrhage photo (4) , Osler’s nodes, capillary refill time. •   Chest: basal crepitation. •   Abdomen; hepatosplenomegaly. •   Limbs: Edema

II-  Systemic Examination

1.   Inspection Visible apical pulsations or hyperdynamic pericardium, pericardial bulge, scars and other pulsations.

2.   palpation: Apical beat, thrills and palpable sounds.

3.   Auscultation:

It should be with bell and diaphragm; photo (5) over cardiac areas to comment on; heart sounds, murmurs and additional sounds.

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Photo (2) photo (3)

Photo (4 & 5)

*Pulse ‒–   The sites of examined central (carotid and femora) or peripheral pulsations in

children (Radial, brachial, popliteal and dorsalis Pedis) are seen Photo (6) ‒–   Use the finger tips to feel the radial and femoral pulse. ‒–   In Coarctation of the aorta there is weak femoral pulse and radio-femoral delay. ‒–   Examine the Rate, Rhythm and Volume (force).

Pulse Rate:

‒–   is related to age and activity. ‒–   Physiologic variations brought on by distress, fever, excitement and exercise. ‒–   The pulse rate will rise approximately 10 beats/min for every 1°C rise in temperature. ‒–  

Normal pulse variation ‒–   Sinus arrhythmia – an increase in pulse rate on inspiration, with slowing on

expiration. Very common in children. ‒–   Bradycardia (pulse rate <60 beats/min) in fit children and adolescents, especially in

good swimmers.

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‒–   Slight tachycardia with excitement due, for example, to clinic attendance or hospital admission.

‒–   Occasional ectopic –need be of no concern. Pulse volume

‒–   Full volume pulses, due to a wide pulse pressure. ‒–   A weak or small volume pulse is indicative of reduced pulse pressure. Most often it is

felt in hypotension or impending shock in infants. Pulse character:

by tips of fingers e.g pulsus paradoxus

Blood pressure**

Photo (6)

‒–   The most obvious statement about children’s blood pressure is that it is not taken. Not taken at all, not taken often enough, or not taken seriously.

Technique •   Record blood pressure on right arm. •   Child preferably seated or standing. •   Child should be relaxed – pressures recorded during crying are unreliable. •   Use the largest cuff width which comfortably fits the upper arm. ( proper size: if

the cuff covers at least two third of upper arm, otherwise false results are anticipated)

•   Ensure the inner bladder encircles the arm. •   Doppler ultrasound recording for neonates and infants. •   Standard auscultatory sphygmomanometer for older children. •   Keep arm–heart–sphygmomanometer on same horizontal plane.

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•   Diastolic pressure preferably recorded at point of muffling. •   Remember that anxiety plus faulty technique are probably the commonest

explanations of elevated blood pressure in children. •   Single raised values are of no significance; they must be repeated . Photo (7).

Systolic BP = 100 mmHg at age 6 years. BP rises by approximately 2.5 mm/year thereafter.

(neonate) 60–70 1–4 (toddler) 90

Normal diastolic blood pressure 60 + age in years.

1)   Inspection: Technique:

Photo (7)

The heart

1-   Look tangentially, from the foot end of the patient, for precordial bulge for children & adolescents (for infants from the side of the baby)

2-   Look tangentially, from the side of the patient for apical pulsation and

other pulsations in suprasternal, aortic and pulmonary areas, parasternal, and epigastrium.

Comment:

•   Precordial bulge (asymmetry). •   Apex beat: Visible or not. Visible in thin, hyperdynamic circulation or left ventricular

hypertrophy. •   Operative scars: median sternotomy or left lateral thoracotomy. •   Other pulsations. The right ventricular impulse may be visible under the xiphisternum

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2)   Palpation: Aims at:

•   localization of the apex and determine type. •   A search for left or right ventricular enlargement •   Detection thrills (palpable murmurs) or palpable heart sounds •   palpation of epigastric pulsations.

Technique

1.   Localize the apex beat by inspection. 2.   Palpate apex by palmer surface of the hands for both sides of chest to exclude

dextrocardia. 3.   Localize the apex (the lowermost outermost powerful pulsation) with the tip of your

index finger and determine the site and character. 4.   Put the patient in the left lateral position if was difficult to be localized (e,g: obese). 5.   Palpate the left parasternal area using the palmer aspect of your right hand for thrills. 6.   Then using the palmer aspect at the base of metacarpals confirm presence of heave or

lift over the left parasternal area. 7.   Put the tips of your fingers in the second left intercostal space to elicit palpable

second sound then try to feel (diastolic shock). 8.   Place the palm of your right hand on the epigastrium and slide your fingers under the

rib cage to palpate epigastric pulsation. Aortic pulsation thrust forward against the palmer surface of your fingers. The pulsation of enlarged liver thrust downwards against your fingertips.

Comment on Cardiac Palpation: I-­  Apex:  1.   Site:  •   The apex beat is found in the 4th intercostal space along the midclavicular (nipple)

line in infants and toddlers. •   In schoolchildren the apex beat is in the 4th–5th left intercostal space in the

midclavicular line. •   It may be difficult to localize in plump, healthy infants and toddlers. •   If you cannot locate the apex beat pericardial effusion •   Left ventricular enlargement causes displacement of the apex laterally and inferiorly.

Right ventricular enlargement causes displacement of the apex laterally 2.   Character:  positive thrust, heaving or tapping apex 3.   Thrill:  systolic or diastole.

II-  Parasternal thrill or lift: Palpation of a thrill is always significant. Left Parasternal lift denotes right ventricular enlargement III-  Palpable diastolic shock: It refers to accentuation of second heart sound e,g: pulmonary hypertension. IV-  Epigastric pulsation: It is either right ventricular apex , or aortic or hepatic pulsations.

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3)   Percussion: vv The apex vv . An impulse may be palpable under the xiphisternum. vv A palpable heart sound usually implies Percussion vv Cardiac border percussion is rarely helpful in children. vv You may wish to percuss the upper border of the liver though (you are going to feel

the lower border later). vv Dullness in the pulmonary area signifies pulmonary artery dilatation.

4)  Auscultation

Comment on heart sounds, murmurs or additional sounds Remember:

vv Should always be left to last, remembering then the old adage ‘sounds first, murmurs second’.

vv When listening: •   Palpate first to determine the site of cardiac area. Photo (8) •   try to ensure the child is not crying. •   Use both diaphragm and bell (preferably pediatric sizes) •   listen with the child in lying and sitting positions •   note any variation with respiration.

Heart sounds:

•   The first sound is best heard at the apex and the second at the base. •   In infancy, the first sound may be louder than the second. A soft first sound is an early

sign of cordites. •   The second sound is usually split in children, this split being physiological and

widening on inspiration. Fixed splitting of second heart sound in atrial septal defects. •   A third heart sound may be a normal finding in some children and heard by bell. •   Gallop is a summation of S3 and or S4 with tachycardia. Photo (9, 10)

Photo (8)

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Photo (9 &10) Murmurs: Heart murmurs are caused by turbulent flow within the heart and great vessels. Occasionally,

the turbulence is caused by increased flow through a normal valve usually aortic or pulmonary producing an ‘innocent’ murmur. Photo (11)

Photo (11)

In so far as students should distinguishing between a significant and an innocent murmur. The majority of murmurs are systolic until proved otherwise (diastolic murmurs are relatively infrequent in children).

‒–   Listen between the first and second sounds very carefully, using both diaphragm and

bell in all cardiac areas.

‒–   Description of murmur: •   Timing – systolic/diastolic/continuous. •   Duration – mid-systolic (ejection)/pansystolic. •   Loudness – systolic murmurs graded:

‒–   1–2: soft, difficult to hear ‒–   3: easily audible, no thrill ‒–   4–6: loud with thrill.

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•   Site of maximal intensity – mitral/pulmonary/aortic/tricuspid areas. •   Radiation: to neck in aortic stenosis, to back in coarctation of the aorta or pulmonary

stenosis, to the axilla in mitral regurgitation. •   Grading: o   Grade 1: barely audible, innocent o   Grade 2: soft, variable, innocent usually o   Grade 3: easy to hear, intermediate, no thrill o   Grade 4: loud, audible to anybody, thrill o   Grade 5: sounds like a train, very significant, thril o   Grade 6: scarcely requires a stethoscope, thrill

•  In relation to posture and respiration

Interpretation: Murmurs of grades 4–6 are always significant. Grades 1–2 are usually innocent, and grade 3 is intermediate. The length of the murmur is important, pan systolic implying significance, mid-systolic suggesting innocence.

Innocent murmurs (also known as physiological, ejection, or flow murmurs) are very

common in childhood (being heard in up to 50% of children). Hallmarks of an innocent ejection murmur are (all have an ‘S’). Look fig:1 and Table I

The first hurdle for the student is to distinguish significant murmurs from innocent murmurs. If the student can determine that the murmur is significant, the next step will be to determine its origin.

A friction rub:

Occurs in pericarditis. It is best heard in maintained expiration with the patient leaning forward as a high-pitched scratching noise audible during any part of the cardiac cycle and over any part of the left precordium.

Principle of Auscultation: In case of case of cardiac murmur follow the propagation as follow:

1-   Auscultate the mitral area (cardiac apex). 2-   Listen first with the diaphragm for high pitched sounds (first and second heart sounds,

mitral regurge, aortic regurge and rub). Time with the carotid pulse. 3-   Then listen by the cone (bell) for low pitched sounds (third and forth heart sounds and

mitral stenosis). 4-   Move stethoscope to axilla. 5-   Move stethoscope down left sternal border. 6-   Move stethoscope to tricuspid area (lower left sternal border). 7-   Move to the base of the heart starting from the first aortic area (second right itercostal

space). 8-   Move stethoscope to the pulmonary area (second left itercostal space). 9- Move stethoscope to the second aortic area (third left itercostal space).

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Table (1): Differences between innocent murmur and pathological murmurs

Innocent murmur (S) Pathological

•   a Symptomatic •   Soft blowing murmur

(intensity 1-2) •   Systolic murmur only, not

diastolic •   left Sternal edge.

•   Pan systolic •   radiate all over precordium •   soft to loud (grades 4–6) in

intensity •   associated with a thrill •   accompanied by other signs, e.g.

ventricular enlargement •   any diastolic murmur and with:

normal heart sounds with no added sounds no thrill no radiation (localized) variable with position and respiration

lesion Timing Site radiation Mitral regurgitation

Pan systolic Apex of heart axilla

Mitral stenosis Mid diastolic rumbling Apex of heart No radiation Aortic stenosis Ejection systolic Aortic area :2nd right

intercostal space at parasternal line

To carotid

Aortic regurgitation

early  diastolic  decrescendo  

Aortic area :2nd right intercostal space at parasternal line

Pulmonary stenosis Ejection systolic pulmonary area :2nd left intercostal space at parasternal line

Upper neck

Pulmonary regurgitation

early  diastolic  decrescendo

pulmonary area :2nd left intercostal space at parasternal line

Tricuspid stenosis Mid diastolic rumbling Lower left sterna border Tricuspid regurgitation

Pan systolic Lower left sterna border

Ventricular septal defect

Harsh pan systolic Left 3rd and 4th intercostal space at parasternal line

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Fig (1): Algorithm for cardiac murmurs

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