The Cardiovascular Exam in Infants and Children

Heart Rate

• Most labile of the vital signs

• Wide variations are normal

• Sensitive to multiple stimuli

0

50

100

150

200

250

Birth 3 Yrs 8 Yrs 15 Yrs

MaxMeanMin

Blood Pressure

• Blood pressure increases with age

• Use appropriate cuff• Repeat if abnormal

0

20

40

60

80

100

120

140

Birth 3 Yrs 8 Yrs 15 Yrs

Systolic Diastolic Mean

Respiratory Rate

• Sensitive but non-specific for CHF

• Most reliable while asleep

• Minimal dyspnea with heart failure

0

10

20

30

40

50

60

70

Birth 3 Yrs 8 Yrs 15 YrsMaxMeanMin

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

Diagnosis: Arms Legs

Coarctation Increased Decreased

Patent Ductus Increased Increased

Aortic Stenosis Decreased Decreased

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

H o losysto licV S DM R

S ysto lic E jec tionA SP S

S ysto lic

D ecresendoA R

R um b leA S DV S D

D iasto lic C on tinuousP D A

M urm urs

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

AoPa

VSD

MRM

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