Heart

1
Heart

• Adapted from Mosbys Guide to Physical
  Examination, 6th Ed.
• Ch. 14 15

2
Newborn Heart Exam

• Examine within the first 24 hours and again at
  2-3 days of age
• Changes from fetal to systemic and pulmonary
  circulation
• Complete evaluation of heart function includes
• Skin
• Lungs
• Liver

3
CLINICAL NOTE

• Congestive Heart Failure (infant)
• Large, firm liver
• Inferior edge 5-6 cm below the R costal margin
• Unlike adults, this finding may be noted before
  pulmonary crackles

4
Fetal Circulation

• Compensates for the non-functional fetal lung
• Foramen ovale
• Blood passes directly from the
  R to L atrium
• Bypasses the lungs

5

• Right ventricle pumps blood through the ductus
  arteriosus
• bypasses lungs

6
At Birth

• Functional closure of foramen ovale
• Ductus arteriosus closes
• Within 24-48 hours

7
Infant Exam
8
Inspection

• Color
• Pink skin and mucous membranes (normal)
• Purplish polycythemia
• Ashy, white shock
• Central cyanosis congenital heart disease
• Note
• Distribution intensity of discoloration
• Extent of change after exertion

9
Cyanosis

• Two primary causes
• Mixture of arterial and venous blood
• Problem that prevents oxygenation of blood

10

• Severe cyanosis evident at birth or shortly
  after suggests
• Transposition of the great vessels
• Tetralogy of Fallot
• Tricuspid atresia
• Severe septal defect
• Severe pulmonic stenosis
• Cyanosis that does not appear until after the
  neonatal period suggests
• Pure pulmonic stenosis
• Eisenmenger complex
• Tetralogy of Fallot
• Large septal defects

Always cyanotic
11
Capillary Refill

• Capillary refill time in infants and children
  under 2 years is very rapid, lt 1 second (normal)
• Prolonged capillary refill time, gt 2 seconds,
  indicates
• Significant dehydration
• Hypovolemic shock

12
Apical Impulse

• 4th - 5th left intercostal space, medial to the
  midclavicular line
• Apex of the heart is higher, heart lies more
  horizontal
• Adult heart position is reached by age 7

13

• Note enlargement of the heart and position
• Dextrocardia
• Apical impulse on the right
• Pneumothorax
• shifts apical pulse away from the area of
  pneumothorax
• Diaphragmatic hernia
• MC on the left side
• Shifts the heart to the right

14
Heart Rate

• More variable than older children
• Eating, sleeping, and waking can change it
  considerably
• Fixed tachycardia may indicate difficulty
• Newborn 120 bpm (few hours old)

15
Pulses

• Brachial, radial, and femoral pulses are palpable
• Weak or thin pulse
• Decreased cardiac output
• Peripheral vasoconstriction
• Bounding pulse
• L to R shunt (patent ductus arteriosus)

16
CLINICAL NOTE

• Coarctation of the Aorta
• Difference in pulse amplitude between femoral and
  radial pulses

17
Infant Heart Sounds

• www.wilkes.med.ucla.edu/pda.htm
• http//depts.washington.edu/physdx/heart/demo.htm
  l

18
Murmers

• Relatively frequent (first 48 hours)
• Most are innocent
• Transition from fetal to pulmonic circulation
• Innocent mumers are usually
• Disappear within 2-3 days (short)
• Grade I or II intensity (soft)
• Systolic
• Unaccompanied by other signs and symptoms

19
CLINICAL NOTE

• A murmur is usually NOT a significant congenital
  anomaly.
• Paradoxically
• a significant congenital anomaly may be
  unaccompanied by a murmur

20

• Must investigate if
• persists beyond 2nd or 3rd day of life
• is intense
• fills systole
• occupies diastole to any extent
• almost always significant
• radiates widely

21

• Push up on the liver
• (increase R atrial pressure)
• L to R shunt will disappear briefly
• Septal opening
• Patent ductus
• R to L shunt will intensify
• Tetralogy of Fallot

22
Blood Pressure Flush Technique

• Place cuff on upper arm (or leg)
• Elevate and wrap the arm firmly with an elastic
  bandage from fingers to antecubital space
• Empty veins and capillaries
• Inflate cuff to a pressure above the systolic
  reading you expect
• Lower the arm and remove the bandage
• Arm will be pale
• Diminish pressure gradually until you see a
  sudden flush and return to usual color

23
Blood Pressure Flush Technique

• The resultant value is an average
• lt systolic pressure
• gt diastolic pressure
• Newborn BP 60-96 mmHg
• 30-62 mmHg

24
Hypertension Newborn

• A sustained increase in BP is almost always
  significant
• Thrombosis after umbilical catheter
• Stenosis of renal artery
• Coarctation of the aorta
• Cystic disease of the kidney
• Neuroblastoma
• Wilms tumor
• Hydronephrosis
• Adreanl hyperplasia
• CNS disease

25
Child Exam
26
Modifying Your Instruments

• Decorative stethoscope covers
• http//quickmedical.com/pediapals/products

27
Inspection

• Bulging?
• Precordium tends to bulge over an enlarged heart
  if the enlargement is long-standing
• Thoracic cage is more cartilaginous and yielding

28
Heart Rate

• More variable than adults react to stress of any
  sort
• Exercise
• Fever
• h HR 10-20 beats for each degree temp. h
• Tension

29
Heart Rate
30
CLINICAL NOTE

• Sinus Arrhythmia
• Rate varies in a cyclical pattern
• Faster on inspiration
• Slower on expiration
• Common in children

31
Auscultation

• Heart sounds
• murmers?
• Venous hum
• Caused by turbulence of blood flow in the
  internal jugular vein
• Continuous low-pitched sound
• Louder during diastole
• Common in children
• Usually has no pathologic significance

32

• Ask child to sit with head turned away tilted
  slightly upward
• Auscultate supraclavicular space
• medial end of the clavicle and along the anterior
  border of the SCM

33
(No Transcript)
34
Blood Pressure (gt2 years)

• Easy to measure (same as adult)
• Correct cuff size
• Cover 2/3 of arm
• To facilitate the exam
• Explain the process
• Let them explore the sphygmomanometer

35
Hypertension

• Do not make the diagnosis of hypertension based
  on one reading
• Many readings should be taken over time
• Elevated systolic but normal diastolic
• May be d/t transient anxiety

36

• Significant 90th percentile
• Severe 95th percentile
• If consistently above the 95th percentile, must
  be carefully examined and followed
• Kidney disease
• Renal arterial disease
• Coarctation of the aorta
• Unexplained hypertension is unlikely in a child.

37
If theres known heart disease

• Take careful note
• Weight gain (or loss)
• Developmental delay
• Cyanosis
• Congenital heart defects that impede oxygenation
• Clubbing
• fingers and toes

38
Congenital Defects
39
Patent Ductus Arteriosus

• Ductus arteriosus fails to close
• Blood flows through the ductus during systole and
  diastole
• Increases pressure in the pulmonary circulation
• Increased workload for the right ventricle

40

• Small shunt
• May be asymptomatic
• Large shunt
• Dyspnea on exertion

Surgical intervention
41

• Exam findings
• Neck vessels are dilated and pulsate
• Wide pulse pressure
• Harsh, loud, continuous murmur (systole
  diastole)
• Machine-like quality
• 1st 3rd intercostal spaces and the lower
  sternal border
• Usually unaltered by postural changes

42
Atrial Septal Defect

• Congenital defect in the septum dividing the left
  and right atria

43

• May not sound particularly impressive
• Especially in an overweight child
• More apt to be significant if
• Palpable thrust
• Radiation through to the back

44
Ventricular Septal Defect

• Regurgitation occurs through the septal defect
• Murmur tends to be holosystolic

45

• Smaller defects
• Louder murmur
• More easily felt thrill

46
Tetralogy of Fallot

• Four cardiac defects
• VSD
• Pulmoic stenosis
• Overriding aorta
• Right ventricular hypertrophy

47

• Exam findings
• Parasternal heave
• Precordial prominence
• Systolic ejection murmur heard over the 3rd
  intercostal space
• Sometimes radiating to the left side of the neck
• Surgical correction

48

• Infants
• Paroxysmal dyspnea with loss of consciousness
  (Tet spells)
• Central cyanosis
• As they get older
• Clubbing of fingers and toes

49
Coarctation of the Aorta

• Congenital stenosis or narrowing

• Most commonly
• descending aortic arch near the origin of the
  left subclavian artery and ligamentum arteriosum

50

• Exam findings
• Compare radial and femoral pulses
• Normal peak at the same time (or femoral
  slightly earlier)
• Coarctation delay and/or decreased amplitude of
  the femoral pulse
• Noted bilaterally
• Compare blood pressure in arms and legs
• Normal BP legs arms, or BP legs gt arms
• Coarctation BP arms gt legs
• Systolic murmur
• Audible over the precordium and sometimes the
  back

51

• Adults
• Films may show
• Notching of the ribs
• 3 sign
• Contour of the left upper
• border of the heart
• Caused by dilation of the aorta distal to the
  area of coarctation
• Adjacent to the shadow of the decending thoracic
  aorta

52
Dextrocardia Sinus Invertus

• Sinus Invertus
• Heart and stomach are on the right, liver on the
  left
• Not very common
• Dextrocardia
• Right thoracic heart
• normally placed
• stomach and liver
• Congenital heart anomoly

53
Dextrocardia

• May be associated with other congenital anomolies
  
• Pulmonic stenosis
• Ventricular septal defect
• Atrial septal defect
• Transposition of the great vessels

54

• The unusually placed heart can change the
  clinical manifestations of disease in adulthood.
• Important to consider when examining the
  patient

55
Common Conditions
56
Acute Rheumatic Fever

• Systemic connective tissue disease
• Follows a strep. pharangitis or skin infection
• May result in serious cardiac valvular
  involvement
• MC mitral or aortic valves
• Both stenotic and regurgitant

57
Jones Criteria Diagnosis of Rheumatic Fever

• 2 major manifestations
• OR
• 1major 2 minor manifestations
• High probability acute rheumatic fever
• If theres evidence of a preceding group A
  strep infection
• Never make the diagnosis on the basis of lab
  findings and 2 minor manifestations alone.

58

• Supporting Evidence
• Increased titer of antistreptolysin antibodies
• Positive throat culture (group A strep)
• Recent scarlet fever

59

• Exam findings
• Murmur
• Mitral regurgitation aortic insufficiency
• Cardiomegaly
• Friction rub (pericarditis)
• Congestive heart failure
• Migratory polyarthritis (larger joints)
• Chorea (may be seen alone)
• Transients erythema marginatum
• Pink margins with pale centers
• Firm, painless subsutaneous nodules
• Rare
• Elbows, knees, wrists

60
Acute Rheumatic Fever

• Erythema Marginatum

61

• Children between 5-15 years of age are most
  commonly affected
• PREVENTION is the best therapy
• Adequate treatment for strep.
  infections

62
Kawasaki Disease

• Acute illness
• Etiology unknown
• Affects the young males gt females

63

• Signs symptoms
• Fever (few days 3 weeks)
• Systemic vasculitis
• Conjunctival infection
• Strawberry tongue
• Edema of hands and feet
• Lyphadenopathy
• Polymorphous nonvesicular rash

64

• Critical concern cardiac involvement
• Vasculitis gt aneurysms (coronary artery)
• Sometimes early, sometimes later
• Other arteries may also become involved