Education for children

1. PEDIATRIC
CVS EXAMINATION
&
APPROACH TO A CHILD
WITH CHD
DrDr. Rani Gera
Dr. Murtaza Kamal
03/ MAY/ 2020
1

2. SCOPE OF THE TALK…
○ Examination of CVS:
● GPE
● Inspection
● Palpation
● Percussion
● Auscultation
○ Approach to a child with suspected CHD
● Cyanotic vs acyanotic
● Increased/ Decreased vs normal pulmonary
blood flow
2

3. HISTORY: SINGS N SYMPTOMS
SUGGESTIVE OF CVS INVOLVEMENT
•Newborns and Infants
• Fast breathing
• Difficult breathing
• Grunting
• Poor feeding – poor weight gain
• Sweating – Suck – Rest – Suck – cycle
• Reduced activities
• Cyanosis – Central
3

4. HISTORY: SINGS N SYMPTOMS
SUGGESTIVE OF CVS INVOLVEMENT
•Toddlers and Preschool
• Previous + followings
• Poor breathing and / or feeding
• Limited activities on playground
• Frequent illnesses – cough, cold , fever
• Poor growth
•Older Children and Adolescents
• All previous + extra
• Chest pain
• Syncope
• Dizziness
• Paroxysmal nocturnal dyspnea
4

5. OTHER IMPORTANT ASPECTS OF
HISTORY…
•H/O frequent cough, cold and/or fever
•H/O Hospital admission
•H/O Surgery
•Perinatal History – Maternal Infection, Maternal autoimmune
diseases, Maternal medications
•Family History – ho similar illness
•Syndrome – Phenotype vs Genotype
5

6. GENERAL PHYSICAL EXAMINATION
◻ Dysmorphic features:
Disorder/Syndrome Common Cardiac Defect
Down’s ECD, VSD
Edward VSD, PDA, PS
Patau VSD, PDA, Dextrocardia
Noonan PS
Marfan AR, MVP
Turner CoA, AS, ASD
Holt-Oram ASD (Ostium Primum) 6

7. ◻ Clubbing
¤ Infective endocarditis, Cyanotic CHD
◻ Odema : Pedal/sacral
¤ Restrictive or severe tricuspid valve diseases
◻ Sweating on forehead
◻ Chest and spine deformities
¤ Shifting of apical impulse in scoliosis/kyphosis
◻ Skin
¤ Rheumatic nodules
◻ Pallor
GENERAL PHYSICAL EXAMINATION CONT…
7

8. ¤ Weight
■ FTT : CHF, cyanotic congenital heart disease
■ Weight might increase due to odema
¤ Height
■ Tall/ short stature
ANTHROPOMETRY…
8

9. CVS EXAMINATION
◻ VITALS: Pulse, BP, Temp, RR, SPO2
◻ JVP
◻ Inspection of precordium
¤ Bony/Spine deformities
¤ Chest shape
¤ Trachea central/deviated
¤ Visible precordial bulge
¤ Visible pulsations
¤ Scars, dilated veins, sinuses.
9

10. ◻ Palpation
¤ Apex beat
¤ Parasternal Heave
¤ Thrills
¤ Any palpable pulsations in precordial region, back, neck,
epigastric region
◻ Percussion: Heart borders, situs, 2nd left intercostal
space dullness
◻ Auscultation:
◻ Heart sounds (HS1, HS2, HS3, HS4)
◻ Extra sounds (Clicks, opening snaps, tumour plop)
◻ Murmurs (Systolic, diastolic, continuous)
CVS EXAMINATION CONT…
10

11. CYANOSIS
Greek word for blue
Bluish discoloration of skin and mucous membranes,
resulting from an increase in reduced Haemoglobin or
of haemoglobin derivatives in small vessels of those
areas
Absolute level of reduced hemoglobin in the
capillary bed exceeds 5 g/dL
Depends upon the total amount of reduced hemoglobin
rather than the ratio of reduced to oxygenated
hemoglobin
11

12. CYANOSIS CONT…
12

13. PULSE
◻ A waveform felt byfinger, produced during cardiac
systole, travels along arterial tree at a rate much
faster than that of blood column
13

14. ASSESSMENT OF PULSE
◻ Rate
◻ Rhythm
◻ Volume
◻ Character
◻ Pulse deficit
◻ Condition of vessel wall
◻ R-F delay
◻ Symmetry
14

15. Counted for full 1 minute by palpating radial
artery
PULSE RATE
15

16. ◻ Tachycardia:
¤ Rheumatic fever
¤ Congestive cardiacfailure
¤ Arrythmias
◻ Bradycardia:
¤ Complete heart block
¤ Sick sinus syndrome (sino-atrial disease)
PULSE RATE CONT…
16

17. ¤ Normal sinus rhythm: Regular
¤ Regularly irregular rhythm :
■ Sinus arrhythmias
¤ Irregularly irregular rhythm:
■ Atrial Fibrillation
■ Atrial Flutter with varying degree of
heart block
PULSE: RHYTHM
17

18. ¤ Assessed by palpating Carotid artery
¤ Pulse pressure (SBP- DBP) gives accurate
measurement of pulse volume
¤ When Pulse Pressure:
■ 20-60mmHg – Normal vol pulse
■ < 20 mm Hg: Low pulse volume
■ < 60 mm Hg: High pulse volume
PULSE: VOLUME
18

19. Large Volume Pulse
(Bounding)
Small Volume Pulse
( Weak, Thready )
Aortic Incompetence (AR) CCF
PDA Pericardial effusion
A-V Fistula Constrictive pericarditis
Persistent truncus arteriosus Lower limb in CoA
PULSE: VOLUME CONT…
19

20. ¤ Best assessed in carotid artery
PULSE: CHARACTER
20

21. ¤ Small weak pulse ( Small vol. And narrow PP)
HYPOKINETIC PULSE
21

22. ¤ Parvus : Low amplitude
¤ Tardus : slow rising and late peak
PULSUS PARVUS ET TARDUS
22

23. ¤ Rapid rise
¤ High amplitude
¤ Large vol. &wide PP
HYPERKINETIC PULSE
23

24. ¤ Rapid upstroke
¤ Rapid downstroke
¤ LargeStroke volume
COLLAPSING PULSE
24

25. ¤ Alternating small & large vol. pulse with irregular
rhythm
¤ Best appreciated by palpating radial and femoral
pulses
PULSUS ALTERNANS
25

26. PULSUS PARADOXUS
26

27. ◻ Fall in BP is more than 10 mmHg during inspiration
PULSUS PARADOXUS CONT…
27

28. ◻ Pulse Deficit:
¤ Difference between HR & PR when counted
simultaneously for 1 min
¤ Causes : Atrial fibrillation and VPCs
◻ Radio-radial delay:
¤ Seen in: Pre Subclavian coarctation, supravalvular AS
◻ Radio-femoral delay:
¤ Seen in: CoA, Aortic embolism
OTHER PULSE CHARACTERISTICS
28

29. BLOOD PRESSURE
◻ Cuff size???
29

30. ◻ Width:
¤ 40% of circumference
◻ Length:
¤ 80-100 % of
circumference
BP CUFF CHARACTERISTICS
30

31. JVP
31
◻ Expressed as vertical height from sternal angle to
zone of transition of distended and collapsed JVP
◻ Patient kept at 45 degree
◻ Upper level of pulsations in the IJV is seen

32. JVP CONT…
32

33. ◻ Indicator of Rt. Atrial pressure
◻ Centre of RA is approx 5 cm from sternal angle
◻ Right Atrial Pressure= Vertical ht. of blood column
+ 5 cms (cm of H20)
◻ Normal JVP = < 8 cms of H2O or <6mmHg
JVP CONT…
33

34. ◻ Elevated JVP:
¤ CCF
¤ TS, TR
¤ Constrictive
pericarditis
¤ Cardiac tamponade
◻ Fall in JVP:
¤ Hypovolaemia
¤ Shock
JVP CONT…
34

35. ◻ Kussmaul’s sign –
¤ Constrictive
pericarditis
¤ Cardiac tamponade
¤ RV failure
◻ Hepato-Jugular
reflex:
¤ Right heart failure
¤ TR
◻ Friedrich’s sign:
¤ Rapid fall and rise of
JVP
¤ TR
¤ Constrictive
pericarditis
JVP CONT…
35

36. PRECORDIUM
○ Area of the chest under which heart lies
○ Precordial bulge: Volume overload of the
underlying heart, long standing heart disease
36

37. VISIBLE PULSATIONS
◻ Carotid Pulsations:
¤ Hyperdynamic
states
¤ AR
¤ CoA
◻ Suprasternal
pulsations:
¤ AR
¤ CoA
¤ Thyrotoxicosis
◻ Epigastric
pulsations:
¤ Pulsations of liverin
CHF with TR
¤ RVH
¤ Abdominal aorta
aneurysm
¤ Tricuspid stenosis
◻ Back:
¤ CoA
37

38. SCAR MARKS
38

39. PALPATION
39
◻ General rule :
¤ Fingertips: To feel
pulsations
¤ Base of fingers:Thrills
¤ Base of hand( or ulnar
aspect) : Heaves

40. Lowermost and outermost point of definite
cardiac impulse, which gives maximum thrust to the
palpating finger
Normal variation in location of apical impulse with
age
Age Position of apical
impulse
Relation to midclavicular
line
Infancy Left 4th ICS Lateral to mid clavicular line
Approx 5 years Left 5th ICS In the Midclavicular line
Older children Left 5th ICS Medial to midclavicular line
APICAL IMPULSE
40

41. TYPES OF APICAL IMPULSE…
41

42. ¤ A palpable thrust, which lifts the palpating hand
¤ Seen in RVH and Left atrial enlargement
¤ Palpated by ulnar aspect of hand
¤ Grading :
I. Instant lift, visible not palpable
II. Visible and palpable, lift can be obliterated
III. Visible and palpable, lift cant be
obliterated
PARASTERNAL PULSATIONS AND
HEAVE
42

43. ¤ Palpable vibrations of murmurswhich accompany
any organic murmur of grade 4 or more
THRILLS
43

44. PERCUSSION
◻ Left heart border
◻ Right heart border
◻ Liver dullness
◻ Stomach tympany
◻ Left second intercostal space
44

45. AUSCULTATION
45

46. ¤ Relative, brief auditory vibrations of variable
intensity, frequency & quality, produced by closure of
heart valves
HEART SOUNDS
46

47. S1 Abnormalities
Soft S1 Loud S1 Split Reverse
split
MR MS RBBB RVP
TR TS LVP Ectopic beats
Calcification
of AVvalves
High output
states
Pulm.
Hypertension
HS-1
47

48. S2 Abnormalities
Soft S2 Loud S2 Single S2
Loud A2 Loud P2 Absent A2 Absent P2
AS Syst. Htn Pulm. Htn AS PS
PS Aortic
aneurysm
ASD, PDA TOF
Calcified lesions of
semilunar valves
Dilated
aorta
LargeVSD TGA
HS-2
48

49. Splitting of S2
Wide- Fixed Wide-
Variable
Narrow Reverse-split
Early A2/Late P2VSD Severe
AS
Late A2/Early
P2
MR LVP Sever
e PS
Aortic stenosis
ASD, RBBB HOCM
HS-2 SPLIT
49

50. HS-3, HS-4 CHARACTERISTICS
50

51. Causes of S3
Physiological S3 Pathological S3
Children High output states
Young adults CHD – ASD, VSD, PDA
MR, TR, AR
HS-3 CAN BE BOTH PHYSIOLOGICAL &
PATHOLOGICAL
51

52. ¤ Due to opening of AV valves
¤ Can be heard at the apex:
■ MS, MR
■ VSD
■ PDA
¤ Can be heard at parasternal region:
■ Tricuspid stenosis
■ Tricuspid regurgitation
■ ASD
EXTRA SOUNDS: OPENING SNAPS
52

53. ¤ A sharp, clicking sound arising from cardiac valves
due dilatation of pulmonary artery, dilatation of
aorta or forceful opening of aortic cusps
¤ Early ejection systolic click: Seen in aortic and
pulmonary valve stenosis
¤ Midsystolic ejection click: Seen in floppy mitral valve
EXTRA SOUNDS: EJECTION CLICK
53

54. ¤ Due to sliding of 2 inflamed layers of pericardium
¤ Scratching, grating in character
¤ Triphasic : during misdystole, mid diastole & pre
systole)
¤ Best heard along left sternal edge in 3rd & 4th ICS
PERICARDIAL RUB
54

55. ¤ Occur due to the turbulence caused by either an
increased flow through a normal/stenosed valve
or a normal flow through a stenosed valve/orifice
¤ Auscultation to be done over precordium, back
and over carotids
MURMURS
55

56. ¤ Systolic/ Diastolic/ Continuous
¤ Timing & character
¤ SPitch
¤ Area where best heard
¤ Intensity
¤ Whether best heard with bell or diaphragm
¤ Conduction
¤ Variation with respiration
¤ Posture in which best heard
¤ Variation with dynamic auscultation
DESCRIPTION OF A MURMUR INCLUDES…
56

57. ◻ Systolic murmur grading
I. Very soft (heard in
quite room)
II. Soft, but easily
audible
III. Moderate, no thrill
IV. Loud with thrill
V. Very loud with
thrill, heard with
steth barely placed
on chest
VI. Loud and audible with
stethoscope just off
the chest wall
◻ Diastolic murmur grading
I. Very soft
II. Soft
III. Loud
IV. Loud with
thrill
GRADING OF CARDIAC MURMURS…
57

58. EARLY SYSTOLIC MURMUR
58

59. EJECTION SYSTOLIC MURMUR
59

60. LATE SYSTOLIC MURMUR
60

61. HOLO/ PAN SYSTOLIC MURMUR
61

62. EARLY DIASTOLIC MURMUR
62

63. MID DIASTOLIC MURMUR
63

64. ¤ MS
¤ TS
¤ Atrial myxomas
LATE DIASTOLIC MURMUR
64

65. CONTINUOUS MURMUR
65

66. ¤ Functional/ benign murmurs
¤ Absence of anatomical/functional abnormalities of
heart and circulation
¤ Accentuated during periods of febrile illness and
high output states
INNOCENT MURMURS
66

67. Characteristic features :
■ Asymptomatic
■ Normal cardiac silhouette on chest-xray
■ Usually systolic
■ Less than grade 3
■ No cyanosis
■ Normal pulses
■ Normal heart sounds
INNOCENT MURMURS CONT…
67

68. DYNAMIC AUSCULTATION
◻ During dynamic auscultation, as opposed to
conventional auscultation, patient is asked to change
position or perform certain activities that enable
the physician to hear the murmurs and heart sounds
68

69. ¤ Respiration
¤ Valsalva manouvre
¤ Muller manouvere
¤ Standing to squatting
¤ Squatting to standing
¤ Passive leg exercise
¤ Isometric hand grip
¤ Leaning forward
¤ Chin turned upwards
DYNAMIC AUSCULTATION
CONTINUED
69

70. APPROACH TO A CHILD WITH
CHD
70

71. 5 BASIC QUESTIONS TO BE
ANSWERED…
1. Is it a CHD??
2. If yes: Cyanotic or acyanotic??
3. Pulmonary Blood flow: Increased??
4. PAH: +/-??
5. Duct dependent lesion??
71

72. FETAL CIRCULATION
72

73. CHD OR NOT??
Hyperoxia test??
Nada’s Criteria??
Echocardiography
73

74. HYPEROXIA TEST
ABG (PO2 and not SPO2)
100% O2 X 10 mins
Rpt ABG (PO2)
PO2> 200—> Points towards respiratory
pathology
< 150—> Points towards CCHD
74

75. NADAS CRITERIA (1 MA/ 2MI)
75
Major:
Cyanosis
CHF
Systolic murmur grade 3 or more
Diastolic murmur
○ Minor:
Abnormal BP
Abnormal 2nd heart sound
Systolic murmur Grade 1 or 2
Abnormal CXR
Abnormal ECG

76. CYANOTIC OR ACYANOTIC??
Wonder nos: 94 and 85
Acyanotic: Shunt/ Obstructive/ Regurgitant lesions
Cyanotic: Decreased PBF/ Increased PBF/ Normal
PBF
76

77. ACYANOTIC CHDS
77

78. CYANOTIC CHDS
78

79. PULMONARY BLOOD FLOW: INCREASED??
CHF (Tachypnea, tachycardia, hepatomegaly)
Suck rest suck cycle
Excessive sweating
FTT
Repeated chest infections
79

80. PULMONARY ARTERIAL
HYPERTENTION
Pressure= Flow x resistance
Hyperkinetic/ obstructive??
80

81. DUCT DEPENDENT LESIONS…
81

82. TAKE HOME MESSAGE
○ Examination in children needs patience and
practice
○ Children are not small adults
○ CHD is not a very rare entity (Incidence: 8-
10/1,000 live births)
○ Keep a high index of suspicion of CHD in children
○ Take expert opinion and involve pediatric
cardiologist in the discussion and management
82

83. THANK YOU…
83