Murmurs and the Cardiac Physical Exam. Carolyn A. Altman Texas Children s Hospital Advanced Practice Provider Conference Houston, TX April 6, 2018

Transcription

1 Murmurs and the Cardiac Physical Exam Carolyn A. Altman Texas Children s Hospital Advanced Practice Provider Conference Houston, TX April 6, 2018

2 The Cardiac Physical Exam Before applying a stethoscope.. Some pearls on General appearance Physical exam beyond the heart 2

3 Jugular Venous Distention Pallor 3 Cyanosis

4 4 Work of Breathing Normal infant breathing Quiet Tachypnea Increased Rate, Work of Breathing

5 5 Beyond the Chest Clubbing Observed in children older than 6 mos with chronic cyanosis Loss of the normal angle of the nail plate with the axis of the finger Abnormal sponginess of the base of the nail bed Increasing convexity of the nail Etiology:? sludging

6 6 Chest Chest wall development and symmetry Long standing cardiomegaly can lead to hemihypertrophy and flared rib edge: Harrison s groove or sulcus

7 7 Ready to Examine the Heart Palpation Auscultation General overview Defects Innocent versus pathologic

8 8 Cardiac Palpation Consistent approach: palm of your hand, hypothenar eminence, or finger tips Precordium, suprasternal notch PMI? RV impulse? Thrills? Heart Sounds?

9 9 Cardiac Auscultation Where to listen: 4 main positions Inching Ancillary sites: don t forget the head in infants

10 Cardiac Auscultation Focus separately on v Heart sounds: S2 normal splitting and intensity? Abnormal sounds? Clicks, gallops v Murmurs 10 v Rubs

11 11 Cardiac Auscultation Etiology of heart sounds: Aortic and pulmonic valves actually close silently Heart sounds reflect vibrations of the cardiac structures after valve closure Sudden deceleration of retrograde flow of the column of blood in the aorta and pulmonary artery when the elastic limits of the tensed valve leaflets are met

12 12 Cardiac Auscultation S2 Physiologic splitting of S2: Increased systemic venous return and increased pulmonary capacitance during inspiration causes delayed closure of the pulmonary valve S2 cannot be considered normal unless physiologic splitting is heard

13 13 S2: normal splitting Single S2: Pulmonar Hypertension Wide, fixed splitting: ASD Paradoxical Splitting of S2: LBBB, severe LVOTO

14 14 S2 HInts If splitting persists while patient supine, try sitting position- less volume in heart may normalize splitting Listen for splitting at mid to ULSB in kids Infants: Mid to LLSB Splitting of S2 if the HR is over 160 hard to hear: gently blowing a breath in the baby s face will slow HR

15 15 Cardiac Auscultation: S1 Physiologic splitting of S1: Can be heard in children with slower heart rates. Varies with respiration as does S2 Soft S1: low cardiac output, tachycardia Loud S1: hyperdynamic (fever, exercise), mitral stenosis

16 16 Cardiac Auscultation Gallops: S3 or S4 Short, low pitched diastolic sounds Abnormal ventricular function

17 17 Auscultation: S3 Gallop Mid way thru diastole Muscle tensing at end of rapid, early filling which occurs with ventricular relaxation Later than split S2 Earlier than S4

18 Auscultation: S4 Gallop If impaired ventricular relaxation, less filling of the ventricles during during early diastole and more during atrial contraction Hypertrophic cardimyopathy, eg S4 is thus a sound generated late in diastole Very close to S1, can mistake for split S1 or S1- ejection click 18 S1-Ej click S4

19 S3 and S4 Gallops Heard best with bell since low pitched Can extinguish the sound by pressing too hard (turning bell into diaphragm) S3 S4 Usually heard over mitral area, if LV dysfunction Listen in left lateral decubitus position too S1-Ej click If RV dysfunction- may hear best at LLSB 19

20 20 Other Extra Heart Sounds Ejection Click: opening of the aortic or pulmonary valve Mid- systolic click: MVP Opening snap of MS Listen for difference in timing, cadence

21 21 How to Characterize Murmurs Timing Site of maximum intensity Intensity Radiation Pitch: Associated findings: clicks, rumbles, precordial activity Different from previous in your patient Innocent or pathologic

22 22 Timing of Murmurs Systolic? Diastolic? or Continuous? Systolic occurs as the heart contracts Diastolic as the heart relaxes Continuous murmurs continue from systole into diastole Find S2 and listen to whether the murmur comes before it, after it, or through it Inching the stethoscope can help with timing

23 23 Murmurs: Timing Systolic murmurs: Regurgitant murmurs: Begin with S1 Ejection murmurs: Begins shortly after S1 Mid- systolic: MVP

24 24 Regurgitant Systolic Murmurs MR, TR, VSD Begin with S1: coincident with S1 Often holosystolic

25 25 Systolic Ejection Murmurs AS/PS, Still s, pulmonary flow Begin after valve opens, so hear S1 then murmur Should be able to hear S2 distinctly Early systolic ejection click if semilunar valve stenosis

26 26 Mid Systolic Murmurs Mitral valve prolapse Click ushers in murmur

27 27 Diastolic murmurs Aortic or pulmonary regurgitation: High pitched Decrescendo

28 28 Diastolic murmurs Diastolic rumbles: Increased volume across MV or TV Low pitched filling noise Absence of silence

29 Continuous Murmurs Start during systole, continue past S2 Louder in systole: PDA, AVM, shunts Venous Hum Louder in diastole: venous hums, coronary fistula 29 PDA Coronary fistula AVM

30 Murmurs by location of greatest intensity: 30 Helpful in figuring out what is generating the murmur URSB: Aortic stenosis ULSB: Pulmonary stenosis, pulmonary flow, ASD LLSB: VSD, Still s, TR Apical: Mitral

31 31 Characterize Murmurs: Grading system allows accurate communication between caretakers Grade I: is there something there? Grade II: Ok, I can hear it Grade III: Boy, that s loud Grade IV: Associated with a thrill, knock your socks off loud Grade V: Audible with scope off chest Grade VI: Audible without stethoscope

32 32 Characterize Murmurs: Important to follow trends: Is an aorto- pulmonary shunt murmur getting softer? A shunt may be getting obstructed, outgrown, or PVR elevated Is the outflow tract obstruction getting worse in a patient with new chest pain? Is the patient with TOF spelling or just colicky: the outflow murmur will get softer during a spell as less flow traverses the RVOT

33 33 Characterize Murmurs by Pitch: High Low Harsh (multitonal)

34 34 Congenital Heart Defects Atrial Septal Defect Patent Ductus Arteriosus Ventricular Septal Defect Pulmonary Stenosis Aortic Stenosis

35 35 CHD: Atrial Septal Defect Anatomy: described by location in the septum Secundum Primum Coronary Sinus Sinus Venosus Physiology and physical signs the same, regardless of location of ASD

36 36 CHD: Atrial Septal Defect Physiology: Amount of shunting depends on v Size of defect v Differences in compliance between RV and LV- flow is usually left to right

37 37 CHD: Atrial Septal Defect Palpation: right ventricular impulse from increased RV volume

38 38 CHD: Atrial Septal Defect Widely split S2: v Persistent separation of A2P2 components of S2 throughout respiratory cycle v Increased pulmonary capacitance or v Reciprocal changes in flow into the right atrium from the defect or systemic veins

39 39 CHD: Atrial Septal Defect Pulmonary flow murmur: v Large volume of blood crossing the pulmonary valve v ULSB to back v Ejection v Medium pitched

40 40 CHD: Atrial Septal Defect Diastolic Rumble: Consistent with at least 2:1 Qp:Qs Low pitched Listen with bell at LLSB

41 41 CHD: Patent Ductus Arteriosus Physiology: v In the setting of low pulmonary vascular resistance, flow is continuous, left to right v If large PDA, PA pressures may be high: flow can be Left to right Bidirectional All right to left

42 42 CHD: Patent Ductus Arteriosus Palpation RV impulse if pulmonary hypertension Hyperactive LV impulse if large volume of flow PDA

43 43 CHD: PDA Murmur v Continuous if low pulmonary vascular resistance v Machinery like v Accentuated at end systole v Left infra- clavicular area, back, and left supraclavicular areas

44 44 CHD: Ventricular Septal Defect Anatomy described by location Perimembranous Inlet Muscular Doubly committed- juxtarterial

45 45 CHD: VSD Physiology: amount of shunting depends on Size of defect Pulmonary resistance: more shunting with decreasing resistance

46 46 CHD: VSD Palpation: Quiet precordium? RV impulse may be present with volume or pressure loading +/- thrill: cannot determine size by presence of thrill

47 47 CHD: VSD S2 in VSDs can be Normally split (typical) Widely split if very generous amount of flow crossing to fill RV Single: if pulmonary hypertension with elevated resistance

48 48 CHD: VSD Auscultation Murmur Usually along LSB Very small defects do not radiate Subpulmonary VSDs follow the RV outflow to the pulmonary arteries Blowing quality Start with S1

49 49 CHD: VSD murmurs Holosystolic murmur: Starts with S1 (obscured) Ends with P2, S2 split normally Plateau shape The smaller the defect, the more high pitched

50 50 CHD: VSD murmur Short systolic murmur consistent with very small defect v v v Starts with S1 Ends before S2, as defect closed by ventricular contraction Usually very localized, may only hear in certain positions

51 51 CHD: VSD Mitral Rumble v Indicates at least 2:1 Qp:Qs v Low pitched v Use bell at apex

52 52 CHD: VSD Diastolic rumble Can be quite subtle Listen for absence of diastolic silence Compare right and lef chest

53 53 CHD: VSD Very Large VSDs v Allow high pressure and high flow v If lef unrepaired: elevated PVR develops, eventually Eisenmenger syndrome Palpahon v RV impulse v Palpable S2

54 54 CHD: VSD Large VSDs: Systolic Murmur v Can be holosystolic, if any pressure restrichon v If no pressure restrichon, may be no murmur, or a pulmonary ouilow murmur

55 55 CHD: VSD Eisenmenger s v S2 loud and single v Pulmonary valve click: dilated pulmonary root v Graham- Steele murmur: pulmonary insufficiency

56 56 CHD: Tetralogy of Fallot Physiology: v Balance between VSD flow and pulmonary valve and sub valve stenosis v Pink tets have little pulmonary stenosis v Other extreme: pulmonary atresia with VSD v PS typically progresses over time

57 57 CHD: TOF Palpahon: v RV impulse v Possible thrill

58 58 CHD: TOF Systolic Murmur: reflects PS, not VSD v MLSB to ULSB to back v Starts with S1, given subvalvar component v As subps worsens, murmur decreases in intensity: pop- off through VSD to systemic circulahon v Listen for murmur to decrease in hypercyanohc spell

59 59 CHD: TOF Systolic Murmur: reflects PS, not VSD

60 60 CHD: TOF post repair To and fro murmur PS/PI The murmur does not carry through S2- not continuous, not the diastolic component The diastolic murmur is of a different pitch

61 61 CHD: Pulmonary Valve Stenosis Anatomy: thickened, possibly dysplashc valve with limited systolic excursion Physiology: usually slowly progressive obstruchon

62 62 CHD: Pulmonary Valve Stenosis Palpahon: v RV impulse: more than mild obstruchon v Thrill indicates more severe obstruchon

63 63 CHD: Pulmonary Valve Stenosis Systolic Ejechon Click: v Either at ULSB, or upstream from valve at LLSB v Increases in intensity with expirahon v Moves closer to S1 with increasing PS

64 64 CHD: Pulmonary Valve Stenosis Systolic Murmur: v Louder, longer, and later peaking with increasing stenosis v ULSB radiahng to back, axilla

65 CHD: Aortic Valve Stenosis 65 Anatomy: Thickened valve with decreased excursion Ofen bicommissural Physiology: Obstruchon can be rapidly progressive, parhcularly in infants Exercise increases the relahve stenosis

66 66 CHD: Aortic Valve Stenosis Palpahon: v Increased LV impulse with significant obstruchon v Thrills frequently presents v Do NOT reflect severity v Can be along LVOT, ULSB, carohds, suprasternal notch

67 67 CHD: Aortic Valve Stenosis Ejechon click: v Opening of non- compliant valve v Moves earlier in systole with increasing severity of obstruchon, may become inaudible v Heard at apex (upstream) or URSB (downstream)

68 68 CHD: Aortic Valve Stenosis Murmur: v With increasing stenosis and normal cardiac output, murmur becomes louder, longer, later peaking v May not have significant murmur if poor funchon (neonatal AS) v Heard at apex (upstream) or URSB (downstream)

69 69 Innocent Murmurs: Learn to recognize the three most common innocent murmurs of childhood: Venous hums, Still s murmurs Physiologic pulmonary branch stenosis in infancy Anything else is not likely to be normal!

70 70 Innocent Murmurs: Still s Shll s: most common innocent murmur I- III/VI SEM Sofer with standing or sinng Vibratory, twanging Low pitched, best heard with bell

71 71 Still s murmur versus subaortic stenosis Subaortic stenosis can mimic Still s: both can be musical

72 72 Still s murmur versus Subaortic Stenosis Use positional changes to help distinguish subas from Still s Dynamic obstruction in HCM accentuated with decrease in filling: murmur gets louder with stand Discrete sub AS will not usually get louder, but will also not diminish with stand

73 73 Innocent Murmur: Venous Hum Venous Hum: innocent continuous murmur Turbulent flow merging from internal jugular and subclavian veins into SVC Louder in diastole Disappear when patient lies supine or turns head Audible along infraclavicular area, and low anterior neck (not the head) I- III/VI

74 74 Innocent Murmur: Venous Hum Continuous murmur: whining, roaring, whirring, waterfall

75 75 Venous Hum versus Pathologic Continuous Murmurs PDA Coronary fistula Cranial AVM AO- PA shunt

76 76 Innocent Murmur: Peripheral Pulmonary Stenosis PPS in infant under 6 mos: same pitch as respirations As loud or loudest in back or axilla Systolic, high pitched, blowing Relatively small branch Pas arising at acute angle from large MPA

77 77 PPS versus Pathologic Murmurs PPS- distinguish from Tiny VSD: better heard at mid to LLSB, not back/axilla PS: has a click ASD: Has abnl S2

78 78 Position Changes Distinguish innocent Still s murmurs from LVOTO Detect gallops: apex, left lateral decubitus Distinguish venous hums from non- innocent continuous murmurs Mitral valve prolapse

79 Mitral Valve Prolapse 79

80 80 Auscultation Artificial valves: should be audible without a stethoscope Artificial aortic valves should have a mechanical S2 Artificial mitral valves should have a mechanical S1 Worry if it goes away- valve thrombosis

81 81 Tips for better exams Quiet room Recognize that naptime, stranger anxiety, hunger can adversely affect the situation Make the child as comfortable as possible: Silent distracters to entertain the child- flashlight, ID badge, toys, siblings

82 82 Tips for Better Exams Tiny bodies: Use the right size stethoscope to minimize ambient noise and to accurately determine the presence and location of a murmur Change the order of the exam to fit the child Warm hands and scopes

83 83 Remember- Always not normal: RV impulse, thrills, apical murmurs, murmurs that increase with sitting or standing, murmurs with extra heart sounds, diastolic murmurs Need to have a normally split S2 to be normal If it does not sound innocent- needs further evaluation Thank you.