Paediatric Murmur

Front 1

What murmurs occur above the nipple line? What sounds?

Back 1

Pulmonary stenosis (ejection systolic - burr de, left sternal border radiating to back)
Aortic stenosis (ejection systolic - burr de, right sternal border radiating to carotid)
PDA (continous machinery murmur - BurrDurr, left under clavical front and back)

Front 2

What murmurs occur under nipple line? What sound?

Back 2

VSD - (pansystolic Burr, left sternal border)
MR - (pansystolic Burr, apex)

Front 3

What are the charateristics of an innocent murmur?

Back 3

The 7 S's
Short
Soft
Systolic
S1 & S2 normal
Standing & sitting variation
Symptomless
Special tests normal (ECG, CXR, Echo)

Commonly ejection systolic murmur at left sternal edge

Front 4

What murmur is heart in ASD? Why is this sound heard?

Back 4

Fixed splitting of the 2nd heart sound - Lub Splat, Lub Splat.
ASD results in left to right shunt at atrial level (from high to low pressure) this results in increased volume in the right ventricle resulting in the pulmonary valve closing slightly later than the aortic valve.

Front 5

Which murmur is heard loudest - small VSD or large VSD? Which produces a thrill &/or heave? Where are these murmurs heard?

Back 5

a) Small VSD are louder due to increase blood flow across the duct
b) Small VSD may produce a thrill and large VSD may produce a heave
c) VSD are typically pansystolic murmurs heard at the left sternal border under the nipple, however large VSD are often not heard there instead pulmonary ejection murmur is heard due to increase blood volume going across the pulmonary valve.

Front 6

How do large VSD typically present?

Back 6

With heart failure at 4-6 weeks.
Infants are often breathless & sweaty on feeding or crying.
It may also cause faltering growth or recurrent chest infections

Front 7

What is the management of VSD?

Back 7

None in small
Diuretics & ACEI for heart failure
Repair if large defect with risk of pulmonary hypertension
N.b. NICE (2008) do not recommend prophylaxis antibiotics (from endocarditis) however may paediatric cardiologist still give it

Front 8

How does ASD present?

Back 8

May be asymptomatic
Recurrent chest infection or heart failure
Arrhythmias common in 30s & 40s (SVT & AFT)

Front 9

How are ASD managed?

Back 9

Trans-catheter closure (via femoral vein & IVC to right atrium) or open heart surgery with patch repair
B4 5th birthday

Front 10

What are the clinical features of a PDA?

Back 10

- Commoner in premature babies (kept open by hypoxia)
- Collapsing pulse
- Continious machinery murmur loudest below left clavicle & radiates to back - BurrrrDurrr

Front 11

How is a PDA managed?

Back 11

Medical closure: Prostaglandin synthetase inhibitor (e.g. indometacin infusion)

Surgical closure: Transcatheter occlusion, surgical ligation

Front 12

What are the charateristic features of Fallot's tetralogy?

Back 12

PROVE
P - Pulmonary stenosis causing
R - Right ventricular hypertrophy
O - Over-riding aorta; R to L shunt across
V - VSD
E - Ejection systolic murmur - pulmonary

Front 13

What sign are found in somepme with Fallot's tetralogy?

Back 13

- Clubbing
- Cynosis
- Right ventricular hypertrophy - Heave
- Ejection systolic murmur - Left sternal edge

Front 14

What is the management of Fallot's tetralogy?

Back 14

Immediate - prostaglandin to keep ducts open

Sugerical repair - 2 stage process:
1) BT shunt: artifical PDA is created
2) Definitive correction

Front 15

What are the charaterisitic X-ray findings in Tetralogy of Fallot?

Back 15

- Relatively small heart
- Uptilted apex (boot-shaped) due to R ventricular hypertrophy
- Right-sided aortic arch
- Pulmonary artery 'bay' a concavity on the left heart border where the convex-shaped main pulmonary artery & R ventricular outflow tracts would normally be profiled
- Decreased vascular markings

Front 16

Fixed splitting of the 2nd heart sound?

Back 16

ASD

Front 17

Lub Splat Lub Splat

Back 17

ASD

Front 18

Spliting of the second heart sound on expiration

Back 18

Normal spittubg