Paediatric Cardiovascular Examination

As with adult cardiovascular examination, this is based on inspection, palpation and auscultation.  However, because of the differences in the common cardiovascular conditions seen in childhood, the exclusion (i.e. presuming the heart is diseased) of these conditions requires a slightly different approach.

Inspection

  • Look for any deformity of the thorax (a bulge might suggest cardiomegaly)
  • Look for any peripheral and central signs of cyanosis (hypercyanosis associated with tetralogy of fallot is a paediatric emergency)
  • Look for other general signs e.g. pallor, increased work of breathing (take a respiratory rate if this is the case)
  • Look for visible palpitations of the heart (this suggests the heart is working too hard)

Palpate

  • First, take a radial pulse
  • Feel for the apex beat
    • In a young child/baby, this is in the 4th intercostal space, mid-clavicular line.
  • Feel for the femoral pulse
    • If possible, do this at the same time
    • If absent, this suggests coarctation of the aorta
  • Feel in the sternal notch for a thrill of aortic stenosis
    • Use 3 fingers (outer two on trachea (central) and inner to feel deep in notch for the purr of the murmur)
  • Also feel for thrills/heaves of murmurs over the sternal edge (might indicate a right ventricular problem e.g. pulmonary stenosis)

Auscultation

  • Auscultate over the apex beat
    • In children, heart sounds (including murmurs) are much easier to hear and so don’t usually require special manoeuvres BUT because of the anatomy of the conditions commonly seen in childhood, any extra sounds should be evaluated further.
  • Pansystolic murmur (i.e. loss of HS I+II but murmur in systole)
    • Find the loudest point
      • To do this, auscultate across the chest in an X (i.e. first from left shoulder to right mid-axillary line then vice versa)
      • If loudest at the sternum/centrally- this suggests an AV-septal defect
      • If the loudest at the left lower region, this suggests a mitral valve defect (regurgitation)
  • Ejection Systolic Murmur (i.e. HS I+II present)
    • Also find the loudest part
      • If, in combination with sternal notch purr, loudest in the right sternal edge, most likely to be aortic stenosis
        • might also radiate to the carotids
      • If, in combination with a parasternal heave, loudest in the left sternal edge, most likely to be pulmonary stenosis
        • might radiate to the back or infraclavicularly
        • there may also be splitting of the second heart sound
  • The Innocent murmur of childhood
    • Still’s Murmur
      • A mid-systolic murmur which has a characteristic low-frequency, musical quality (like a ‘seagull’s cry’)- heard best with the bell
      • Usually loudest at the lower left sternal edge, radiating to the apex/carotids; loudest when the child is supine, is acutely unwell or has been exercising/out of breath (this feature is NOT seen in pathological murmurs)
    • Pulmonary flow murmur
      • Caused by turbulent blood flow in the head and neck veins
      • continuous low-pitched rumbling (can be quite loud)
        • eliminated by lying flat or by compressing the ipsilateral jugular vein
        • loudest usually at upper left sternal edge or infraclavicularly
    • The child will be otherwise normal and healthy- caused by turbulent flow
  • Other murmurs
    • Continuous murmurs not relieved by lying/jugular compression may suggest patent ductus arteriosus although these usually also present with bounding or collapsing pulses in infants and young children, respectively
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