Murmurs and the Cardiac Physical Exam

TCH APP Conference April 2019.keyCarolyn  A.  Altman   Texas  Children’s  Hospital  Advanced   Practice  Provider  Conference   Houston,  TX   April  6  ,  2018
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Some  pearls  on     • General  appearance   • Physical  exam  beyond  the   heart  
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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
Chest  wall   development  and   symmetry  
 
Palpation  
Auscultation  
Cardiac  Palpation  
Consistent  approach:    palm  of  your  hand,   hypothenar  eminence,  or  finger  tips  
Precordium,  suprasternal  notch  
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• Abnormal  sounds?   Clicks,  gallops  
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
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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  
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S2:  normal  splitting Single  S2:    Pulmonar  Hypertension
Wide,  fixed  splitting:  ASD Paradoxical  Splitting  of  S2:  LBBB,   severe  LVOTO
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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
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Varies  with  respiration  as  does  S2  
Soft  S1:    low  cardiac  output,  tachycardia  
Loud  S1:  hyperdynamic  (fever,  exercise),  mitral   stenosis  
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Abnormal  ventricular  function
Mid  way  thru  diastole    
Muscle  tensing  at  end  of  rapid,   early  filling  which  occurs  with   ventricular  relaxation  
Later  than  split  S2  
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
S1-Ej click S4
Heard  best  with  bell  since  low   pitched  
Can  extinguish  the  sound  by   pressing  too  hard  (turning  bell   into  diaphragm)  
Usually  heard  over  mitral  area,   if  LV  dysfunction  
Listen  in  left  lateral  decubitus   position  too  
If  RV  dysfunction-­may  hear  best   at  LLSB
S4
S3
Mid-­systolic  click:  MVP  
Opening  snap  of  MS  
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Innocent  or  pathologic
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
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Ejection  murmurs:  Begins   shortly  after  S1  
Mid-­systolic:  MVP
Often  holosystolic
Begin  after  valve  opens,  so  hear  S1   then  murmur  
Should  be  able  to  hear  S2  distinctly  
Early  systolic  ejection  click  if   semilunar  valve  stenosis
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Low  pitched  filling  noise  
Louder  in  diastole:  venous  hums,   coronary  fistula
PDA Coronary fistula AVM
Helpful  in  figuring  out   what  is  generating   the  murmur  
URSB:  Aortic  stenosis   ULSB:  Pulmonary  
stenosis,  pulmonary   flow,  ASD  
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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
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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
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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
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v Size  of  defect   v Differences  in  compliance  between  RV  
and  LV-­  flow  is  usually  left  to  right
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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
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Pulmonary  flow  murmur:     v Large  volume  of  blood  crossing  the  
pulmonary  valve   v ULSB  to  back   v Ejection   v Medium  pitched
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CHD:  Atrial  Septal  Defect  
Diastolic  Rumble:     Consistent  with  at   least  2:1  Qp:Qs   Low  pitched   Listen  with  bell  at   LLSB
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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
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CHD:  Patent  Ductus  Arteriosus
Palpation   RV  impulse  if  pulmonary  hypertension   Hyperactive  LV  impulse  if  large  volume  
of  flow  PDA
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
juxtarterial
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Size  of  defect  
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CHD:  VSD
Palpation:     Quiet  precordium?     RV  impulse  may  be  present   with  volume  or  pressure   loading  
+/-­  thrill:  cannot  determine   size  by  presence  of  thrill
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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
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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
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(obscured)     Ends  with  P2,  S2  split  
normally   Plateau  shape   The  smaller  the  defect,  
the  more  high  pitched
CHD:  VSD  murmur
Short  systolic  murmur  consistent  with  very  small  defect   v Starts  with  S1       v Ends  before  S2,  as  defect  closed  by  ventricular  
contraction   v Usually  very  localized,  may  only  hear  in  certain  
positions
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Compare  right  and  lef  chest
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         eventually  Eisenmenger  syndrome  
vCan  be  holosystolic,  if     any  pressure  restrichon  
v  If  no  pressure   restrichon,  may  be  no   murmur,  or  a  pulmonary   ouilow  murmur
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v  Pulmonary  valve  click:  dilated  pulmonary  root  
v  Graham-­Steele  murmur:  pulmonary  insufficiency
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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
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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
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not  carry  through   S2-­not  continuous,   not  the  diastolic   component  
The  diastolic  murmur   is  of  a  different  pitch
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 Physiology:  usually  slowly   progressive  obstruchon
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v  Thrill  indicates  more  severe  obstruchon  
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v  Either  at  ULSB,  or   upstream  from  valve  at   LLSB  
v  Increases  in  intensity   with  expirahon  
v  Moves  closer  to  S1  with   increasing  PS
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v  ULSB  radiahng  to  back,  axilla  
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 Ofen  bicommissural    
 Exercise  increases  the   relahve  stenosis
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v  Thrills  frequently  presents  
vCan  be  along  LVOT,  ULSB,  carohds,     suprasternal  notch
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 Ejechon  click:   vOpening  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)
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 Murmur:  
v  With  increasing  stenosis  and   normal  cardiac  output,    murmur   becomes  louder,  longer,  later   peaking    
vMay  not  have  significant   murmur  if  poor  funchon   (neonatal  AS)  
v  Heard  at  apex  (upstream)  or   URSB  (downstream)
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Innocent  Murmurs:
Learn  to  recognize  the  three  most   common  innocent  murmurs  of  childhood:    Venous  hums,    Still’s  murmurs    Physiologic  pulmonary  branch  stenosis  
in  infancy  
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 I-­III/VI  SEM  
 Vibratory,  twanging  
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Subaortic  stenosis  can  mimic  Still’s:   both  can  be  musical
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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
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 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
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PDA  
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
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Tiny  VSD:  better   heard  at  mid  to   LLSB,  not  back/axilla  
PS:  has  a  click  
ASD:  Has  abnl  S2
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
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Worry  if  it  goes  away-­valve  thrombosis
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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
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  
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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.