Cardiovascular Examination in Children

Cardiovascular Examination in Children Component What to do/rational Wash hands Introduce self Basics Consent Explain Activity/alertness Distress Colour Growth Anything else obvious Cyanosis Poor circulation Due to: Hypovolemia -> vasoconstriction Inadequate blood oxygenation Right to left cardiac shunting SOB Cardio -> congenital heart disease Respiratory disease -> asthma Pallor Anaemia Poor perfusion General Inspection Congestive heart failure Oedema Mainly pedal Ascites Due to: Cardiac failure Nephrotic syndrome Rashes Petechiae Clotting disorders Weight Syndrome features Stature -> tall/short Oxygen Saturation probe, mask, nasal prongs, oxygen tank and other breathing support Environment Mobility equipment Medications General inspection Colour Pallor -> poor perfusion -> CHF Cyanosis -> hypoxemia Xanthomata Familial hypercholesterolemia -> risk factor for CVD Arachnodactyly -> spider fingers Abnormally long and slender in comparison to palm of hand and arch of the foot Marfan syndrome -> mitral and aortic valve prolapse and aortic dissection Absent thumbs Holt-Oran syndrome Causes arm bone abnormalities and heart abnormalities e.g. arterial septal defect, heart block Finger clubbing Uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of normal angle between nail and the nail bed Place nails of index fingers back-to-back Look for small diamond shaped window -> Schamroth’s window This is absent in finger clubbing If child is too young Inspect fingers and look for soft tissue swelling ot the terminal phalanx of digits Causes: Congenital heart disease -> TOF Infective endocarditis Features of infective endocarditis Splinter haemorrhages Local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease Janeway lesions Typical of IE Non-tender haemorrhagic lesions Hands On thenar and hypothenar eminences or palms and soles General Malar flush -> plum red discolouration of the cheeks -> mitral stenosis Nasal flaring/grunting -> congenital cyanotic heart disease or heart failure Eyes Conjunctival pallor Xanthelasma Kay Fleischer rings Wilison’s disease Cardiomyopathy Head Mouth Central cyanosis Hypoxemia -> right to left cardiac shunt Angular stomatitis Common inflammatory conditions affecting the corners of the mouth -> iron deficiency High arched palate Marfan’s syndrome Dental hygiene Infective endocarditis JVP Indirect pressure of central venous pressure Between the medial end of the clavicle and the ear lobe, under the medial aspect of the SCM muscle Do it for the IJV even though the external is easier Neck External is less reliable as branches from subclavian vein at 90, while the IJV sits at straight angle about the RA Only for children more than 8 Position at 45 degrees Should be no more than 3cm Causes: RHF, pulmonary hypertension, tricuspid regurgitation and constrictive pericarditis Scars -> cardiothoracic surgery Pectus excavatum Caved it or sunken appearance of chest -> Marfan’s syndrome Pectus carinatum Chest Inspection Protrusion of the sternum and ribs -> Noonan syndrome Visible ventricular impulse Normal in thin children Associated with ventricular hypertrophy Palpate apex with fingers placed horizontally Less than 7 -> 4 th intercoastal space to the left of the midclavicular line More than 7 -> 5 th intercoastal space in the midclavicular line Abnormal positions Left displaced Cardiomegaly, pectus excavatum and scoliosis Right displaced Dextrocardia, left diaphragmatic hernia, collapsed right lung, left pleural effusion and left tension pneumothorax Heaves Pericardial impulse that can be palpated Chest Palpation In babies and younger children use fingertips rather than the palm of hands Place parallel to the left sternal edge (vertical) If present -> fingers or heel of hand should be lifted with each systole Associated with right ventricular hypertrophy Thrills Palpable vibration caused by turbulent blood flow though a heart valve -> palpable murmur Place hand horizontally to the chest wall Flat fingers and palms over the valve to be assessed Pulmonary and aortic -> second intercostal Mitral -> 5th intercoastal Tricuspid -> 4 th or 5 th Auscultate at the valves Do with diaphragm and bell Bell is more effective at detecting low frequency sounds including mid-diastole murmur of mitral stenosis Diaphragm is more effective at detecting high frequency sounds including ejection systolic murmur of aortic stenosis, Heart Auscultation the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation. If murmur is present, check for auscultation at: Axillae Carotids Back Percussion of the heart Auscultate for breath sounds Lung examination Percussion Liver palpation Others Sleep palpation Back for sacral oedema or tibial edema