Normal
Regular rate for age
Regular rhythm
S1 and S2 audible
No extra heart sounds
2+ pulses
Capillary refill < 2 seconds
Normal blood pressure for age
Abnormal
Abnormal rate for age
Abnormal rhythm
Obscured S1 or S2
Murmur present
Weak or brisk pulses
Prolonged capillary refill
Abnormal blood pressure
Cyanosis
Clubbing of digits
Normal
Techniques
Bonafide, Christopher P., et al. “Development of heart and respiratory rate percentile curves for hospitalized children.” Pediatrics 131.4 (2013): e1150-e1157.
Auscultation
Normal Heart Sound
- Listen at 4 points – A, P, T, M
- Listen for radiation to axillae or back, as well as to neck
Physiologic split S2
- Variation with respiration, can hear split during inspiration
Blood Pressure
- Cuff size is important – if cuff is too small, can falsely give reading of systolic hypertension
- If concern for coarctation of aorta or valvular disease, should be checking 4-limb BPs
Abnormal
Heart Rates
Pathologic Rhythms
Supraventricular tachycardia
- Rate over 200 bpm, most frequent at 0-3 months of age, then 8-10 years of age and adolescence
Ventricular tachycardia
- Rate in upper 100 bpm, associated with hemodynamic instability
1st degree heart block
- Prolonged PR interval; seen in hypokalemia, increased vagal tone, or myocarditis
2nd degree heart block, type II
- Dropped beats; seen in autoimmune or inflammatory conditions and hyperkalemia
PACs
- Premature beat initiated outside of the SA node; benign, feels like palpitations
PVCs
- Heartbeat is initiated in Purkinje fibers of ventricle rather than SA node; also feel like palpitations; intermittent can be benign; more frequent may transition to v-tach
Torsades de pointes
- Polymorphic v-tach; can progress to v-fib; associated with long QT; can be seen with hypokalemia and hypomagnesemia
Asystole
- Heart has stopped beating or leads are disconnected
Murmurs
Things to Look Out For:
- Location or valve area where murmur is best heard
- Frequency and pitch
- Intensity – I to VI grading system
- Barely audible in a quiet room with good stethoscope
- Quiet but audible with stethoscope
- Easily audible with stethoscope
- Loud obvious murmur with a thrill
- Loud murmur with thrill that is heard with stethoscope barely on chest
- Loud murmur with thrill heard with stethoscope off of chest
- Quality – blowing, harsh, rough, rumbling
- Timing – systolic, diastole, or both; early, mid, or late
- Radiation of sound
- Changes due to position or respiration
Innocent Murmurs
Still’s murmur
- Vibratory musical murmur, loudest at mid left sternal border
Peripheral Pulmonic Stenosis
- Early systolic ejection murmur, radiates to axillae and back; due to narrow size of pulmonary branch arteries compared to main pulmonary artery
Venous Hum
- Continuous, at neck and under clavicle, loudest when sitting, absent when supine
Pathologic Murmurs
PDA
- Systolic ejection murmur at left upper sternal border under clavicle, machine-like quality
VSD
- Holosystolic at left sternal border, cannot appreciate S1 or S2; usually louder if defect is smaller; large defect may not produce sound in newborn due to minimal shunting with high pulmonary vascular resistance
Aortic stenosis
- Systolic murmur at right upper sternal border, ejection click with crescendo-decrescendo, radiates to neck; harsh quality
Mitral insufficiency
- Holosystolic murmur at apex, radiates to axilla; blowing and musical in quality
Mitral valve prolapse
- Mid to late systolic click with late systolic murmur, heard at apex
AV malformation
- Continuous murmur heard over peripheral vessel due to abnormal flow from artery to vein
* Diastolic murmurs are always pathologic!*
Aortic regurgitation
- High frequency blowing quality, early diastolic, heard best at right upper sternal border
Pulmonic regurgitation
- Rough quality, heard slightly after P2, best during inspiration at left sternal border
Mitral stenosis and tricupsid stenosis
- Low and rumbling, mid to late diastole
Abnormal Heart Sounds
ASD
- Fixed split S2
Gallop
- S3 – KEN-tuck-y or SLOSH-ing in
- S4 – te-NNE-ssee or a STIFF…wall
Friction Rub
- Scratching or grating quality, high in frequency; may be heard in pericarditis, MI, after trauma, or with autoimmune disease; best heard at left lateral sternal border
Other Exam Findings
Delayed capillary refill
Right sided heart failure
- JVD
- Liver edge
Left sided heart failure
- Cyanosis
Bacterial endocarditis
- New murmur. May also have petechiae, Osler nodes, splinter hemorrhages, Janeway lesions
Signs of Congenital Heart Disease
- Clubbing – can be seen as early as 3 months of age, loss of angle of nail, may indicate chronic hypoxemia or presence of right-to-left shunt
- Cyanosis – seen at lips or mucous membranes
- Pathologic heart murmurs – see above
Findings Associated with Congenital Syndromes
- Down syndrome – AV septal defects, VSD, PDA
- DiGeorge syndrome – abnormalities with aortic arch, right-sided aortic arch
- Marfan syndrome – aortic root dilation
- Noonan syndrome – ASD, abnormal pulmonic valve
- Turner syndrome – coarctation of aorta, bicuspid aortic valve
- Williams syndrome – aortic or pulmonic stenosis
Systemic Diseases with Cardiac Findings
- Acute rheumatic fever – occurs after Strep infections, associated with serpiginous rash, fever, painful joints, subcutaneous nodules, and chorea; can cause pericarditis or myocarditis; if chronic, can lead to valvular damage and can progress to heart failure
- Kawasaki disease – unknown etiology; associated with 5+ days of fever, swollen lymph nodes, hands and feet, rash, conjunctivitis, and erythema of mucous membranes; if untreated, can progress to coronary artery aneurysms
Causes of Chest Pain
- Anxiety
- Costochondritis
Causes of Syncope
- Vasovagal
- Breath holding spells
- Orthostatic hypotension
- Hypoglycemia
- Hyperventilation
- Migraines
- Emotional trigger
- Conversion disorder
- Seizures
- Toxic Exposures
- Arrhythmias
- Less likely, structural heart defect