Innocent pediatric murmurs: Difference between revisions
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==Background== | ==Background== | ||
* 72% of all school-age children have innocent murmurs | *72% of all school-age children have innocent murmurs | ||
* Congenital heart disease 0.8% of live births | *Congenital heart disease 0.8% of live births | ||
* Check height and weight- L-to-R can cause decr., but are usually symptomatic. | *Check height and weight- L-to-R can cause decr., but are usually symptomatic. | ||
* Color- so, so but cynanosis of hands,feet,perioral on exertion. | *Color- so, so but cynanosis of hands,feet,perioral on exertion. | ||
* Feeding- fatigue or short feeding times for infants- perspiring, grunting, coughing, tachycardia while feeding. Severe CHF may show at rest deep breathing with dyspnea w/ distress. | *Feeding- fatigue or short feeding times for infants- perspiring, grunting, coughing, tachycardia while feeding. Severe CHF may show at rest deep breathing with dyspnea w/ distress. | ||
* Enlarged heart (ie ASD) can cause bulging of chest | *Enlarged heart (ie ASD) can cause bulging of chest | ||
* Older kids- activity causing dyspnea/cyanosis- keeping up with peers, grunting, coughing, tired from stairs. Syncopal/presyncopal, incr fatigue, palpitations/angina can occur with IHSS | *Older kids- activity causing dyspnea/cyanosis- keeping up with peers, grunting, coughing, tired from stairs. Syncopal/presyncopal, incr fatigue, palpitations/angina can occur with IHSS | ||
* Yet older- Aortic valve with rheumatic fever,myocarditis (h/o URI), endocarditis (IV drug use) | *Yet older- Aortic valve with rheumatic fever,myocarditis (h/o URI), endocarditis (IV drug use) | ||
* Preg Hx- Diabetes M (ASD, coarctation of aorta, cardiomyopathies), CMV, Coxsackie B5, warfarin, antiseizure, EtOH (ASD,VSD), prematurity (PDA) | *Preg Hx- Diabetes M (ASD, coarctation of aorta, cardiomyopathies), CMV, Coxsackie B5, warfarin, antiseizure, EtOH (ASD,VSD), prematurity (PDA) | ||
* Worry when- fam hx of IHSS/sudden death & prominent apical thrust indicates LVH | *Worry when- fam hx of IHSS/sudden death & prominent apical thrust indicates LVH | ||
==Clinical Features== | ==Clinical Features== | ||
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==Diagnosis== | ==Diagnosis== | ||
* most innocent murmurs are | *most innocent murmurs are | ||
** not holo or diastolic | **not holo or diastolic | ||
** not >grade III | **not >grade III | ||
** hockey stick dist | **hockey stick dist | ||
** normal S1 & S2 | **normal S1 & S2 | ||
===Types=== | ===Types=== | ||
* Still's | *Still's | ||
**Mid-Systolic, best at LLSB, likely from harmonic vibrations of LV outflow tract (chordae tindinae). All ages, particularly young school age. Low pitch, musical. Decr. with inspiration, sitting, standing. Not a VSD- not regurgitant or w/ thrill. VSD - HSM | **Mid-Systolic, best at LLSB, likely from harmonic vibrations of LV outflow tract (chordae tindinae). All ages, particularly young school age. Low pitch, musical. Decr. with inspiration, sitting, standing. Not a VSD- not regurgitant or w/ thrill. VSD - HSM | ||
* Innocent Pulmonary Flow Murmur | *Innocent Pulmonary Flow Murmur | ||
**Systolic best at LUSB, minor turbulence in RV outflow tract & main pulm. a. Often infants and preschool age. Higher pitched than still's, less musical. Not PS- no ejection click, no incr. RV impulse. no wide s2 split. Not Pulm M of ASD, no fixed splitting, no diastolic tricuspid flow rumble, no incr. RV impulse. Decr. on inspiration/sitting/standing. | **Systolic best at LUSB, minor turbulence in RV outflow tract & main pulm. a. Often infants and preschool age. Higher pitched than still's, less musical. Not PS- no ejection click, no incr. RV impulse. no wide s2 split. Not Pulm M of ASD, no fixed splitting, no diastolic tricuspid flow rumble, no incr. RV impulse. Decr. on inspiration/sitting/standing. | ||
* Innocent Pulmonary Branch Murmur of Infancy | *Innocent Pulmonary Branch Murmur of Infancy | ||
**SEM from turbulence in Pulm. A. branches (one or both). Med pitch. Physiologic in neonates, becoming audible at L,R,B USB btwn 0-2wks; transmits well to back and axilla. Common in premature; disappears early in infancy. Not PS- no eject click, no incr. RV impulse. | **SEM from turbulence in Pulm. A. branches (one or both). Med pitch. Physiologic in neonates, becoming audible at L,R,B USB btwn 0-2wks; transmits well to back and axilla. Common in premature; disappears early in infancy. Not PS- no eject click, no incr. RV impulse. | ||
* Supraclavicular Bruit | *Supraclavicular Bruit | ||
**SEM of med pitch from physiologic turbulence of carotid/subclavian and heard at base of neck. Can be palpable. Disappears on hyperextension of shoulders. Not AS which is loudest at URSB with systolic thrill, sometimes with click. | **SEM of med pitch from physiologic turbulence of carotid/subclavian and heard at base of neck. Can be palpable. Disappears on hyperextension of shoulders. Not AS which is loudest at URSB with systolic thrill, sometimes with click. | ||
* Venous Hum | *Venous Hum | ||
**Continuous murmur from turb.flow in SVC heard at L,R,or B infraclavicular position while sitting/standing. Not PDA (bounding pulse, systolic>diastolic sound) or AV malformation. Disappears in recumbent position, rotation of head, by pressure at jugular. | **Continuous murmur from turb.flow in SVC heard at L,R,or B infraclavicular position while sitting/standing. Not PDA (bounding pulse, systolic>diastolic sound) or AV malformation. Disappears in recumbent position, rotation of head, by pressure at jugular. | ||
* Mammary Souffle | *Mammary Souffle | ||
**Blood flow in A and V to engorged breast. - systolic or continuous, disappears with stethoscope pressure. | **Blood flow in A and V to engorged breast. - systolic or continuous, disappears with stethoscope pressure. | ||
* Cardiorespiratory murmur | *Cardiorespiratory murmur | ||
**High pitched cooing, anywhere, but esp apex. Breath sound so not timed to heart, disappear when holding breath. | **High pitched cooing, anywhere, but esp apex. Breath sound so not timed to heart, disappear when holding breath. | ||
Revision as of 20:45, 5 July 2016
Background
- 72% of all school-age children have innocent murmurs
- Congenital heart disease 0.8% of live births
- Check height and weight- L-to-R can cause decr., but are usually symptomatic.
- Color- so, so but cynanosis of hands,feet,perioral on exertion.
- Feeding- fatigue or short feeding times for infants- perspiring, grunting, coughing, tachycardia while feeding. Severe CHF may show at rest deep breathing with dyspnea w/ distress.
- Enlarged heart (ie ASD) can cause bulging of chest
- Older kids- activity causing dyspnea/cyanosis- keeping up with peers, grunting, coughing, tired from stairs. Syncopal/presyncopal, incr fatigue, palpitations/angina can occur with IHSS
- Yet older- Aortic valve with rheumatic fever,myocarditis (h/o URI), endocarditis (IV drug use)
- Preg Hx- Diabetes M (ASD, coarctation of aorta, cardiomyopathies), CMV, Coxsackie B5, warfarin, antiseizure, EtOH (ASD,VSD), prematurity (PDA)
- Worry when- fam hx of IHSS/sudden death & prominent apical thrust indicates LVH
Clinical Features
Differential Diagnosis
Valvular Emergencies
Diagnosis
- most innocent murmurs are
- not holo or diastolic
- not >grade III
- hockey stick dist
- normal S1 & S2
Types
- Still's
- Mid-Systolic, best at LLSB, likely from harmonic vibrations of LV outflow tract (chordae tindinae). All ages, particularly young school age. Low pitch, musical. Decr. with inspiration, sitting, standing. Not a VSD- not regurgitant or w/ thrill. VSD - HSM
- Innocent Pulmonary Flow Murmur
- Systolic best at LUSB, minor turbulence in RV outflow tract & main pulm. a. Often infants and preschool age. Higher pitched than still's, less musical. Not PS- no ejection click, no incr. RV impulse. no wide s2 split. Not Pulm M of ASD, no fixed splitting, no diastolic tricuspid flow rumble, no incr. RV impulse. Decr. on inspiration/sitting/standing.
- Innocent Pulmonary Branch Murmur of Infancy
- SEM from turbulence in Pulm. A. branches (one or both). Med pitch. Physiologic in neonates, becoming audible at L,R,B USB btwn 0-2wks; transmits well to back and axilla. Common in premature; disappears early in infancy. Not PS- no eject click, no incr. RV impulse.
- Supraclavicular Bruit
- SEM of med pitch from physiologic turbulence of carotid/subclavian and heard at base of neck. Can be palpable. Disappears on hyperextension of shoulders. Not AS which is loudest at URSB with systolic thrill, sometimes with click.
- Venous Hum
- Continuous murmur from turb.flow in SVC heard at L,R,or B infraclavicular position while sitting/standing. Not PDA (bounding pulse, systolic>diastolic sound) or AV malformation. Disappears in recumbent position, rotation of head, by pressure at jugular.
- Mammary Souffle
- Blood flow in A and V to engorged breast. - systolic or continuous, disappears with stethoscope pressure.
- Cardiorespiratory murmur
- High pitched cooing, anywhere, but esp apex. Breath sound so not timed to heart, disappear when holding breath.