Cyanotic neonates and infants 1 yr with a murmur Well appearing with normal physical exam other than precordial findings? ' V Normal CXR/EKG /Limited bedside cardiac ultrasound and pulse oximetry \ '1 Noncardiac causes of apparent cyanosis with clinically insignificant murmur Abnormal CXR /EKG/Limited bedside cardiac ultrasound and pulse oximetry r \ ’ Possible cyanotic congenital cardiac defect ’< B - Polycythemia - Mild methemoglobinemia FIGURE 35.2 A: Assessment of a noncyanotic, sick child year or older in whom a murmur is heard B: Assessment of a cyanotic child year of age or older EKG, electrocardiogram Children Greater Than Year of Age With Murmur By the time children who have easy access to medical care reach year of age, most severe congenital lesions have been identified and many have been surgically repaired Therefore, acquired cardiac and noncardiac etiologies constitute a larger proportion of new murmurs in this age group Functional murmurs are by far the most commonly discovered murmurs in an older child Acyanotic Children Greater Than Year of Age The acyanotic child with a murmur who appears well and has an otherwise normal physical examination, most likely has a clinically insignificant murmur, indicating a mild acyanotic cardiac lesion such as small atrial or ventricular septal defects ( Table 35.3 ) If the examining provider is satisfied that the murmur is benign, further workup and specialty consultation are not indicated while the child is in the ED Additional evaluation can be determined by the child’s outpatient primary care provider If uncertainty exists, an EKG and CXR can be ordered If these are normal, one has further assurance that primary care followup is all that is necessary If either of these tests is abnormal, a more severe acyanotic defect is possible and echocardiography should be obtained Referral should be made to a pediatric cardiologist on a nonemergency basis for further characterization If the acyanotic child appears acutely ill (Fig 35.2A ), has a history of recent illness, swollen, red, or tender joints, and signs or symptoms of heart failure, acute rheumatic fever should be strongly considered The child should be hospitalized for evaluation of acute rheumatic fever (see Chapter 86 Cardiac Emergencies ) including cardiology consultation and echocardiography In contrast, the ill-appearing acyanotic child, with joint findings but without signs of cardiac failure or EKG changes, is more likely to have a normal murmur with a concurrent illness such as septic, reactive, or rheumatologic arthritis These children need diagnostic evaluation of their acute illness but only primary care follow-up for their murmur TABLE 35.3 COMMON INNOCENT HEART MURMURS Murmur Age Character Positioning Etiology Differential diagnosis Peripheral pulmonic Newborn to yr old I-II/VI low -pitched, Increased with viral respiratory infections, lower heart rate, decreased with Turbulence at the peripheral pulmonary artery branches due to Williams syndrome: significant branch pulmonary artery stenosis Congenital rubella : higher-pitched murmur , extends beyond S2, older child VSD: much harsher stenosis Still vibratory murmur 2-6 yrs most commonly, but can present at any age Venous hum Pulmonary flow murmur Child Child to young adult Supraclavicular or Child to brachiocephalic young adult Mammary souffle Pregnant Lactating Rare adolescent early to midsystolic ejection murmur in the pulmonic area and radiating to the axillae and back I—III/ VI early systolic tachycardia Louder when supine ejection murmur Left lower sternal border to apex Twanging musical quality Most common benign murmur in children I-IV/VI, continuous, humming, low anterior neck to lateral SCM to anterior infraclavicular chest II-III/VI crescendodecrescendo, early to midsystolic, left upper sternal border , second intercostal space Crescendodecrescendo, systolic, low pitched, above the clavicles, radiating to the neck , abrupt onset and brief Louder when sitting or looking away from murmur Softer when lying, with compressed jugular vein or head turned toward murmur Louder when patient supine Decreases with rapid hyperextension of shoulders High pitched , systole into diastole, anterior chest over breast, varies day to day narrow angles in infants Thought to be due to ventricular false tendons Turbulence from the internal jugular and subclavian veins entering the murmur PDA: machinery murmur , not compressible, bounding pulses superior vena cava Flow in the pulmonary outflow tract ASD: fixed split S2 Pulmonic stenosis: higher -pitched, longer murmur, ejection click Flow through the major brachiocephalic vessels arising from the aorta Idiopathic hypertrophic subaortic stenosis: louder with Valsalva and softer with rapid Plethora of vessels over the chest wall squatting Aortic stenosis: higher-pitched ejection click PDA: machinery murmur , does not vary day to day ASD, atrial septal defect; VSD, ventricular septal defect; PDA, patent ductus arteriosus The ill-appearing acyanotic child with a murmur and a history of chronic or recent illness, but no joint findings, may have myocarditis or pericarditis EKG and CXR should be obtained and if abnormal, echocardiography should be ordered, in consultation with a pediatric cardiologist These children should be admitted for ongoing monitoring and therapy The ill-appearing acyanotic child, who has a murmur but no chronic or recent illness but who shows signs of CHF, may have severe acyanotic congenital heart disease, myocarditis, or high-output failure secondary to severe anemia, large ... is possible and echocardiography should be obtained Referral should be made to a pediatric cardiologist on a nonemergency basis for further characterization If the acyanotic child appears acutely... should be obtained and if abnormal, echocardiography should be ordered, in consultation with a pediatric cardiologist These children should be admitted for ongoing monitoring and therapy The