arteriovenous malformation, or thyrotoxicosis ( Fig 35.2A ) This child requires further evaluation and admission If the ill-appearing acyanotic child with a murmur has a fever, he should be examined carefully for splenomegaly and petechiae If present, infectious endocarditis is of immediate concern and the child should be admitted for antibiotics, pediatric cardiology consultation, and echocardiography (see Chapter 86 Cardiac Emergencies ) In addition to infectious endocarditis, consideration must also be given to other conditions characterized by petechiae, such as meningococcemia, idiopathic thrombocytopenic purpura (ITP), rickettsial infection, hemolytic uremic syndrome (HUS), or Henoch–Schönlein purpura (HSP) Blood cultures and other appropriate labs should be drawn, treatment initiated, and the child admitted for further evaluation and monitoring If the acyanotic ill-appearing child with a murmur is not in failure, has no splenomegaly or petechiae , and has a normal EKG, the murmur is most likely normal or associated with the high cardiac output state associated with hyperpyrexia or anemia These children should be evaluated for underlying noncardiac conditions Cyanotic Children Greater Than Year of Age As with infants, cyanotic older children ( Fig 35.2B ) with heart murmurs should have an EKG, CXR, pulse oximetry, and blood gas after a careful history and complete physical examination If these studies are normal, the child probably does not have cardiac-associated cyanosis The murmur may be normal or associated with a small acyanotic congenital defect Entities such as polycythemia and methemoglobinemia should be considered and the primary condition further investigated If uncertainty exists about a noncardiac etiology once the studies are obtained, an echocardiogram should be performed in consultation with a pediatric cardiologist The cyanotic child who is well appearing but has an abnormal EKG, CXR, and pulse oximetry likely has cyanotic heart disease that may require surgical intervention The child should be referred to a pediatric cardiologist for further evaluation, including echocardiography If the cyanotic child appears acutely ill and has signs of CHF, severe cardiac disease is present The etiologies include a congenital cardiac defect with associated progressive cardiac compromise, in which case the cyanosis is intense ( Table 35.4 ), or cardiac failure secondary to acquired disease, in which the cyanosis is related to hypoperfusion and is usually less intense These children need to be admitted for therapy and further cardiac evaluation A careful neurologic examination should be part of the evaluation of every ill child with cyanotic heart disease If findings are abnormal, complications of hypoxemic “spells,” cerebrovascular accident (“stroke”), or, if febrile, brain abscess must be considered Regardless of whether there are signs of CHF, in the cyanotic child with a murmur in the presence of fever, splenomegaly, and/or petechiae, blood cultures should be drawn given the concern for infective endocarditis If the child is not in failure and petechiae are found, infective endocarditis is still a possibility, but other noncardiac causes of petechial presentations must be considered (meningococcemia, Valsalva maneuvers, HUS, ITP, HSP) Appropriate laboratory studies should be obtained and the child hospitalized TABLE 35.4 INNOCENT VERSUS PATHOLOGIC HEART MURMUR Timing Intensity Location of maximal intensity Radiation Quality Heart sounds Normal Pathologic Midsystole Grades I through III, varies with position Left sternal border Diastole, continuous Grades III and above Variable Possibly faint to the Variable to carotids, axilla, precordium and neck, but or back rarely the back “Twangy” or “vibratory” Harsh Readily definable, including Variable, may be obscured splitting of S2 If the ill-appearing cyanotic child has an abnormal CXR but shows significantly improved oxygen saturations with supplemental oxygen, the child most likely has primary pulmonary disease The murmur may be related to tricuspid regurgitation secondary to the high right ventricular pressure These children need admission for evaluation and treatment In the cyanotic child who has a normal EKG and chest film, but abnormal pulse oximetry with normal arterial PO , the possibility of acute toxin-induced methemoglobinemia must be considered, with the murmur being clinically insignificant Co-oximetry blood gas studies should be obtained SUMMARY This chapter provides recommendations for the initial assessment and disposition of infants and children in whom a murmur is discovered in the ED Although diagnostic pathways have been suggested herein, definitive diagnosis of the underlying cardiac defect is not the primary aim of ED evaluation, but rather the careful assessment of the patient and safe disposition are The emphasis is on the patient and less so on the murmur Suggested Readings and Key References Bonow RO, Carabello BA, Chatterjee K, et al Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to develop guidelines for the management of patients with valvular heart disease) Circulation 2008;118:e523–e661 Bronzetti G, Corazani A The seven “S” murmurs: an alliteration about innocent murmurs in cardiac auscultation Clin Pediatr 2010:49(7):713 Etoom Y, Ratnapalan S Evaluation of children with heart murmurs Clin Pediatr 2014;52(2):111–117 Gladman G Management of asymptomatic heart murmurs Pediatr Child Health 2012;23(2):64–68 Hoffmann JIE Cardiology In: Rudolph CD, Hoffmann JIE, Rudolph AM, eds Pediatrics 21st ed New York: McGraw-Hill; 2003:1780–1842 Kwiatkowski D, Wang Y, Cnota J The utility of outpatient echocardiography for evaluation of asymptomatic murmurs in children Congenit Heart Dis 2012;7:283–288 Mahle WT, Newburger JW, Matherne GP, et al Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP Pediatrics 2009;124:823–836 Marin JR, Lewiss RE; American Academy of Pediatrics, Society for Academic Emergency Medicine, American College of Emergency Physicians, World Interactive Network Focused On Critical UltraSound Policy statement: pointof-care ultrasonography by pediatric emergency medicine physicians Pediatrics 2015;135(4):e1113–e1122 Menashe V Heart murmurs Pediatr Rev 2007;28:e19–e22 Section on Cardiology and Cardiovascular Surgery, American Academy of Pediatrics Guidelines for pediatric cardiovascular centers Pediatrics 2002;109(3):544–549 Shaddy RE, Wernovsky G, eds Pediatric heart failure London: Taylor & Francis; 2005 Tanel RE ECGs in the ED Pediatr Emerg Care 2008;24:586–587 ... statement from the AHA and AAP Pediatrics 2009;124:823–836 Marin JR, Lewiss RE; American Academy of Pediatrics, Society for Academic Emergency Medicine, American College of Emergency Physicians, World... Focused On Critical UltraSound Policy statement: pointof-care ultrasonography by pediatric emergency medicine physicians Pediatrics 2015;135(4):e1113–e1122 Menashe V Heart murmurs Pediatr Rev 2007;28:e19–e22... Cardiovascular Surgery, American Academy of Pediatrics Guidelines for pediatric cardiovascular centers Pediatrics 2002;109(3):544–549 Shaddy RE, Wernovsky G, eds Pediatric heart failure London: Taylor