Paediatric Cardiology- after one year of age Jon Skinner

Paediatric Cardiology- after one year of age

Jon Skinner

Topics to cover

• Murmur in a well four year old

• ECG in diagnosis of CHD

• CXR in diagnosis of CHD

Murmur in a well four year old

• What are the possibilities?


• What are the possibilities?– Innocent murmur


• What are the possibilities?– Innocent murmur– Atrial septal defect


• What are the possibilities?– Innocent murmur– Atrial septal defect– Ventricular septal defect


• What are the possibilities?– Innocent murmur– Atrial septal defect– Ventricular septal defect– Valvar stenosis


• What are the possibilities?– Innocent murmur– Atrial septal defect– Ventricular septal defect– Valvar stenosis– Aortic coarctation


• What are the possibilities?– Innocent murmur– Atrial septal defect– Ventricular septal defect– Valvar stenosis– Aortic coarctation– Patent arterial duct


• What are the possibilities?– Innocent murmur– Atrial septal defect– Ventricular septal defect– Valvar stenosis– Aortic coarctation– Patent arterial duct– Miscellaneous rare stuff- HCM, valvar regurg etc


• No. 1 What is this? – Pulses normal, BP 95/60– RV lift– 2-3/6 ESM at upper LSE– ECG-– CXR

Murmur in a well four year old No. 1

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Murmur in a well four year old No. 1

•


• No. 1 What is this? – Pulses normal, BP 95/60– RV lift– 2-3/6 ESM at upper LSE– ECG- normal axis IRBBB– CXR-mild cardiomeg, plethora, prominent PA

Murmur in a well four year oldNo. 2

• No. 2 What is this? – Pulses normal, BP 95/60– Normal precordium– 2-3/6 vibratory ESM at upper and lower LSE– ECG- normal axis IRBBB– CXR-normal

Murmur in a well four year oldNo. 2- murmur disappears doing this


• No. 2 What is this? – Pulses normal, BP 95/60– Normal precordium– 2-3/6 vibratory ESM at upper and lower LSE– murmur disappears on stretching the neck– ECG- normal axis IRBBB– CXR-normal


• No. 3 What is this? – History of recurrent chest infections– Pulses normal, BP 100/65– RV lift. – 2-3/6 ESM at upper LSE, fixed split of second

sound– ECG- IRBBB– CXR- Cardiomeg, plethora, prominent PA



• No. 3 What is this? – Pulses normal, BP 100/65– RV lift. Harrison’s sulci– 2-3/6 ESM at upper LSE, fixed split of second

sound– ECG- IRBBB– CXR- Cardiomeg, plethora, prominent PA– Diagnosis--


• No. 4 What is this? – Pulses normal, BP 100/65– Parasternal thrill– 4/6 PSM at lower LSE, – ECG-– CXR- Normal




• No. 4 What is this? – Pulses normal, BP 100/65– Parasternal thrill– 4/6 PSM at lower LSE, – ECG- Borderline LVH– CXR- Normal– Diagnosis?


• No. 5 What is this? – Slim child, recurrent chest infections– Pulses normal, BP 95/60– Overactive precordium– 2/6 low pitched PSM at lower LSE, 2/4

diastolic murmur at apex– ECG-– CXR-



Murmur in a “well” four year oldNo. 5


• No. 5 What is this? – Slim child, recurrent chest infections– Pulses normal, BP 95/60– Overactive precordium– 2/6 low pitched PSM at lower LSE, 2/4 diastolic

murmur at apex– ECG- RVH, LVH– CXR- Cardiomegally and plethora– Diagnosis?

ECG diagnosis of atrial hypertrophy?

ECG diagnosis of atrial hypertrophy?

• Lead II

Conditions causing Atrial hypertophy on the ECG

• RAH

• LAH


• No. 6 What is this? – BP 130/90– Soft ESM at upper RSE– ejection click– ECG- LVH with strain– CXR- unavailable


• No. 6 What is this? – BP 130/90– Soft ESM at upper RSE– ejection click– ECG- LVH with strain– CXR- unavailable

– What do you wish to examine now?


• No. 6 What is this? – BP 130/90– Soft ESM at upper RSE– ejection click– ECG- LVH with strain– CXR- unavailable– What do you wish to examine now?– Diagnosis?- what might the CXR show?

Boys GirlsPaediatrics (suppl) 59:797, 1977

Normal blood pressure values in children


• No. 7 What is this? – Pulses normal, BP 90/65– RV lift. – 2-3/6 ESM at upper LSE, fixed split of second

sound– ECG-– CXR-




• No. 7 What is this? – Pulses normal, BP 90/65– RV lift. – 2-3/6 ESM at upper LSE, fixed split of second

sound– ECG- LAD IRBBB– CXR- CM plethora– Diagnosis?

Types of ASD

What does this ECG show?

2 year old, loud systolic murmur, mild cyanosis (88%)

What does this CXR show?

3 month cyanotic infant

What does this CXR show?

Topics we have covered (superficially!)

• Murmur in a well four year old• ECG in diagnosis of CHD

– chamber hypertrophy– QRS axis– RBBB in ASD

• CXR in diagnosis of CHD– L-R shunts-> cardiomegally and plethora– oligaemia– chamber hypertrophy

Useful texts• Essential paediatrics- Hull and Johnstone,

Church Liv

• Pediatric Cardiology for practitoners- Myung K Park, Mosby

• How to Read Pediatric ECGs- Park and Guntheroth, Mosby

• Heart Disease in Paediatrics- Jordan and Scott, Butterworths

Paediatric ECGsthe rules

Jon Skinner

Green Lane Hospital

Criteria for chamber enlargement• RA p wave amp >3mm• LA bifid p wave and prolonged >.10 secs - ie 2.5

squares (.08 secs in infants)• RV - use Davignon charts. R in V1>20v (4 squares)

>25v in neonates or S in V6 >7v. OR upright T wave in V1 after 72 hours and up to 5 years. Severe RVH- ST and T wave now invert with ST depression, and small Q wave in lead V1.

• LV R in V6 >25v (5 squares). Severe- ST depression and T wave inversion V6.

Q- waves

• Are allowed (usual) in 1,2, 3 and aVf, V5 and V6 and are narrow and up to 7mm deep in 2 and 3

• Are pathological in V1 (except occasional newborns) and indicate LTGA, single ventricle, severe RVH or anterior MI (deep and wide).

QT interval

• QTc = QT (ms)/ sq root R-R interval (ms)• is less than 0.45sec• Refer to Normal reference values• Measure in lead 2 and V5 (and particularly not in V2- V4)

Abnormal ST segment (up or down)

• Up to 1mm is normal

• Up to 2 mm is normal in V2- V4

• Causes?

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Paediatric Cardiology- after one year of age Jon Skinner