Paediatric Cardiovascular Examination
A paediatric cardiovascular examination is a critical component of assessing a child with suspected heart disease. Unlike an adult exam, it requires a careful, calm approach, often starting with observation to avoid distressing the child. The focus is on a structured, top-to-toe assessment to identify subtle signs of cardiac compromise.
General Examination
Begin by observing the child from the end of the bed.
General Appearance: Note if the child is comfortable at rest or is showing signs of distress, such as being breathless. Assess their overall state of health—are they well-nourished? Plot their weight and height on a growth chart, as poor growth can be a sign of a significant congenital heart defect.
Vital Signs:
Heart Rate: Record the heart rate and note if it’s regular. Be aware of the normal ranges, which are higher in children and vary significantly with age.
Pulse Assessment: Check for a radial-femoral pulse delay, which is a classic sign of coarctation of the aorta. A bounding pulse may suggest a patent ductus arteriosus (PDA).
Capillary Refill Time (CRT): Check CRT centrally (on the sternum) and peripherally (on a fingertip). A prolonged CRT (>2 seconds) can indicate poor perfusion or shock.
Respiratory Rate: A high respiratory rate or signs of increased work of breathing (nasal flaring, tracheal tug, intercostal recession) can be a sign of heart failure.
Systemic Signs: Look for signs of cardiac or systemic disease.
Cyanosis: Assess for a bluish discolouration of the skin, especially in the lips and tongue (central cyanosis), as this is a sign of poor oxygenation.
Clubbing: Look for clubbing of the fingers, a sign of chronic hypoxia.
Oedema: Check for oedema, particularly in the face and lower legs in older children, as it can be a sign of fluid overload or right-sided heart failure.
Dysmorphic Features: Many congenital heart diseases are associated with specific syndromes (e.g., Down syndrome, DiGeorge syndrome).
Cardiovascular Examination
Inspection
Precordium: Look for visible scars from previous surgery, such as a midline sternotomy or left lateral thoracotomy. Note any chest wall deformities like pectus excavatum.
Heave: A parasternal heave is an outward movement of the chest wall near the sternum, suggesting right ventricular hypertrophy.
Palpation
Apex Beat: Locate the apex beat, which is typically in the 4th intercostal space at the left mid-clavicular line in infants and the 5th in older children.
Thrills: Palpate over all four heart areas for a thrill, a palpable vibration that indicates a loud murmur.
Auscultation
Heart Sounds (S1 & S2): Listen to the S1 and S2 heart sounds over all four areas (aortic, pulmonary, tricuspid, mitral).
S2 Split: A widely split S2 that does not vary with respiration is a classic sign of an atrial septal defect (ASD).
Murmurs: If a murmur is heard, characterise it thoroughly.
Timing: Is it systolic, diastolic, or continuous? A systolic murmur occurs between S1 and S2.
Location: Where is it loudest?
Radiation: Does it radiate? For example, an aortic stenosis murmur may radiate to the carotids, while a mitral regurgitation murmur may radiate to the left axilla.
Quality and Intensity: Is it loud, soft, harsh, or blowing?
Extra Sounds: Listen for an S3 (a gallop rhythm, which can indicate heart failure) or a pericardial rub (suggesting pericarditis).
Paediatric Cardiac Emergencies
Septic Shock: A child with a cardiac defect can deteriorate rapidly with sepsis.
Heart Failure: Signs include poor feeding, lethargy, tachypnoea, and hepatomegaly.
Arrhythmias: A sudden change in heart rate can indicate a life-threatening arrhythmia.
Cyanosis: A new or worsening episode of cyanosis in an infant with a known heart defect requires urgent attention.