Pediatric : Circulatory System

    • Circulatory System
      • Heart
        • Inspection
          • Precordial activity
          • Shape and symmetry
            • Heave: an obvious lifting of the chest wall during contraction, may indicate an enlarged heart
        • Palpation
          • Apical impulse
          • Thrills
        • Auscultation
          • Rate and rhythm
Age Heart Rate range (Beats/min) Average Heart Rate (Beats/min)
Newborns 100-170 120
Infants to 2 years 80-130 110
2-6 years 70-120 100
6-10 years 70-110 90
10-16 years 60-100 85
      • Heart sounds
        • Auscultation should be done in both sitting and reclining position
        • S1 and S2 heart sounds should be clear and crisp. S1 is louder near the base of the heart. Physiological splitting of S2 and S3 heart sounds are expected findings in some children. Sinus arrhythmias that are associated with respirations are common
Auscultatory Site  Chest Location  Characteristics of Heart Sounds
Aortic area  Second right ICS close to sternum
  • S2 heard louder than S1; aortic closure heard loudest
Pulmonic area Second left ICS close to the sternum
  • Splitting of S2 heard best, normally widens on inspiration; pulmonic closure heard best
Erb’s point  Second and third left ICSs close to sternum
  • Frequent site of innocent murmurs and those of aortic or pulmonic origin
Tricuspid area Fifth right and left ICSs close to sternum
  • S1 heard as louder sound preceding S2 (S1 synchronous with carotid pulse)
Mitral or apical area Fifth ICS, LMCL (third to fourth ICS and lateral to LMCL in infants)
  • S1 heard loudest; splitting of S1 may be audible because mitral closure is louder than tricuspid closure
  • S1 heard best at beginning of expiration with child in recumbent or left side-lying position; occurs immediately after S2; sounds like word S1 S2 S3: “Kentuck-y”
  • S4 heard best during expiration with child in recumbent position (left side-lying position decreases sound); occurs immediately before S1; sounds like word S4 S1 S2: “Ten-nes-see”
      • Heat Murmurs
        • Intensity, location, radiation, timing, quality
        • Venous hum
          • Caused by turbulent blood flow through the jugular veins
        • Types:
          • Innocent: No anatomic or physiologic abnormality exists.
          • Functional: No anatomic cardiac defect exists, but a physiologic abnormality (such as, anemia) is present.
          • Organic: A cardiac defect with or without a physiologic abnormality exists.
Grade  Description
I  Very faint; often not heard if child sits up
II  Usually readily heard; slightly louder than grade I; audible in all positions
III  Loud, but not accompanied by a thrill
IV Loud, accompanied by a thrill
V  Loud enough to be heard with a stethoscope barely touching the chest; accompanied by a thrill
VI  Loud enough to be heard with the stethoscope not touching the chest; often heard with the human ear close to the chest; accompanied by a thrill
      • Pulses
        • Infants: Brachial, temporal, and femoral pulses should be palpable, full, and localized
        • Children and adolescents: Pulse locations and expected findings are the same as those in adults


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