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
    - S₁and S₂heart sounds should be clear and crisp. S₁ is louder near the base of the heart. Physiological splitting of S₂ and S₃heart 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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