Pediatrician Ilembula Hospital Normal heart sounds during a single cardiac cycle ----------------------------------------------------------------------- S1 S2 S1
S1-S2 Sytole; S2-S1 Diastole
S1= Opening of mitral and tricuspidal valve S2= Concomitant closure of Aortic and Pulmonal valve During inspiration S2 is splitted, the aortic valve closes earlier then the pulmonal valve. During expiration the valves close concomitantly and no splitting of S2 can be observed. Not every murmur points to a defect So called physiologic murmurs consist of a melodic, vibrational and smooth component and have usually their origin in turbulences of blood flow or are due to vibration of vessel walls. They are usually proto-mesosystolic.
The second heart sound should not be permanently splitted.
Physiological murmurs do usually not appear during the diastolic
phase. Examples of physiological murmurs Stills murmur: - Vibratory, musical sound, sometimes high pitched and appears during the proto- mesosystolicum. The best auscultation point is the mitral-valve area and the murmur may disappear when the child is raised into the upright position. Physiologic ejection sounds: - Smooth, blowing sound during early systolic phase. Is enhaced when the child is in supine position. Venous murmur: - Is the only physiologic murmur, which can be best heared during the diastolic phase. Best point for auscultation is the right supraclavicular region. The murmur is due to venal blood-flow into the upper caval vein, sometimes beautifully emerges as the call of a seagull. Pathologic Murmurs Persistant ductus arteriosus (PDA) -holosystolic, reaching into the diastole, machinery murmur. -PM left side of upper sternum, pulmonal auscultation point
Ventricle septum defect (VSD)
-holosystolic, harsh, blowing sound -PM apex area, mitral valve auscultation point Pathologic murmurs Atrial septum defect (ASD) -weak systolic murmur, PM pulmonal auscultation area -S2 is permanently splitted which can be best heard at the second intercostal space at the left sternal margin.
Aortic coarctation (CoA)
-Systolic, smooth murmur, PM at the inferior angle of left scapula -The systolic sound may be undetactable if the patient has left heart insufficiency. Measuring of the blood pressure of all four extremities differs the coarctation from innocent heart murmurs Pathologic murmurs Aortic stenosis (AS) -systolic, harsh murmur with a crescendo and decrescendo in intensity. PM right upper sternal margin, propagated to the neck
Pulmonal stenosis (PS)
-holosystolic, harsh murmur, PM pulmonal auscultation area propagated to the back Auscultation points How to make records on murmurs Grade of sound (loudness and propagation) usually grade I-V -Grade I-II: low intensity, grade I is barely auscultable -Grade II-III: clearly auscultable, moderate intensity -Grade III-IV: loud murmurs, grade IV is also palpable -Grade V: loud murmur, palpable vibration Localisation during the heart cycle and quality of murmurs Systole or diastole, holosystolic
Quality of sound: harsh, soft, blowing, increasing or decreasing during
the end of systole or diastole (crescendo-decrescendo) Appearance of additional components before or after the murmur, like opening clicks or snaps Area where best heard (punctum maximum) Describe the site for best and clearest ausculation: -pulmonal area -aortic area -axilla or apex -intercostal space on left or right margin of sternum -back -propagations Example -VSD: Holosystolic, harsh and blowing, grade III murmur, p.m. left parasternal region, 4. ICS, no propagation. S2 not permanently divided
-PDA: Holosystolic and diastolic, mashinery murmur, grade II-III, p.m. pulmonal region, no propagation, (errecting of the child doesent change grade and quality of the murmur). Thank you for listening