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Cardiac Auscultation (PowerPoint)

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									Cyanosed Newborn

Dr. Zakariya Hubail, MD, FAAP
• You are called by a nurse from the
  post-natal ward to evaluate a newborn:

  – “Tachypneic and dusky”
•   4 hour old
•   39 weeks, B. wt. 3.5 kg
•   Mother 28 yr, G2P1
•   Uneventful pregnancy, normal delivery
•   Clear amniotic fluid
•   Apgars 81, 95
     “Tachypneic and dusky”
• What is the RR?
  72 breaths/min
• Dusky? Cyanosed?
• Saturation by pulse oximetry 71%-93%
  from hand 71%
  from leg 93%
              Examination
• T 36.8ºC, HR 142/min, RR 72/min, BP
  62/30 mmHg
• Normal pulses
• Heart:
  – normal precordial impulse, normal S1, loud
    S2, no murmur, clicks or gallop
              Examination
•   Abdomen: normal
•   Lungs: normal
•   Nervous system: normal
•   Extremities: normal
•   Genitalia: normal
               Summary
• 4 hr old, tachypnea
• Cyanosis
            What will you do?
•   Call your senior
•   Chest X-ray
•   ABG
•   CBC
•   Blood culture
•   Consult cardiologist
           What will you do?
• Call your senior
  – admit baby to NICU
• Get a chest X-ray
  – mild cardiomegaly, increased pulmonary vascular
    markings
• ABG
  – pO2 50, pCO2 32, saturation 73%, HCO3 20
• CBC
  – Hb 17.4, WBC 14 500, Plt 156
• Blood culture
•   Is this respiratory or cardiac?
•   What are the cyanotic heart diseases?
•   What does this neonate most likely have?
•   How is the diagnosis confirmed?
•   How is it treated?
     “Tachypneic and dusky”
• Respiratory:
  – RDS
  – TTN
  – pneumonia, sepsis
  – meconium aspiration
  – central hyperventilation
  – Pneumothorx
  – diaphrgamtic hernia
     “Tachypneic and dusky”
• Cardiac:
  – Cyanotic heart disease
  – Obstructive heart disease
  – Shunt lesions
  – Heart failure
                Cardiac?
• T’s
  – Tetralogy of Fallot
  – Transposition of great arteries
  – Tricuspid atresia
  – Total anomalous pulmonary venous return
  – Truncus arteriosus
• HLHS, pulmonary atresia, univentricular
  hearts, DCRV, Ebstein’s anomaly
            Cyanotic Defects

  Increased PBF         Decreased PBF




• Truncus arteriosus   • Tricuspid atresia
• TGA                  • TOF
• TAPVR                • PA
• HLHS                 • TGA +PS
                 Diagnosis
• Best established by echocardiography
• D-transposition of the great arteries
    • with PDA, ASD and intact ventricular septum
     “Tachypneic and dusky”
• Saturation 71%-93%
  – 71% from hand, 93% from leg
                 Treatment
• Temporizing measures
  – PGE1
  – Balloon atrial septostomy


• Definitive repair
  – Arterial switch operation
That’s all folks!




  Any questions?
               Auscultation
•   Areas of auscultation
•   Positional changes
•   S1
•   S2
•   Additional sounds
•   Murmur
S1   S2
S1   S2
S1   S2
S1   S2   S1
S1   S2           S1




          • VSD
          • MR
          • TR
S1   S2          S1




          • AR
          • PR
S1   S2           S1




          • PDA
      All of the followings are usually
     associated with cyanosis except

A. TOF
B. Aortic stenosis
C. Ebstein’s anomaly
D. Total anomalous pulmonary venous
   return
E. Tricuspid atresia
 The most common manifestation of a
      small to moderate VSD is

A.   Murmur
B.   CHF
C.   Cyanosis
D.   Chronic bronchitis
E.   Chest pain
  A 2-day old neonate with a murmur and
cyanosis. CXR shows decreased PVM. ECG
               shows LAD.

A.   Transposition of GA
B.   TOF
C.   Tricuspid atresia
D.   Hypoplastic Left Heart S
E.   Coarctation of aorta
 Hypercyanotic spells are seen in patients
 with TOF. They are treated with all of the
            following except

A.   Oxygen
B.   Digoxin
C.   Knee-chest position
D.   Phenylephrine
E.   NaHCO3
Pulmonary vascular markings are commonly
   increased in all of the following except


A.   Total Anomalus Pulmonary Venous Retrun
B.   TGA
C.   VSD
D.   ASD
E.   Tetralogy of Fallot
      What type of murmur is typically
       associated aortic stenosis?

A.   Holosystolic murmur
B.   Continuous murmur
C.   Ejections systolic murmur
D.   Early diastolic murmur
E.   Mid-diastolic murmur
A 2-month-old infant has severe dyspnea
and cyanosis. Chest radiograph reveals
minimal cardiomegaly and a diffuse
reticular pattern of the lung fields. Which
of the following best explains these
findings?
 A. acute viral myocarditis
 B. hypoplastic left heart syndrome
 C. pulmonary artery atresia
 D. total anomalous pulmonary venous drainage
    with obstruction
 E. transposition of the great arteries
  Some of the things you should
      have learned today

• Cyanosis in neonates
• Murmur types
• Common patterns of CXR in heart
  diseases
• TGA
                          Apgar score

                      0            1                2

Heart rate            Absent       <100             >100
                      Absent,
Resp effort                        slow             good
                      irregular
Muscle tone           limb         Some flexion     Active motion

Reflex irritability   No response Some grimace      Sneeze, cough

Colour                Blue, pale   Extremities blue All pink
            RR
Age (yr)   Boys     Girls
Newborn <60         <60
0-1        31+ 8    30 + 6
1-2        26 + 4   27 + 4
2-3        25 + 4   25 + 3
3-4        24 + 3   24 + 3
4-5        23 + 2   22 + 2
5-6        22 + 2   21 + 2
               Cyanosis
• 5 grams of desaturated Hb/ dl.
Hb-O2 dissociation curve




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