PHYSICAL DIAGNOSIS OF PEDIATRIC CHF

A 4 week old presents with respiratory distress.  Could this be congenital heart disease?

Today most cases of congenital heart disease are picked up in screening either in utero or shortly after birth.  However, we as emergency physicians will continue to see cases that are initially unrecognized.  Here is a reminder of some pediatric-pertinent findings of congenital heart disease.

  1. Cyanosis – this is only present when desaturated hemoglobin levels are above 3-5 g/dl.  A pulse oximeter will be needed to identify most patients with oxygen desaturation.  Place the oxygen probe on the right upper extremity, which is proximal to any possible aortic coarctation.  If hypoxemia is found, see if it corrects with 100% oxygen, called the hyperoxia test.  If it does not, this indicates intracardiac shunting.
  2. Hepatomegaly – infants develop hepatomegaly from venous congestion rather than peripheral edema.  Don’t forget to palpate for the liver.  Inch inward during exhalation and feel for the liver edge on inhalation.
  3. Point of maximal impulse – The normal location is the left 4th intercostal space, mid-clavicular line.  Infants have thin chest walls so this does actually provide valuable information.  The PMI may be displaced to the left or right, and it can be enlarged.  Visualization alone often provides this information.
  4. Precordial activity – a hyperactive precordium suggests volume overload.
  5. Auscultation – Listen individually to S1, systole, S2, and diastole.  Isolate each sound in your mind.  That can help you decide whether a murmur is holosytolic or ejection. If you are trying to exclude congenital heart disease, listen for physiologic splitting of S2.  Most congenital heart defects disrupt this process.
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