1. Paediatric Cardiology- after one year of age
Jon Skinner

2. Topics to cover Murmur in a well four year old ECG in diagnosis of CHD
CXR in diagnosis of CHD

3. Murmur in a well four year old
What are the possibilities?

4. Murmur in a well four year old
What are the possibilities?
Innocent murmur

5. Murmur in a well four year old
What are the possibilities?
Innocent murmur
Atrial septal defect

6. Murmur in a well four year old
What are the possibilities?
Innocent murmur
Atrial septal defect
Ventricular septal defect

7. Murmur in a well four year old
What are the possibilities?
Innocent murmur
Atrial septal defect
Ventricular septal defect
Valvar stenosis

8. Murmur in a well four year old
What are the possibilities?
Innocent murmur
Atrial septal defect
Ventricular septal defect
Valvar stenosis
Aortic coarctation

9. Murmur in a well four year old
What are the possibilities?
Innocent murmur
Atrial septal defect
Ventricular septal defect
Valvar stenosis
Aortic coarctation
Patent arterial duct

10. Murmur in a well four year old
What are the possibilities?
Innocent murmur
Atrial septal defect
Ventricular septal defect
Valvar stenosis
Aortic coarctation
Patent arterial duct
Miscellaneous rare stuff- HCM, valvar regurg etc

11. Murmur in a well four year old
No. 1 What is this?
Pulses normal, BP 95/60
RV lift
2-3/6 ESM at upper LSE
ECG-
CXR

12. Murmur in a well four year old No. 1

13. Murmur in a well four year old No. 1

14. Murmur in a well four year old
No. 1 What is this?
Pulses normal, BP 95/60
RV lift
2-3/6 ESM at upper LSE
ECG- normal axis IRBBB
CXR-mild cardiomeg, plethora, prominent PA

15. Murmur in a well four year old No. 2
No. 2 What is this?
Pulses normal, BP 95/60
Normal precordium
2-3/6 vibratory ESM at upper and lower LSE
ECG- normal axis IRBBB
CXR-normal

16. Murmur in a well four year old No. 2- murmur disappears doing this

17. Murmur in a well four year old No. 2
No. 2 What is this?
Pulses normal, BP 95/60
Normal precordium
2-3/6 vibratory ESM at upper and lower LSE
murmur disappears on stretching the neck
ECG- normal axis IRBBB
CXR-normal

18. Murmur in a well four year old
No. 3 What is this?
History of recurrent chest infections
Pulses normal, BP 100/65
RV lift.
2-3/6 ESM at upper LSE, fixed split of second sound
ECG- IRBBB
CXR- Cardiomeg, plethora, prominent PA

19. Murmur in a well four year old No. 3

20. Murmur in a well four year old No. 3
No. 3 What is this?
Pulses normal, BP 100/65
RV lift. Harrison’s sulci
2-3/6 ESM at upper LSE, fixed split of second sound
ECG- IRBBB
CXR- Cardiomeg, plethora, prominent PA
Diagnosis--

21. Murmur in a well four year old No. 4
No. 4 What is this?
Pulses normal, BP 100/65
Parasternal thrill
4/6 PSM at lower LSE,
ECG-
CXR- Normal

22. Murmur in a well four year old No. 4

23. Murmur in a well four year old No. 4

24. Murmur in a well four year old No. 4
No. 4 What is this?
Pulses normal, BP 100/65
Parasternal thrill
4/6 PSM at lower LSE,
ECG- Borderline LVH
CXR- Normal
Diagnosis?

25. Murmur in a well four year old No. 5
No. 5 What is this?
Slim child, recurrent chest infections
Pulses normal, BP 95/60
Overactive precordium
2/6 low pitched PSM at lower LSE, 2/4 diastolic murmur at apex
ECG-
CXR-

26. Murmur in a well four year old No. 5

27. Murmur in a well four year old No. 5

28. Murmur in a “well” four year old No. 5

29. Murmur in a well four year old No. 5
No. 5 What is this?
Slim child, recurrent chest infections
Pulses normal, BP 95/60
Overactive precordium
2/6 low pitched PSM at lower LSE, 2/4 diastolic murmur at apex
ECG- RVH, LVH
CXR- Cardiomegally and plethora
Diagnosis?

30. ECG diagnosis of atrial hypertrophy?

31. ECG diagnosis of atrial hypertrophy?
Lead II

32. Conditions causing Atrial hypertophy on the ECG
RAH
LAH

33. Murmur in a well four year old No. 6
No. 6 What is this?
BP 130/90
Soft ESM at upper RSE
ejection click
ECG- LVH with strain
CXR- unavailable

34. Murmur in a well four year old No. 6
No. 6 What is this?
BP 130/90
Soft ESM at upper RSE
ejection click
ECG- LVH with strain
CXR- unavailable
What do you wish to examine now?

35. Murmur in a well four year old No. 6
No. 6 What is this?
BP 130/90
Soft ESM at upper RSE
ejection click
ECG- LVH with strain
CXR- unavailable
What do you wish to examine now?
Diagnosis?- what might the CXR show?

36. Normal blood pressure values in children
Boys
Girls
Paediatrics (suppl) 59:797, 1977

37. Murmur in a well four year old
No. 7 What is this?
Pulses normal, BP 90/65
RV lift.
2-3/6 ESM at upper LSE, fixed split of second sound
ECG-
CXR-

38. Murmur in a well four year old No. 7

39. Murmur in a well four year old No. 7

40. Murmur in a well four year old
No. 7 What is this?
Pulses normal, BP 90/65
RV lift.
2-3/6 ESM at upper LSE, fixed split of second sound
ECG- LAD IRBBB
CXR- CM plethora
Diagnosis?

41. Types of ASD

42. What does this ECG show?
2 year old, loud systolic murmur, mild cyanosis (88%)

43. What does this CXR show?
3 month cyanotic infant

44. What does this CXR show?

45. Topics we have covered (superficially!)
Murmur in a well four year old
ECG in diagnosis of CHD
chamber hypertrophy
QRS axis
RBBB in ASD
CXR in diagnosis of CHD
L-R shunts-> cardiomegally and plethora
oligaemia

46. Useful texts Essential paediatrics- Hull and Johnstone, Church Liv
Pediatric Cardiology for practitoners- Myung K Park, Mosby
How to Read Pediatric ECGs- Park and Guntheroth, Mosby
Heart Disease in Paediatrics- Jordan and Scott, Butterworths

47. Paediatric ECGs the rules
Jon Skinner
Green Lane Hospital

48. Criteria for chamber enlargement
RA p wave amp >3mm
LA bifid p wave and prolonged >.10 secs - ie 2.5 squares (.08 secs in infants)
RV - use Davignon charts. R in V1>20v (4 squares) >25v in neonates or S in V6 >7v. OR upright T wave in V1 after 72 hours and up to 5 years. Severe RVH- ST and T wave now invert with ST depression, and small Q wave in lead V1.
LV R in V6 >25v (5 squares). Severe- ST depression and T wave inversion V6.

49. Q- waves
Are allowed (usual) in 1,2, 3 and aVf, V5 and V6 and are narrow and up to 7mm deep in 2 and 3
Are pathological in V1 (except occasional newborns) and indicate LTGA, single ventricle, severe RVH or anterior MI (deep and wide).

50. QT interval QTc = QT (ms)/ sq root R-R interval (ms)
is less than 0.45sec
Refer to Normal reference values
Measure in lead 2 and V5 (and particularly not in V2- V4)

51. Abnormal ST segment (up or down)
Up to 1mm is normal
Up to 2 mm is normal in V2- V4
Causes?