Pediatric emergency medicine trisk 0729 0729

Cyanotic neonates and infants
<1 yr with a murmur
Well appearing with normal physical
exam other than precordial findings?

'

I

Normal CXR/EKG/Limited bedside
cardiac ultrasound and pulse oximetry

1

Abnormal CXR/EKG/Limited bedside
cardiac ultrasound and pulse oximetry

V

1

'
Noncardiac causes of apparent cyanosis
with clinically insignificant murmur
1

Cyanotic congenital
cardiac defect

i

i

- Peripheral acrocyanosis

- Tetralogy of Fallot

- Methemoglobinemia

- Truncus arteriosus
- Ebstein anomaly
- Tricuspid atresia with PFO
- Anomalos pulmonary venous drainage
- Pulmonary stenosis with R-L shunting

- Polycythemia

- TOGV with single ventricle

Cyanotic neonates and infants
<1 yr with a murmur
Well appearing with normal physical
exam other than precordial findings ?
V

Abnormal CXR/EKG/Limited bedside cardiac
ultrasound and pulse oximetry
Signs of congestive heart failure or
cardiogenic shock

'

<

1

Severe congenital cardiac defect or
primary pulmonary hypertension

I

- Hypoplastic left heart
- Severe coarctation of the aorta

;
- Methemoglobinemia

- Critical aortic stenosis
- Critical pulmonary stenosis
- Pulmonary atresia with intact V septrum
- Tricuspid atresia with closed foramen

A

1

Color improves with crying, pulse
oximetry improves with high- flow 02

- Primary lung disease with incidental
normal murmur

- Infection
- Hypoperfusion
- Pulmonary arteriolar hypertension

Acyanotic neonates and infants
<1 yr with a murmur
Well appearing with normal physical
exam other than presence of a murmur ?

I

Probably normal murmur or mild congenital defect
If uncertain, consider CXR and/ or EKG

I

B

Normal murmur or mild acyanotic
cardiac defect:
- Peripheral pulmonary stenosis
Small patent ductus
- Atrial or ventricular septal defect
- Mild aortic or pulmonary stenosis
Partial anomalous pulmonary
venous drainage

1

Normal EKG, CXR , or limited
bedside cardiac ultrasound?

)
- Acyanotic tetralogy of Fallot

-

FIGURE 35.1 A: Assessment of a cyanotic infant younger than 1 year of age in whom a
murmur is heard. B: Assessment of a noncyanotic infant younger than 1 year of age in whom a