Box 6-1. SUMMARY OF ABNORMAL S2 *


ABNORMAL SPLITTING
Widely Split and Fixed S2
Volume overload (e.g., ASD, PAPVR)

Abnormal pulmonary valve (e.g., PS)

Electrical delay (e.g., RBBB)

Early aortic closure (e.g., MR)

Occasional normal child


Narrowly Split S2
Pulmonary hypertension

AS

LBBB

Occasional normal child


Single S2
Pulmonary hypertension

One semilunar valve (e.g., pulmonary atresia, aortic atresia, truncus arteriosus)

P2 not audible (e.g., TGA, TOF, severe PS)

Severe AS

Occasional normal child


Paradoxically Split S2
Severe AS

LBBB, Wolff-Parkinson-White syndrome (type B)


ABNORMAL INTENSITY OF P2
Increased P2 (e.g., pulmonary hypertension)

Decreased P2 (e.g., severe PS, TOF, TS)


*From Park MK. Pediatric cardiology for practitioners, 3rd ed. St. Louis: Mosby; 1996. PAPVR, Partial anomalous pulmonary venous return; MR, mitral regurgitation; LBBB, left bundle-branch block; TS, tricuspid stenosis; ASD, atrial septal defect; PS, pulmonary stenosis; RBBB, right bundle-branch block; AS, aortic stenosis, TGA, transposition of the great arteries; TOF, tetralogy of Fallot.



TABLE 6-3 -- COMMON INNOCENT HEART MURMURS
Type (Timing) Description of Murmur Age Group
Classic vibratory murmur (Still’s murmur; systolic) Maximal at MLSB or between LLSB and apex 3-6 yr; occasionally in infancy
Grade 2-3/6 in intensity
Low-frequency vibratory, twanging string, groaning, squeaking, or musical
Pulmonary ejection murmur (systolic) Maximal at ULSB 8-14 yr
Early to midsystolic
Grade 1-3/6 in intensity
Blowing in quality
Pulmonary flow murmur of newborn (systolic) Maximal at ULSB Premature and full-term newborns
Transmits well to left and right chest, axillae, and back Usually disappears by 3-6 mo of age
Grade 1-2/6 in intensity
Venous hum (continuous) Maximal at right (or left) supraclavicular and infraclavicular areas 3-6 yr
Grade 1-3/6 in intensity
Inaudible in supine position
Intensity changes with rotation of head and disappears with compression of jugular vein
Carotid bruit (systolic) Right supraclavicular area over carotids Any age
Grade 2-3/6 in intensity
Occasional thrill over carotid
From Park MK. Pediatric cardiology for practitioners, 3rd ed. St. Louis: Mosby, 1996.
LLSB, Lower left sternal border; MLSB, middle left sternal border; ULSB, upper left sternal border.