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There are 6 common clinical presentations of pediatric heart disease: cyanosis, shock, congestive heart failure (CHF), pathologic murmur, hypertension, and syncope. Table 72-1 lists the most common lesions in each category. While cyanosis and shock typically appear in the first weeks of life and are often dramatic in their presentation, the symptoms of CHF may be subtle and include respiratory distress or feeding intolerance, which may be misdiagnosed as viral upper respiratory tract illness, especially in winter months. A high index of suspicion must therefore be maintained in order to make the correct diagnosis. This chapter focuses on conditions producing cardiovascular symptoms seen in the emergency department (ED) that require immediate recognition, therapeutic intervention, and prompt referral to a pediatric cardiologist.

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Table 72-1 Clinical Presentation of Pediatric Heart Disease
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The evaluation of an asymptomatic murmur is a nonemergent diagnostic workup that can be done on an outpatient basis. Innocent murmurs, often described as flow murmurs, are of low intensity, are brief, and occur during systole. In general, common pathologic murmurs in children are typically harsh, holosystolic, continuous, or diastolic in timing and often radiate. They may be associated with abnormal pulses or symptoms such as syncope or CHF.

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The treatment of dysrhythmias is discussed in Chapter 3, pediatric hypertension is discussed in Chapter 26, and syncope is discussed in Chapter 78. Chest pain is usually of benign etiology in children, though may occasionally represent congenital (eg, aberrant left coronary artery) or acquired (eg, Kawasaki disease, myocarditis, pericarditis, cardiomyopathy) heart disease. Myocarditis and cardiomyopathy are covered in Chapter 24, chest pain and acute coronary syndrome in Chapters 17 and 18, and Kawasaki disease in Chapter 83.

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Cardiac causes of cyanosis and shock typically present in the first 2 weeks of life and present in the critically ill neonate. The differential diagnosis, however, is broad at this age, and, in addition to congenital heart disease, the clinician should consider infection (sepsis, pneumonia), metabolic disease (see Chapter 79) and nonaccidental trauma. For the neonate presenting with cyanosis, the hyperoxia test helps to differentiate respiratory disease from cyanotic congenital heart disease (although imperfectly). When placed on 100% oxygen, the infant with cyanotic congenital heart ...

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