Physiologic anatomical peculiarities of the heart and blood vessels in children. Percussion of the...

Physiologic anatomical Physiologic anatomical peculiarities of the heart and peculiarities of the heart and blood vessels in children. blood vessels in children. Percussion of the heart.Percussion of the heart.

Doc. Nykytyuk S.O.

Timeline for development of the heart

Paired endocardial tubes form in cardiogenic region of splanchnic mesoderm

Fuse to form a single heart tube

Ectoderm - blueMesoderm - redEndoderm - yellow

Four layers contribute to the wall of the heart tube

Lumen ofheart

Constrictions & expansions foreshadow adult heart

Development of the septae of the heart

• The single heart tube is divided into four definitive chambers by internal partitioningduring weeks 4-7

1. Interatrial2. Atrioventricular3. Interventricular4. Ventricular outflow tract

• Many congenital heart defects arise during septation

Fetus Neonate

Fetal and neonatal circulatory systems: shunts and changes at birth

1. Fetal foramen ovale shunts blood from right to left atrium

•Adult remnant is fossa ovalis

2. Fetal ductus arteriosus shunts 90% of blood from pulmonary trunk to aorta

•Adult remnant is ligamentum arteriosum

3. Fetal ductus venosus shunts 50% of blood from umbilical vein to inferior vena cava by passing liver

•Adult remnant is ligamentum venosum

Differences in circulatory systems

Prenatal:

• Little pulmonary blood flow• Gas exchange via placenta• Nutrient delivery to fetus through placenta• Right to left shunting of blood in heart

Postnatal:

• Functional pulmonary respiration and gas exchange• Loss of placental circulation• Occlusion of right to left shunt in heart and fetal anastomoses

Congenital heart defects

• Most common type of congenital malformations

• Incidence of nearly 1% of live births

• Causes elusive, multifactoral: single gene & chromosome defects, environmental factors, viruses, toxins, alcohol, drugs

• Specific etiology unknown in many cases but most arise during critical period of heart dev. 20-50 days after fertilization

• Well tolerated before birth because of fetal shunts

• Most produce symptoms postnatally

FIGURE 26–1 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. The ductus venosus, the foramen ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs. After circulating through the fetus, the blood returns to the placenta through the umbilical arteries. From Ladewig, P. W., London, M. L., Moberly, S., & Olds, S. B. (2002). Contemporary Maternal-Child Nursing Care (8th ed,. p. 51 ). Upper Saddle River, NJ: Prentice Hall.

Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

FIGURE 26–2 A, Fetal (prenatal) circulation. B, Pulmonary (postnatal) circulation. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.




FIGURE 26–3 Normal pressure gradients and oxygen saturation levels in the heart chambers and great vessels. The ventricle on the right side of the heart has a lower pressure during systole than the left ventricle because less pressure is needed to pump blood to the lungs than to the rest of the body.




THE PECULIARITIESTHE PECULIARITIESOF INTRAUTERINE CIRCULATION.OF INTRAUTERINE CIRCULATION.

Superior Superior vena vena cavacava

Descending Descending aortaaorta

Inferior vena cava

Pulmonai Pulmonai arteryartery

Plumonary Plumonary veinvein

Postnatal circulation.Postnatal circulation.

Spumoni Spumoni arteryartery

Pulmonary Pulmonary veinvein

Ligamentum Ligamentum teresteres

2 – SA node;

3 – Bachman tract;

4 – tracts of Bachman, Venkebach,

Torel

6 – AV node

7 – Hiss bungle

8 – right leg of Hiss bungle

9 – anterior brunch of left leg of Hiss bungle

10 – posterior brunch of left leg of Hiss bungle

11 - Kent bungle

12 – Jams bungle

13 - Meacham bungle

Conductive system of heart

Cardiac cycleSystole

• 1. period of tension• asynchrony contraction• isometric contraction• (all valves are closed) • 2. period of ejection• protosphigmic interval

(opening of semilunear valves)• fast ejection• slow ejection

Cardiac cycle Diastole

• 1. Period of relaxation• protodiastolic interval (closing of

semilunear valves)• phase of isometric relaxation

(opening of AV-valves is end of this phase)• 2. Period of filling• phase of rapid filling• phase of slow filling• phase of filling by help of atrium

systole

Hypoxemia in the infant

• below 95% pulse oximetry.

• cyanosis results from hypoxemia

• perioral cyanosis indicates central hypoxemia

• acrocyanosis does not.

ASSESSMENT OF HEART ASSESSMENT OF HEART DISORDERS IN DISORDERS IN

CHILDRENCHILDREN HistoryHistory Physical Physical

assessmentassessment general general

appearanceappearance pulse, blood pulse, blood

pressure, & pressure, & respirationsrespirations

Hypoxemia in the infantHypoxemia in the infant

below 95% pulse oximetry.below 95% pulse oximetry. cyanosis results from hypoxemiacyanosis results from hypoxemia perioral cyanosis indicates central perioral cyanosis indicates central

hypoxemiahypoxemia acrocyanosis does not.acrocyanosis does not.

clinical symptomsclinical symptoms

Generalised Generalised moderate moderate peripheral peripheral cyanosis cyanosis in a in a shocked new shocked new born with born with vasomotor vasomotor instability and instability and poor lung poor lung expansion.expansion.


A‘ blue baby' A‘ blue baby' There There is severe is severe peripheral and peripheral and central cyanosis.central cyanosis.Post-mortem Post-mortem revealed revealed Fallot's Fallot's tetralogy. tetralogy. Note Note the malformed the malformed low-set ear.low-set ear.


Severe peripheral Severe peripheral and central and central cyanosis cyanosis ConvulsionConvulsion

was produced by was produced by increased hypoxia increased hypoxia after prolonged after prolonged crying. Post crying. Post mortem revealed mortem revealed atresia of the atresia of the pulmonary artery pulmonary artery and a and a single single ventricle.ventricle.


““pitting” pitting” edemaedema

Abnormal Pulse patternsAbnormal Pulse patternsPulse Pulse patternspatterns

Description Description

Water Water hammerhammer

Very forceful and Very forceful and bounding pulse bounding pulse (Corrigan's pulse)and (Corrigan's pulse)and capillary pulsation may be capillary pulsation may be apparent even in the apparent even in the fingernails suggest fingernails suggest cardial insufficiency, as in cardial insufficiency, as in patient ductus arteriosuspatient ductus arteriosus

Pulsus Pulsus alternantalternant

DicroticDicrotic Adouble radial pulse for Adouble radial pulse for every apical beat, every apical beat, symptomatic of aortic symptomatic of aortic stenosis stenosis

Average pulse rates at rest (beats per minute)

Newborn140-160

6 months130-135

1 year 120-125

2 years 110

3 years 105

4 years 100

5 years 98-100

6-7 years 90-85

10 years 78-85

12 years 70-75

The normal rate is not more then 10 % of average

Blood pressure, mmHgUpper extremity Newbornsystolic: 70-76diastolic: 35For children younger

12 monthssystolic: 76 + 2 x n (n

is age in months) diastolic: 1/2-1/3 of

systolic

Lower extremityNewbornsystolic: 70-76diastolic:35 For children younger

9 monthssystolic: 76 + 2 x n (n

is age in months) diastolic: 1/2-1/3 of

systolic

Blood pressure, mmHgUpper extremity 1 yearsystolic:90-100 diastolic: 60For children older 1 yearsystolic: min. 90 + 2 x n (n

is age in years) max. 100 + 2 x n (n

is age in years) diastolic: 1/2-1/3 of systolic

Lower extremityIn children older 9-10

monthsthe blood pressure is 5-20

mm Hg more than upper extremity

HypotensionHypotension

Blood PressureBlood Pressure Lowest acceptable systolic blood pressureLowest acceptable systolic blood pressure

Birth – 1 monthBirth – 1 month:: 60 mmhg 60 mmhg 11 month – 1 year month – 1 year:: 70 mmhg 70 mmhg 1 year – 10 year1 year – 10 year:: 70 + (2 X age in years) 70 + (2 X age in years) >10 years >10 years : : 90 mmhg90 mmhg

Normal systolicNormal systolic 80 + (2 x age in years)80 + (2 x age in years) oror fiftieth percentile fiftieth percentile

Border's of heart relative dullness

Border

Right

Upper

Left

Transversal size

2-7 years

•right parasternal line

•the II intercostals space

•1 cm outward from left midclavicular line

•8-12 cm

Border

Right

Upper

Left

Transversal size

7-12 years•Between the right paraste-rnal line and the right sternal line•the III rib•0.5 cm outward from left midclavicular line•9-14 cm

Border

Right

Upper

Left

Transversal size

until 2 years•right parasternal line•the II rib•2 cm outward from left midclavicular line•6-9 cm

Border

Right

Upper

Left

Transversal size

older 12 years•the right sternal line•the III intercostals space•0.5 cm medially from left midclavicular line

•9-14 cm

Border's of heart absolute dullness

Border

Right

Upper

Left

Transversal size

2-7 years

•left sternal line

•the III rib

•left midclavicular line

•4 cm

Border

RightUpper

Left

Transversal size

7-12 years•left sternal line•the III intercostal space•Between the left midclavicular line and left parasternal line•5-5.5 cm

Border

Right

Upper

Left

Transversal size

until 2 years•left sternal line

•the II intercostal space

•1.0-0.5 cm outward from left midclavicular line

•2-3 cm

Border

Right

Upper

Left

Transversal size

older 12 years

•left sternal line

•the IV rib

•left parasternal line

•5-5.5 cm

Clinical symptomsClinical symptoms

TachycardiaTachycardia BradycardiaBradycardia Pulsus alternansPulsus alternans

Pulsus bigeminusPulsus bigeminus

Increased rateIncreased rate Decreased rateDecreased rate Strong beat Strong beat

followed by weak followed by weak beatbeat

Coupled rhythm in Coupled rhythm in which beat is felt which beat is felt in pairsin pairs

FIGURE 26–13FIGURE 26–13 Clubbing of the fingers is one manifestation of a cyanotic defect in an older child. Clubbing of the fingers is one manifestation of a cyanotic defect in an older child. What neurologic signs may be associated with such a defect? What neurologic signs may be associated with such a defect?

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Child Health Nursing: Partnering with Children & FamiliesFamilies

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey Upper Saddle River, New Jersey

0745807458All rights reserved.All rights reserved.

Blue-or-tet-spellsBlue-or-tet-spells

FIGURE 26–12FIGURE 26–12 Place the infant who has a hypercyanotic spell in Place the infant who has a hypercyanotic spell in the knee–chest position. This position increases systemic vascular the knee–chest position. This position increases systemic vascular resistance in the lower extremities.resistance in the lower extremities.




FIGURE 26–10FIGURE 26–10 A child with a cyanotic heart defect squats A child with a cyanotic heart defect squats (assumes a knee–chest position) to relieve cyanotic spells.(assumes a knee–chest position) to relieve cyanotic spells.




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Physiologic anatomical peculiarities of the heart and blood vessels in children. Percussion of the...

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