Download The physical examination of a child with cardio

STATE UNIVERSITY OF MEDICINE AND PHARMACY
„NICOLAE TESTEMITSANU” FROM REPUBLIC OF MOLDOVA
THE SEMEIOLOGY OF
CARDIOVASCULAR SYSTEM
CHISINAU 2013
Morpho-functional peculiarities of
cardiovascular system in different stages of development
The ontogenesis of cardiovascular system begins in the II week of gestation, in mesoderma, by the
appearance of primitive ,, cardiac tube”, from which is forming:
•
•
•
•
•
Common arterial trunk, from which ulteriorly the magistral vessels will forming (aorta and
pulmonary artery);
Cardiac bulb, from which the right ventricle will developing;
primitive ventricle– predecessor of left ventricle;
primitive atrium– preceeds the both atria;
venous sinus, from which the great veins will forming.
In the III week two layers appear from cardiac tube:
• internal, from which the endocardium will developing;
• external, from which the myocardium and epicardium will proceed.
The IV week- the heart with 2 cavities will forming
The IV week- the conducing system is constituing:
• Sinus node,
• Atrioventricular node,
• His fascicle,
• Bahman fascisle,
• Supplementary pathways (Kent etc.)
The V week – the heart with 3 cavities
The VI-VII week:
•
•
The division of common arterial trunk in pulmonary artery and aorta,
Division of unique ventricle in the left and right ventricle (forming of
interventricular septum).
Fetal circulation
The setting up of placentar circulation begins in theVIII week ofintrauterine development.
Thus, the oxygenated blood from placenta, through ombilical vein, gets in the foetus liver, where
being divided in a lot of pathways reaches in vena portae and the fortus liver receives the most
oxygenated blood.
Through venous channel(Arantius) another part of blood is getting to inferior vena cava, being
mixed with venous blood, arrived from inferior parts of foetus body and liver and is flowing in
the right atrium, where is also flowing the superior vena cava which brings the venous blood
from the superior part of body.
The blood arrived on 2 these pathways in the right atrium will not be completely mixed, the most
part, arrived through inferior vena cava, through foramen ovale will pass in the left atrium, left
ventricle and ascendent aorta.
The blood from superior vena cava will getting from right atrium in right ventricle.
In the left atrium also arrives the blood from nonfunctional pulmonary veins, but this quantity of
blood is not important from gas exchange.
The blood from left ventricle through ascendent aorta in systole reaches in the vessels irrigating the
superior part of body(aa. Anonyma, Carotis, Subclavia sin.),
About 10% of blood from right ventricle through pulmonary artery, gets in the not functioning
lungs and through pulmonary veins is returning in the left atrium.
The most part of blood from pulmonary artery, through arterial channel(Botallo), arrives in the
descendent aorta, lower of vessels that irrigate the brain, heart and superior part of body.
The fetal circulation is characterizing by:
•
•
•
Existence of fetal communications between the right and left part, also between magistral
vessels– respectively two right-left shunts.
Significant increasing of minute-volume of big circulation due to the absence of pulmonary
function.
Preferential ensurence with richly ooxygenated blood of vital organs(brain, heart, liver,
superior members) through ascendent artery and its arch.
•
Practically equivalent pressure in aorta and pulmonary artery.
Postnatal circulation
After infant’s birth and first inspiration realizing, the pulmonary resistance decreases and a lot of
modifications are producing:
•
•
•
•
•
•
•
The stopping of ombilical circulation concomitantly with ligaturing and sectioning of
ombilical cord.
Elimination or extraction of placenta.
Decreasing of vascular pulmonary resistance and substantial increasing of vascular pulmonary
debit .
Increasing of peripheral vascular resistance and decreasing of peripheral sanguine debit .
Closing of venous channel (Arantius), of arterial duct (through decreasing of de
prostaglandin E1 production), of foramen ovale
The maturation of pulmonary vascularization and decreasing of arterial pulmonar pressure at
the level of vascular bed
The heart of new-born has in reserve an important potential of adaptation:
Decreasing of blood viscosity through increasing of figurate elements number(erythrocytes,
leucocytes);
•
•
Stopping of placentar circulation, which diminishes the volume of circulant blood with 2530% and reduces the covered distance of this;
After birth the loading of left ventricle increases and the loading of right ventricle gradually
decreases.
The physiologic evolution of pregnancy, without the action of noxious factors, especially
teratogenic, ensures also the adequate development of cardiovascular system.
In the contrary case the serious disturbances of ontogenesis, with the forming of congenital cardiovascular malformations can be produced.
The functional peculiarities of cardio-vascular system in children
•
•
•
•
•
•
The child’s organism has net superior necessities to the heart due to more intense metabolism.
The heart function has more favourable conditions in comparison with adults due to the
absence in children of chronic intoxication(alchool, nicotine, diverse professional noxious
factors etc.).
The cardio-vascular system in children has the restoration possibilities more than in adults.
The nervous regulation of cardiac activity in children is represented by predomination of
sympathetic system on the parasympathetic.
The physiologic tachycardia is characteristic for children, respectively high frequency of
cardiac contractions (in new-born120-140 beats/min.).
The lability of cardiac contractions frequency is an important peculiarity of the child. It can
be in:
• screaming,
• crying,
• movement (accelerating),
• sleeping (diminishing).
The establishing of correct and complete diagnosis in a cardio-vascular disease in children needs the
using of following diagnostic methods:
•
Anamnesis
•
•
•
•
•
Physical examination
•
•
•
•
inspection
palpation
percussion
auscultation
X-ray chest
Noninvasive graphic examinations:
a) echocardiography;
b) fonocardiogram;
c) Methods of nuclear cardiology, pulmonary radiocardiography, radiospirometry;
d) tomodensitometry (computer triaxial tomography )
Invasive examinations: catheterism and angiography
Investigation of fetal rhythm (fetal cardiology).
The principal symptoms cardio-vascular system affection
Palpitations are the expression of cardiac organic or functional arrhythmia.
They can be generated by neuro-vegetative dystonia, by some functional states and, more rarely in
children, by some organic lesional background.
Precordial pains are alarming for patient, they can be manifested under the form of:
•
•
•
•
•
•
sting,
precardialgies,
pression,
burn,
Thoracic constriction etc.,
With precordial localizing.
If they have cardiac origin, they will be produced by:
• coronarian insufficiency(aortic stenosis),
• Some congenital cardiopathies,
•
Pulmonary hypertension etc.
There are a lot of situations(acute articular rheumatism , some myocardites, pericardites,
endocardites, extrasystoles) which can produce precordial pains by noncoronarian cause.
The pains with precordial localization can also appear in intercostal neuralgia, but they can be easely
diffetentiated.
•
•
Cyanosis by cardiac type is central, appears when the reduced hemoglobin exceeds 5% and
can be accentuated at effort.
Dyspnoea, relatively precocious symptom , is the result of tissue oxygenation disturbances; is
met at effort (dyspnoea of effort), in rest(orthopnoea) or suddenly (paroxystic dyspnoea,
sometimes nocturnal, acute pulmonary edema).
The swoon
•
Loss of consciousness by short time, but with the keeping of vital functions (circulation and
respiration).
Syncope
•
•
•
•
•
•
•
Loss of consciousness, by short time, without keeping of vital functions:
Marked decreesing until the stopping of cardiac contractions;
Absence of pulse;
Decreasing until the stopping of respiration.
Falling of arterial pressure;
neurological manifestations;
duration 3-4 minutes, after 5 minutes the decerebration is producing.
There is a difference between syncope and swoon, both having as background the disturbances of
cerebral irrigation – reducing of cerebral debit.
The physical examination of a child with cardio-vascular system affections
•
The physical examination of cardio-vascular system includes the same stages and methods as
the general physical examination: inspection, palpation, percussion and auscultation.
•
The examination includes not only precordial region or only cardio-vascular system, but the
entire organism, because every sign can be very important.
The peculiarities of cardio-vascular system inspection methods in children:
1. The inspection of cardio-vascular system in children is performing in conditions in which the
child is quiet or in the time of his sleeping.
2. The general inspection of entire organism and local, at the level of cardiovascular system is
performing.
3. There will be appreciated the constitutional type, the anthropometric parameters, the physical
delaying being characteristic for children with severe cardiac affections, especially with
congenital cardiac malformations .
The peculiarities of palpation method in cardio-vascular system examination in children
In children the palpation represents a method to verify the found at inspection signs and to find
anothers.
•
•
•
•
•
•.
The palpation can give information about:
Cardiac volume,
Apexian beat (more upper in suckling babies),
Fremitus and gallop,
Character of pulse,
Quality of peripheral circulation etc.
The apex beat in children is palpating in the precordial region with the palm and after that with the
tips of the fingers:
•
In children until 2 years it is situated in the IV left intercostal space 2 cm exteriorly from left
medioclavicular line;
• In 2-5 years age – in the IV intercostal space 1 cm exteriorly from left medioclavicular line;
•Supplementarly
In more than 5 years age – in the V intercostal space on the left medioclavicular line.
the apex beat is also characterized by mobility and amplitude.
At palpation of precordial area there can be constated:
Palpator equivalents of sounds or cardiac murmurs (fremitus).
Systolic and diastolic fremitus, (palpator transmission of existent murmurs) is appreciating in
children only in the case of organic valvular lesions:
•
•
•
•
•
The diastolic fremitus on apex– in mitral stenosis;
Parasternal systolic fremitus – in interventricular septal defect or in potent ductus arteriosus
(Botallo).
Systolic fremitus in the II intercostal right space– in aortic stenosis.
The pulse in children is more difficult for evaluation due to age peculiarities.
As a rule, the pulse is palpating on radial and femoral artery (its absence denotes the
coarctation of the aorta).
The characteristics of pulse include:
•
frequency,
• amplitude,
• rhythm,
• capacity.
•
•
I.
-
II.
-
The frequency of pulse in children can be appreciated also by big fontanelle, temporal,
carotidian arteries pulsation.
The frequency of cardiac contractions normally must coincide with the frequency of pulse,
contrary there is a deficit of pulse.
The technique of percussion:
Delimitation of heart apex- superficial percussion- verify the obtained at palpation data:
3 lines are percussing:
• vertical, from down to up, on the medioclavicular line, until matitaty meating;
• horizontal - from lateral to medial, on the line passing through the anteriorly determined
point – apex beat will be situated at the intersection of these two lines;
• the third„verify” line is the bisectrix of angle determined by the first two lines, and the first
percussed dullness on this line must coincide with determined apex beat.
The determining of superior margin of hepatic dullness (lung interposing):
Is performed by deep percussion;
Is percussing from down to up- usually on the right medioclavicular line.
III. The determining of right heart margin:
•
Is performing by superficial percussion;
•
•
•
IV.
•
•
•
•
•
Is percussing- parallel with the ribs perpendicular on sternum- on the II-V (VI) spaces, until
the dullness meeting, and uniting the points of dullness from each intercostal space we obtain a
line corresponding to the right heart margin;
In normal heart it not exceeds the right margin of sternum;
The angle formed by superior margin of liver and right margin of heart is naming
„cardiohepatic angle” which must not exceed 90°.
The determining of left heart margin:
Performing of superficial percussion;
The percussion begins from II intercostal space until the heart apex (apex beat);
It is performing from periphery to the center –moving parallel to the ribs;
In normal conditions, the left margin of the heart is on the line uniting the normal apex beat
with subdull zones.
In normal mode it must not exceed the lateral margins of manubrium.
The limits of relative cardiac dullness in children are relatively more that in adults(,,dilated heart”):
Age until 2 years:
•
•
•
right: right parasternal line;
left: 1,5-2 cm exteriorly from medioclavicular left line;
superior: rib II.
Age of 2 - 7 years:
•
•
•
right: 0,5-1 cm exteriorly from parasternal right line;
left: 0,5-1 cm exteriorly from medioclavicular left line;
superior: II intercostal space.
Age of 7-12 years:
•
•
•
right: right sternal line;
left: left medioclavicular line;
superior: rib III.
The cardiac dullness is increased at percussion in pericarditis, myocarditis, dilative
cardiomyopathies and decreased in pulmonary emphysema and in pneumothorax.
The peculiarities of
cardio-vascular system auscultation method in children
•
The auscultation constituies the most advantageous physical method for heart examination.
The auscultation and auscultation points respect the same rules as in adult, but an stethoscope
adequate to the age of patient is using.
The auscultation in the child requires many ability and knowledge of sistemului cardiovascular
system peculiarities. Thus, in suckling and infant the supplementary factors during auscultation
can appear(agitation on examination, crying, absence of cooperation), which can influence the
conclusions of examinator. From this motive it is recommended to perform auscultation, as
possible, when the child is quiet or when he sleeps.
The auscultation will be performed in all points, on the all area of precordial dullness, on the route
of vessels and posterior between scapula and vertebral column. The method allows to
appreciate the cardiac frequency, the rhythm and character of normal or superposed
(clackments, clicks) sounds, of murmurs etc.
•
•
•
•
•
•
•
•
The cardiac sounds in children are more frequent, more intense (the suckling has more thin
thorax), with the tendency to equalization (in suckling).
During the child’s growing, the I sound is accentuating on apex, and the II sound - on
pulmonary artery, sometimes splitting variably with respiration.
The presence of III sound in youths is physiological, due to good tonus of myocardium, which
makes it to vibrate in the phase of rapid diastolic filling.
Its presence in myocarditis equates with the gallop rhythm and signify myocardic hypotonia .
The diminishing of cardiac sounds intensity appears in: myocardites, pericardites, pulmonary
emphysema etc.;
The increasing of I sound intensity appears in mitral stenosis, and of II sound in arterial
hypertension .
The both sounds are accentuated at effort, emotions, hyperthyroidism etc.
The rhythm disorders are found most frequent at auscultation, and ECG must precise the
nature of cardiac arrhythmia.
Auscultatively:
The first cardiac sound in children, meaning the beginning of ventricular systola, is
auscultating maximally on apex;
the II sound closes the ventricular systole , more intensively is auscultating on the basis of
heart;
-
the II sound on pulmonary artery is auscultating accentuated or splitted due to topographic
sitting of
pulmonary artery near to the thoracic wall and due to the preponderant activity of right ventricle;
In the first 3 months the cardiac sounds have practically the same intensity, and the pauses are
equal (embryocardia).
•
•
•
•
•
•
•
Cardiac murmurs, appreciated auscultatively, are characterized by the place of producing,
duration, intensity, timbre, propagating and with or without association of fremitus.
Degrees of intensity by Levine
(Freeman-Lee)
degree 1(1/6): audible only in a room with reduced level of noise; are merosystolic
degree 2 (2/6): murmurs by low intensity
gradul 3 (3/6): medium intensity, not heard at partial detaching of stethoscope from the
thorax
gradul 4 (4/6): increased intensity, are listening at partial detaching of stethoscope from the
thorax
gradul 5 (5/6): high intensity, are listening with the stethoscope at small distance from the
thorax
gradul 6 (6/6): are listening at distance from thoracic wall or by direct hearing.
After the period of appearance the murmurs are classified in:
•
•
•
•
systolic
diastolic
systolo-diastolic
continuous
After duration they can be:
•
•
•
•
protosystolic
mezosystolic
telesystolic
holosystolic
The cardiac murmurs are also classifying in:
•
•
organic;
functional.
The organic murmurs are characterizing by: high intensity, as a rule by 4-6 degree, are propagating
out from the heart limits, are accompanied by fremitus.
The organic murmurs also can be:
•
•
•
valvular – in congenital or acquired valvular defects;
myocardial – which appear in inflammatory processes or in myocardium dystrophy;
Organic murmurs in the case of congenital anomalies of heart/magistral vessels.
Functional murmurs can have a different genesis and localization, as a follows:
anemic - which appear at rheologic circulant blood peculiarities modification ( in
the case of anemia, thyrotoxicosis, fever);
cardiopulmonary - appear at respiratory pathways compression;
functional murmurs due to magistral vessels compression;
hypertonic murmurs, due to papillar muscles hypertonia;
murmurs at pulmonary artery, at its bifurcation;
myocardic murmurs, which appear in children as a result of long-term maitaining
of chronic bacterial foci(chronic tonsillitis), with direct toxico-infectious action
on the heart.
Systolic murmurs:
• are
auscultatively perceived on the basis of heart in cardiac congenital
pathologies;
• are auscultatively perceived on apex in acquired pathologies;
• are auscultatively perceived on the heart basis in stenosis.
Diastolic murmurs:
• Have at origin the acquired valvulopathies;
• Being perceived on apex suggest the acquired stenosis;
• Being perceived at basis can characterize the acquired valvular insufficiency.
•
The measurement of arterial pressure is obligatory in pupil and adolescent, and if necessary
will be performed in suckling baby and infant.
The measurement of arterial pressure will taking into consideration:
Patient position(sitting or recumbent),
Dimension of the cuff (adecuate for age),
type of apparatus,
Normal values for the child’s age etc.
Obtained values will be compared with the respective centilic tables.
In the cases of standard width of cuff the necessary corrections of obtained values will be
performed.
Correction of systolic and diastolic arterial pressure values for different ages children in the case
of standard cuffs using
Bibliography:
1. Kliegman: Nelson Textbook of Pediatrics, 18th edition. ISBN-13; 978-1-41602450-2457.
2. Maydannic V.G. Propedeutics of pediatrics. Kharkiv National Medical University. 2010, p.348
3. Susan M., White, Andrew J. Washington Manual TM of Pediatrics, The, 1st Edition, 2009,
Lippincott Williams & Wilkins.
4. Colin D. Rudolph. Rudolphs Pediatrics, The 21 st Edition, 2003.