Download The Child with Cardiovascular Dysfunction

The Child with
Cardiovascular Dysfunction
Prepared by /miss:Amira Ali
Out line
over view on Fetal circulation
 Physiological changes at birth
 Congenital Heart Disease (CHD)
 Cyanotic heart disease
 A cyanotic heart disease

Objectives
At the end of these lecture all student
will be able to
 Identify Fetal circulation
 mention the main Physiological changes
at birth
 define causes of Congenital Heart
Disease (CHD)
 Identify Cyanotic heart disease
 Identify A cyanotic heart disease

Fetal Circulation
Fetal Circulation

Fetal circulation (prenatal circulation) differs
from adult circulation in several ways and is
designed to ensure a high oxygen blood
supply to the brain and myocardium of the
fetus.
Characteristics of fetal circulation
Placenta is the source of oxygen for the
fetus, it has 2 arteries and 1 vein.
 Fetal lungs receive less than 10% of the
blood volume ; lung don’t exchange gas.
 Right atrium of fetal heart is the chamber
with the highest oxygen concentration.

The three openings that close at birth
are:
Ductus Arteriosus connects the pulmonary
artery to the aorta, bypassing the lungs
 Ductus Venosus connects the umbilical vein
and the inferior vena cava bypassing the liver.
 Foramen Ovale is the opening between right
and left atrias of the heart , bypassing the lungs.

Pattern of fetal circulation
Oxygenated Blood is carried from
placenta through the umbilical vein and
enters the inferior vena cava thought
the Ductus Venosus .
 This permits most of the highly
oxygenated blood to go directly to the
right atrium , bypassing the liver.

….. Continue pattern

This right atrial blood flows directly into
the left atrium through the foramen
ovale an opening between the right and
the left atriums .
….. Continue pattern

From the left atrium blood flows directly
into left ventricle and the Aorta
through the subclavian arteries , to the
cerebral and coronary arteries ,
resulting in the brain and the heart
receiving the most highly oxygenated
blood .
….. Continue pattern

Deoxygenated blood returns from the
heart and the arms through the superior
vena cava, enters the right atriums and
passes into the right ventricle.

Blood from the right ventricle flow into
pulmonary artery, but because fetal lungs
are collapsed, the pressure in the
pulmonary artery is very high .
….. Continue pattern
Because pulmonary resistance is high ,
most of the blood passes into the distal
aorta through the Ductus Arteriosus,
which connects the pulmonary artery and
the aorta distal to the origin of the
subclavian arteries.
 From the aorta blood flows to the rest of
the body.

Normal circulatory changes at birth
Physiological changes at birth
Foramen Ovale: Opening Between Atria;
Allows Blood to Bypass Lungs intrauterinely;
Closes With Increased Left-Sided Pressure
 Ductus Arteriosus: Opening Between
Pulmonary Artery & Aorta; Allows Blood to
Bypass Lungs intrauterinely; Closes Within 1015 Hours After Birth With Permanent
Closure By 10-21 Days of Life

….. Physiological changes
 Cyanosis
results from 5 or more Grams
of Unoxygenated Hemoglobin per 100
ml of Blood: So, If Hemoglobin is Low,
You Won’t See Cyanosis In Spite of Low
PaO2!
….. physiologic

Polycythemia: Increase in Production of
Erythrocytes To Compensate for Chronic
Hypoxemia; If Hemoglobin Greater Than 20
g/dl & Hematocrit Greater Than 55-60%,
Increased Risk for thromboembolism

Infants Respond to Severe Hypoxemia With
BradyCardia
Normal vital signs at birth
Heart rate= 120-140 beat/min
 Blood pressure= 65/41 mmHg
 Respiratory rate= 30-60 breath/min
 Temperature= Axillary 35.5-37oC.
 Oxygen saturation (SpO2 )= >93%

Congenital Heart Disease (CHD)
Approximately 5-8 Per 1000 Live Births;
Combination of Genetic & Environmental
Factors : X-ray exposure
Maternal Rubella
Maternal alcoholism
Maternal type 1 diabetes
Maternal over 40 of age
 Occur EARLY in Gestation (3-8 Weeks) in
the first trimester

CHD

Classification of CHD:
Acyanotic versus cyanotic
Acyanotic
Pulmonary
Blood flow
Obstruction to
Blood flow
from ventricles
•Atrial septal
defect (ASD)
•Ventricularr
septal defect
(VSD)
•Coarctation
of Aorta
•Aortic
stenosis
Cyanotic
Pulmonary
blood flow
•Tetrology
of Fallot
•Tricuspid
atresia
Mixed
blood flow
•Transposition
Of great vessels
•Truncus
arteriosus
Selected Acyanotic defects
(1) ASD, or atrial septal defect:
•Abnormal opening between atria, allowing
blood from Lt atrium (higher pressure) to
go to right atrium (lower pressure).
Pathophysiology:
•the new volume in the right ventricle is
tolerable because it was sent by a low
pressure from the right artium.
S&S: Patients may be asymptomatic
they may develop heart failure, atrial
arrhythmias are present.
Surgical treatment: Surgical Dacron
Patch Closure .
Non-surgical Repair: in catheterization,
a repair pad is implanted.
• Patients with ASD may live several
decades without S&S and the prognosis
after operation is very high.
…. Cont. acyanotic
(2) VSD, or Ventricular Septal Defect:
•It is an abnormal opening between the right
and
the left ventricles, resulting in a common
ventricle.
• its found that 20% of all VSDs close
spontaneously during the first year of life
• Pathophysiology: the blood turns from
the left ventricle (higher pressure) to the
right ventricle(lower pressure) causing
left-to-right shunt , then to pulmonary
Artery, which increases RV pressure causing
RV hypertrophy and by time RV failure.
• S&S : congestive heart failure is common.
• Surgical treatment: complete repair.
•Non-surgical treatment: closure devise is
usually implanted during cardiac
catheterization
-Aortic Stenosis
• Stenosis of the aortic
valve prevents blood
from passing from the
left ventricle into the
aorta, leading to
hypertrophy of the left
ventricle
• S/S
– Usually asymptomatic but
with murmur
– May have chest pain and
even sudden death
• Therapeutic
Management
– Stabilization with a Beta
Blocker or Calcium
Channel Blocker
– Balloon valvuloplasty
– Valve replacement
– Coarctation of
the Aorta
• Narrowing of the
lumen of the
aorta
• S/S
– Absence of
palpable femoral
pulses;
headache,
vertigo,
nosebleeds,
CVA; leg pain
• Therapeutic
Management
– Surgery or
angiography
Selected cyanotic defect:
- Tetrology of Fallot (TOF)
- Tricuspid Atresia
- Transposition of the Great Arteries or
Vessels
- Truncus Arteriosus

Tetrology of Fallot (TOF)
•The classic form includes four defects: (1)
ventricular Septal Defect, (2) pulmonic
stenosis,(3) overriding aorta, (4) right
ventricular hypertrophy.
•Pathophysiology: the altered
hemodynamic status depends on the size of
the pulmonary stenosis, blood get shunted
from right to left, if the pressure in the
pulmonary is higher than the systemic
pressure, and blood gets shunted from left
to right if the systemic pressure is higher
than pulmonary. S&S: cyanosis, clubbing
fingers, poor growth. crying during or after
feeding.
•Surgical treatment: complete repair is
required, open heart surgery& VSD closure.
• Defects with decreased
pulmonary blood flow
– Tricuspid Atresia
• The tricuspid valve is
closed, blood flows
through the patent
foramen ovale into the
left atrium, bypassing
the lungs. Then it is
shunted back through a
PDA into the lungs.
When these structures
close, cyanosis,
tachycardia, and
dyspnea occur.
Surgery must correct.
• Treatment: IV infusion
until surgery
CONAL–TRUNCAL
DEFECTS
• Conal–truncal defects develop during the formation
of the trunk dissection. Embryologically, the
pulmonary artery and the aorta begin as a large
“trunk.” The ventricles then fold on themselves, the
atria rise into position, and the great vessels form
when the trunk twists around and separates (having
a dividing wall). Transposition of the great
vessels(TGA) and truncus arteriosus occur in
children when there is a disruption in this process.
Transposition of the Great
Arteries or Vessels
• SIGNS AND SYMPTOMS. Symptoms
appear at birth or soon afterwards and
include cyanosis, shortness of breath,
poor feeding, and clubbing of the
fingers and toes.
• DIAGNOSIS. Diagnosis is based on signs
and diagnostic testing including pulse
oximetry, ECG, echocardiogram, chest
x-ray exam, and cardiac
catheterization. If an echocardiogram
is done before birth, it is called a fetal
echocardiogram.
• Surgical treatment. TGA in all cases must
be surgically corrected
Truncus Arteriosus
• SIGNS AND SYMPTOMS. Clinical
signs and symptoms of truncus
arteriosus include cyanosis,
congestive heart failure, and
low cardiac output.
• DIAGNOSIS. Diagnosis is based
on signs and diagnostic testing
that includes pulse oximetry,
ECG, echocardiogram, chest
radiograph, and cardiac
catheterization.
• Surgical treatment. TGA in all
cases must be surgically
corrected
Cardiac Diseases
• SUBACUTE BACTERIAL ENDOCARDITIS
(SBE) occurs subsequent to a bacterial infection
or introduction of an infective agent into the
child’s blood stream
• The infection may be caused by an invasive
procedure such as surgery, urological
procedures, or most often dental cleaning.
• (SBE) is most commonly seen in patients with
an unrepaired congenital heart defect or valve
disease, but can also occur in normal hearts
•
•
•
•
•
SIGNS AND SYMPTOMS
low-grade fever : malaise, loss of appetite, and
muscle aches
A high fever: chills, sweating, stiff joints, or
back pain can indicate that acute illness has
occurred
DIAGNOSIS. thorough medical history and a
physical exam are essential to diagnosis.
Which contain
1- symptoms 2- valve replacement
3- bacterial or fungal infection(dental
procedures)
Treatment:
• SBE is treated with antibiotics, but the most
effective approach is prevention.
CARDIAC SURGERY

Discharge Teaching:
◦
◦
◦
◦
◦

Activity Tolerance;
No Bike Riding Until Sternotomy Healed
Signs & Symptoms of Wound Infection
Return to School in 2 Weeks
Usually, No Further Cardiovascular Problems
ALLOW THE CHILD TO LIVE A NORMAL AND
ACTIVE LIFE!
Congestive Heart Failure (CHF)
Cardiac Output (CO) Inadequate to Support Circulatory
& Metabolic Needs
 Causes: volume overload, pressure overload, decreased
contractility, high cardiac output demands
 Infant Tires During Feeding (OFTEN FIRST Indication of
CHF)
 Symptoms Increase With Progressing Disease
 Cardiomegaly Occurs As Heart Attempts to Maintain
Cardiac Output
 If Tachycardia Greater than 180-220 BPM; Ventricles
Unable to Fill & CO Falls

CHF
CHD Most Common Cause of CHF in Infants
 S/S: Tachycardia Diaphoresis, Tachypnea,
Feeding problem, Crackles & Respiratory Distress;
Edema, increase weight
 CXR Shows Large Heart.
 Echocardiogram is Diagnostic.

CHF

Medical Management:
◦ Digoxin To Make Heart Work More Efficiently
◦ Lasix/Diuretics To Remove Excess Fluid
◦ Oxygen: Potent Vasodilator which decreases
pulmonary vascular resistance.
◦ Rest, a neutral thermal environment, semiFowler position, cluster care to promote
uninterrupted rest

CHF
Nursing care
◦ Monitor physiologic functions: BP, HR, RR
◦ Prevent infection; Group care; Semi-Fowler
position.
◦ Adequate Nutrition: Feeding Techniques: 45 Degree
Angle; Rest Frequently.
◦ Promote Development: Play, Age Appropriate Toys,
Physical Activities With Rest Periods
◦ Emotional Support: Prevent Hypoxia From
Agitation or Distress; Consistency(suport) of
Caregiver for Patient; Refer-Parent-to-Parent
Support Groups.
RHEUMATIC FEVER






Inflammatory Disease Following Initial Infection by
Group A Beta Hemolytic Streptococci; Cause
Changes in Heart, Joints, Skin & CNS.
Diagnosis: ESR( erythrocyte segmentation rate),
CRP(C- reactive protein), ASLO (anti-streptolysin Otiters)
Treatment With Antibiotics To Treat Strep Infection
Aspirin To Control Joint Pain & Inflammation
Prevention is Best
Treatment: Throat Culture & Treat With Antibiotics
for 10 Days
The End