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Physiologic anatomical peculiarities of the heart and blood vessels in children. Percussion of theDoc. heart. 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 - blue Mesoderm - red Endoderm - yellow Four layers contribute to the wall of the heart tube Lumen of heart Constrictions & expansions foreshadow adult heart Development of the septae of the heart • The single heart tube is divided into four definitive chambers by internal partitioning during weeks 4-7 1. Interatrial 2. Atrioventricular 3. Interventricular 4. 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. Bindler Child 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. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. 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. FIGURE 26–3 Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. THE PECULIARITIES OF INTRAUTERINE CIRCULATION. Superior vena cava Pulmonai artery Plumonary vein Descending aorta Inferior vena cava Postnatal circulation. Spumoni artery Pulmonary vein Ligamentum teres Conductive system of heart 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 Cardiac cycle Systole • 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 DISORDERS IN CHILDREN History Physical assessment general appearance pulse, blood pressure, & respirations Hypoxemia in the infant below 95% pulse oximetry. cyanosis results from hypoxemia perioral cyanosis indicates central hypoxemia acrocyanosis does not. clinical symptoms Generalised moderate peripheral cyanosis in a shocked new born with vasomotor instability and poor lung expansion. clinical symptoms A‘ blue baby' There is severe peripheral and central cyanosis. Post-mortem revealed Fallot's tetralogy. Note the malformed low-set ear. clinical symptoms Severe peripheral and central cyanosis Convulsion was produced by increased hypoxia after prolonged crying. Postmortem revealed atresia of the pulmonary artery and a single ventricle. clinical symptoms “pitting” edema Abnormal Pulse patterns Pulse patterns Water hammer Description Very forceful and bounding pulse (Corrigan's pulse)and capillary pulsation may be apparent even in the fingernails suggest cardial insufficiency, as in patient ductus arteriosus Pulsus alternant Dicrotic Adouble radial pulse for every apical beat, symptomatic of aortic stenosis Average pulse rates at rest (beats per minute) Newborn 6 months 1 year 2 years 3 years 140-160 130-135 120-125 110 105 4 years 5 years 6-7 years 10 years 12 years 100 98-100 90-85 78-85 70-75 The normal rate is not more then 10 % of average Blood pressure, mmHg Upper extremity Newborn systolic: 70-76 diastolic: 35 For children younger 12 months systolic: 76 + 2 x n (n is age in months) diastolic: 1/2-1/3 of systolic Lower extremity Newborn systolic: 70-76 diastolic:35 For children younger 9 months systolic: 76 + 2 x n (n is age in months) diastolic: 1/2-1/3 of systolic Blood pressure, mmHg Upper extremity 1 year systolic:90-100 diastolic: 60 For children older 1 year systolic: 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 extremity In children older 9-10 months the blood pressure is 5-20 mm Hg more than upper extremity Hypotension Blood Pressure Lowest acceptable systolic blood pressure Birth – 1 month: 60 mmhg 1 month – 1 year: 70 mmhg 1 year – 10 year: 70 + (2 X age in years) >10 years : 90 mmhg Normal systolic 80 + (2 x age in years) or fiftieth percentile Border's of heart relative dullness Border Right Upper Left until 2 years •right parasternal line •the II rib •2 cm outward from left midclavicular line Transvers •6-9 cm Border Right Upper Border Right Border Right Upper Left older 12 years •the right sternal line •the III intercostals space •0.5 cm medially from left midclavicular line Transversal size •9-14 cm al size 7-12 years •Between the right parasternal line and the right sternal line Upper Left Transversa l size •the III rib •0.5 cm outward from left midclavicular line •9-14 cm Left Transversal size 2-7 years •right parasternal line •the II intercostals space •1 cm outward from left midclavicular line •8-12 cm Border's of heart absolute dullness Border Right Upper Left until 2 years •left sternal line •the II intercostal space •1.0-0.5 cm outward from left midclavicular line Transvers •2-3 cm al size Border Right Upper Left Transversa l 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 2-7 years •left sternal line •the III rib •left midclavicular line Transversal size •4 cm Border Right Upper Left Transversal size older 12 years •left sternal line •the IV rib •left parasternal line •5-5.5 cm Clinical symptoms Tachycardia Bradycardia Pulsus alternans Pulsus bigeminus Increased rate Decreased rate Strong beat followed by weak beat Coupled rhythm in which beat is felt in pairs FIGURE 26–13 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? Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Blue-or-tet-spells FIGURE 26–12 Place the infant who has a hypercyanotic spell in the knee–chest position. This position increases systemic vascular resistance in the lower extremities. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. FIGURE 26–10 A child with a cyanotic heart defect squats (assumes a knee–chest position) to relieve cyanotic spells. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Thank you for attention