seidels chap 15 (heart) - skills unit 3

what is the name of the area that the heart is located

mediastinum

dextrocardia

heart positioned to the right as a mirrored image

sinus inversus

when the heart and stomach are placed to the right and the liver to the left

pericardium

tough, double-walled fibrous sac encasing and protecting the heart - fluid is between outer and inner layers of pericardium for movement

epicardium

thin outermost muscle layer that covers surface of heart and extends onto great vessels

myocardium

thick muscular middle layer responsible for pumping action

endocardium

innermost layer that lines chambers of heart and covers valves + small muscles associated w/ opening/closing of valves

interventricular septum

blood-tight partition that divides the left and right heart

coronary sulcus

seperates atria from the ventricles on the anterior external surface of the heart

order of cardiac valves

"try pulling my arm"

tricuspid, pulmonic, mitral, aortic

what happens during systole

ventricles contract -- ejects blood from R ventricle into pulmonary artery

what happens during diastole

ventricles dilate -- draws blood into ventrocles as atria contract and move blood from atria to ventricles

what causes the S1 (lub) sound

mitral and tricuspid valve closure from raised ventricular pressure during contraction to prevent backflow

what causes the S2 (dub) sound

aortic and pulmonic valve closure when empty ventricles have low pressure

S2 sound components

A2 = produced by aortic valve closure

P2 = pulmonic valve closure

what can cause an S3 sound

filling of ventricle during diastole

what can cause an S4 sound

atria contracting to ensure ejection of any remaining blood

what causes an S2 split

aortic valve closing slightly before pulmonic (pressures on the right side are lower and events can occur slightly later on right side vs left)

process of electrical activity for contraction and the order of structures

1. impulse originates and paced by sinoatrial node (SA) located on wall of R atrium

2. impulse travels through both atria to atrioventricular node (AV) in atrial septum

3. AV node delays impulse then passes it down bundle of His to purkinje finbers in ventricular myocardium

4. ventricular contraction initiates @ apex and goes up to base of heart

what is an electrocardiogram (ECG)

graphic recording of electrical activity during cardiac cycle from movement of ions in/out of myocardial cell membranes

what is depolarization

spread of stimulus through heart muscle

what is repolarization

return of stimulated heart muscle to resting state

what does the P wave on ECG represent

spread of a stimulus through atria AKA atrial depolarization

what does the PR interval on ECG represent

time from initial stimulation of atria to initial stimulation of ventricles

what does the QRS complex on ECG represent

spread of stimulus through ventricles AKA ventrical depolarization

what does the ST segment and T wave on ECG represent

return of stimulated ventricular muscle to a resting state AKA ventricular depolarization

what does a U wave on ECG represent

small deflection rarely seen just after T wave thought to be related to repolarization of purkinje fibers

what conditions would present with a U wave

bradycardia mostly

sometimes seen with electrolyte abnormalities, hypothermia, hypothyroidism

what does the QT interval on ECG represent

time elapsed from onset of ventricular depolarization until completion of ventricular repolarization

fetal circulation

blood flows from right atrium - L atrium via foramen ovale -- R ventricle --- patent ductus arteriosus (instead of to lungs)

possible cardiac causes of chest pain

angina

acute myocardial infarction

coronary insufficiency

myocardial infarction

nonobstructive/nonspastic angina

mitral valve prolapse

possible aortic causes of chest pain

aortic dissection

possible pleuropericardial causes of chest pain

pericarditis

pleurisy

pneumothorax

mediastinal emphysema

possible GI disease causes of chest pain

hiatus hernia

reflux esophagitis

esophageal rupture

esophageal spasm

cholecystitis

peptic ulcer disease

pancreatitis

possible pulm disease causes of chest pain

pulm HTN

pneumonia

PE

bronchial hyperreactivity

tension pneumothorax

possible MSK causes of chest pain

cervical radiculopathy

shoulder disorder/dysfunction (arthritis, bursitis, rotator cuff injury, biceps tendonitis)

costochondral disorder

xiphodynia (pain @ breastbone)

possible psychoneurotic causes of chest pain

drug use (cocaine)

herpes zoster (when lesions occur in thoracic region)

characteristics of cardiac chest pain

substernal

provoked by effort, emotion, eating

relieved by rest, nitroglycerin

can be accompanied by diaphoresis and nausea

characteristics of pleural chest pain

precipiated by breathing or coughing

sharp, present during respiration, absent wwhen breath held

characteristics of esophageal chest pain

burning, substernal, occasional radiation to shoulder

nocturnal occurance

daytime attacks relieved by food

unrelated to activity

characteristics of peptic ulcer chest pain

infradiaphragmatic and epigasteric

nocturnal occurance and daytime attacks relieved by food and unrelated to activity

characteristics of biliary chest pain

usually under right scapula

prolonged in duration

often occuring after eating

will trigger angina more often than mimic it

characteristics of arthritis/bursitis chest pain

lasts for hours

local tenderness/pain with movement

characteristics of cervical chest pain

associated with injury

provoked by activity and persists after activity

painful on palpation/movement

characteristics of musculoskeletal chest pain

intensified/provoked by movement like twisting/bending

long lasting

often w/ focal tenderness

characteristics of psychoneurotic chest pain

associated w/ anxiety

poorly described

located in intramammary region

risk factors of cardiac disease

gender (men > women)

hyperlipidemia

smoking

elevated homocysteine level (metabolizes proteins)

family history

DM

obesity

sedentary lifestyle

examples of light exercise intensity

walking 10-15 steps

preparing simple meal for 1

retrieving newspaper

pulling down bedspread

brushing teeth

examples of moderate exercise intensity

making the bed

dusting/sweeping

walking a level or short block

office filing

examples of moderately heavy exercise intensity

climbing one/two flights of steps

lifting full cartons

long walks

sexual intercourse

examples of heavy exercise intensity

jogging

vigorous activity

cleaning entire house

raking leaves

mowing lawn w/ push mower

shoveling deep snow

hypovolemia vs autonomic failure (orthostatic hypotension)

hypovolemia increases HR as BP falls

orthostatic hypotension has no reflex-induced increased HR as BP falls = autonomic failure

what is a thrill

grade 4 or higher heart murmur that is felt on palpation

what conditions can increase intensity of S2 sound

systemic hypertension

syphillis of aortic valve

exercise

excitement

what conditions can decrease intensity of S2 sound

shock like state w/ arterial hypotension

immobile/thickened valves

aortic stenosis (affects A2)

pulm stenosis (affects P2)

overlying fat/tissue/fluid

where is a split S2 best heard

pulm area during inspiration

how are heart sounds characterized

pitch

intensity

duration

timing

S1 sound is ____ in pitch and heard ____ than S2

S1 is lower in pitch and heard longer than S2, occuring right after diastole (bc mitral valve shuts more vigorously)

S2 is _____ in pitch and heard ____ than S1

S2 is higher in pitchc and shorter duration than S1

what is wide splitting

split of S2 becomes wider when delayed activation of contraction or R ventricle emptying slows pulmonic valve closure

ex: during RBBB

what is fixed splitting

S2 splitting unaffected by respiration

ex: septal defects

what is paradoxical (reversed) splitting

closure of aortic valve is delayed so P2 occurs 1st followed by A2

where is mitral stenosis best heard

with bell at apex, pt in left lateral decubitus

findings on exam for mitral stenosis

low diastolic rumble w/o radiation

palpable thrill @ apex in late diastole

mitral stenosis description/causes

narrowed valve restricts foward flow and makes forceful ejection into ventricles

often occurs w/ mitral regurg

caused by: rheumatic fever or cardiac infection

where is aortic stenosis best heard

aortic area w/ ejection sound at second right intercostal border

findings on examination for aortic stenosis

midsystolic ejection murmur w/ medium pitch crescendo-decrescendo

radiates along L sternal border and carotid w/ thrill

description/causes of aortic stenosis

calcified valves restrict forward flow = forceful ejection from ventricle to circulatory system

causes: congenital bicuspid (instead of tricuspid), rheumatic heart disease, atherosclerosis

where is subaortic stenosis best heard

at apex and along left sternal border

findings on examination for subaortic stenosis

crescendo-decrescendo during systole w/ medium pitch and thrill at apex

S2 usually split and S3/S4 often heard

jugular venous pulse prominent

description of subaortic stenosis

fibrous ring below aortic valve becomes more severe

where is pulmonic stenosis best heard

pulmonic area radiating to left and neck

thrill in second/third left intercostal spaces

findings on examination for pulmonic stenosis

systolic ejection murmur, crescendo-decresendo, medium pitch usually w/ thrill

dimished S2 with wide split

description/cause of pulmonic stenosis

valve restricts forward flow = forecful ejection from ventricle into pulmonary circulation

causes: almost always congenital

where is tricupsid stenosis best heard

with bell over tricuspid area

findings on physical exam for tricuspid stenosis

diastolic rumble louder on inspiration

diastolic thrill palpable over R ventricle

jugular venous pulse prominent

description/causes of tricuspid stenosis

calcification of valve restricts forward flow = forceful ejection into ventricles

usually seen w/ mitral stenosis and rarely occurs alone

causes: rheumatic heart disease, congenital defect, R atrial myxoma

where is mitral regurgitation best heard

best heard/loudest at apex and can transmit to left axilla

findings on physical exam for mitral regurgitation

holosystolic high pitch blowing murmur that can obliterate S2

radiates from apex to base or to left axilla

thrill may be present at apex

mitral regurgitation description/causes

valve incompetence allows backflow from ventricle to atrium

causes: rheumatic fever, MI, myxoma (benign tumor), rupture of chordae

where is mitral valve prolapse best heard

apex and left sternal border

easily missed in supine

findings on PE for mitral valve prolapse

late systolic murmur preceded by midsystolic clicks

description of mitral valve prolapse

valve is competent early in systole but prolapses into atrium later in systole, often concurrent w/ pectus excavatum

where is aortic regurgitation best heard

with diaphragm, pt sitting and leaning forward

ejection click heard @ second intercostal space

findings on PE for aortic regurgitation

early diastolic high pitch blowing w/ crescendo-descrecendo midsystolic murmur

can have austin-flint murmur (low pitch rumbling @ apex)

description/causes of aortic regurgitation

valve incompetence allows backflow from aorta to ventricle

caused by: rheumatic heart disease, endocarditis, aortic diseases (Marfan), syphilis, ankylosing spondylitis, dissection, cardiac trauma

description/causes of pulmonic regurgitation

valve incompetence allows backflow from pulm artery to ventricle (hard to distinguish from aortic regurg)

causes: secondary to pulm hypertension or bacterial endocarditis

where is tricuspid regurgitation best heard

left lower sternal border sometimes slightly radiating

findings on PE for tricuspid regurgitation

holosystolic murmur over R ventricle, blowing & increased on respiration

S3 and thrill over tricuspid area

description/causes of tricuspid regurgitation

valve incompetence allows backflow from ventricle to atrium

causes: congenital defects, bacterial endocarditis (especially IV drug users), pulm HTN, cardiac trauma

structural heart disease causing a murmur in a child sounds like...

holosystolic or diastolic

grade 3 or higher

systolic click associated

increased in intensity when standing

harsh quality

SAFER approach for history taking for high risk children w/ underlying structural heart defect

S- Syndromic features (kids w/ syndromes/chromosomal abnormalities)

A- Age (murmurs in infants = pathological)

F- Family history (3-5% risk passed onto offspring)

E- Evaluation of feeding/growth

R-Rheumatic fever/significant pervious med history (Kawasaki disease)

cyanosis at birth or shortly after indicates...

transposition of great vessels

tetrology of fallot

tricuspid atresia (defect/missing valve)

severe septal defect

severe pulmonic stenosis

cyanosis after neonatal period indicates...

pulmonic stenosis

Eisenmenger complex (defect that leads to right-to-left shunt)

tetrology of fallot

large septal defects

a pneumothorax in a child shifts the heart...

shifts apical impulse away from area of pneumothorax

a diaphragmatic hernia in a child shifts the heart...

to the right (hernias commonly found on the left)

dextrocardia in a child shifts the heart...

shifts apical impulse to the right

are S3 and S4 commonly heard in peds?

yes

are murmurs commonly heard in peds?

yes, within 48 hours of age (grade 1-2)

most are not pathological and caused by transition from fetal to pulmonic circulation

what accounts for most acquired murmurs in children

Kawasaki disease - rare/ acute illness affecting kids under 5 that causes inflammation of vessels