Perfusion-HEART & PERIPHERAL VASCULATURE

Overview of Perfusion

Anatomical Landmarks

• Pericardium: Membrane enclosing the heart, providing a protective barrier and reducing friction during heartbeats.

• Pleural Sac: Contains the lungs; crucial for respiratory function, allowing lungs to expand and contract.

• Base of the Heart: Top part where major vessels (aorta, pulmonary arteries, and veins) enter and exit the heart; involved in circulation management.

• Apex of the Heart: Bottom pointed part of the heart, vital for the heart's pumping action and direction of blood flow.

Major Vessels

• Superior Vena Cava: Blood vessel that carries deoxygenated blood from the upper body to the right atrium of the heart.

• Inferior Vena Cava: Returns deoxygenated blood from the lower body to the right atrium.

• Aorta: Major artery carrying oxygenated blood from the left ventricle to the systemic circulation, essential for providing oxygen to all tissues.

• Pulmonary Artery: Transports deoxygenated blood from the right ventricle to the lungs for oxygenation.

Right Side of the Heart

• Tricuspid Valve: Controls blood flow from the right atrium to right ventricle; ensures unidirectional blood flow, preventing backflow during contraction.

• Pulmonary (Semi-lunar) Valve: Regulates blood flow from the right ventricle to the pulmonary artery, integral for directing blood to the lungs.

Left Side of the Heart

• Bicuspid (Mitral) Valve: Manages blood flow from left atrium to left ventricle; prevents backward flow into the atrium during ventricular contraction.

• Aortic (Semi-lunar) Valve: Controls blood flow from the left ventricle into the aorta, critical for maintaining systemic blood pressure.

• Septal Wall: Divides the left and right sides of the heart, preventing mixing of oxygenated and deoxygenated blood.

Anatomical Position for Assessment

• APE To Man: Mnemonic for heart valve locations.

  • Aortic Valve: S2 @ Right side, 2nd Intercostal Space (ICS)/Right sternal border.

  • Pulmonic Valve: S2 @ 2nd Left ICS/Left sternal border.

  • Erb’s Point: Left 3rd ICS - the center of the heart mass, useful for assessing heart sounds.

  • Tricuspid Valve: S1 @ 5th Left ICS - Left sternal border; key for evaluating right heart function.

  • Bicuspid/Mitral Valve: S1 @ Left 5th ICS/Mid-clavicular line (PMI/Apex of heart), significant for left heart assessment.

Language of the Heart

Terms and Definitions

• Ischemia: Lack of blood supply to the heart muscle, can result in chest pain or myocardial infarction if prolonged.

• Infarction: Death of heart tissue due to extended ischemia; can be reversible if treated timely.

• Angina: Chest, neck, or arm pain caused by reduced blood flow to the heart; often a precursor to heart attack.

• Cardiac Cycle: One complete sequence of heart contraction (systole) and relaxation (diastole).

• Systole: Peak pressure in the heart during ventricular contraction; essential for blood ejection to the body.

• Diastole: Lowest pressure in the heart when the myocardium relaxes; critical for ventricular filling.

Anatomy of the Heart Beat

• Normal Heart Rate: 60-100 beats per minute; indicates healthy cardiovascular function.

• Apical Rate: A rate that can be as low as 50 beats; important to assess in specific populations such as athletes.

• Rhythm Assessment: Regular Rhythm indicates normal heart function.

• Irregular Rhythm raises flags for potential dysrhythmias, requiring further investigation.

• Regularly Irregular indicates a pattern of dysrhythmia, often necessitating interventions.

Diastole and Systole

• Diastole: Starts Passively and Ends with Atrial Kick, wherein ventricles fill passively from atria (80% passive, 20% active). The closing of Aortic and Pulmonic valves marks the end. Sounds produced include S2 (lubb-DUBB).

• Systole: Ventricular contraction occurs, with semi-lunar valves closing after ejecting blood into the pulmonary arteries and aorta. Produced sounds include S1 (LUBB-dubb).

Evaluating Heart Sounds

• S1: Closing of Mitral and Tricuspid valves during ventricular contraction; presents as "LUBB-dubb."

  • Locations:

    • Tricuspid Valve: 4th intercostal space, left of sternum.

    • Bicuspid Valve: 5th intercostal space at mid-clavicular line.

• S2: Closing of Aortic and Pulmonic valves during relaxation; presents as "lubb-DUBB."

  • Locations:

    • Aortic Valve: 2nd ICS, right of sternum.

    • Pulmonic Valve: 2nd ICS, left of sternum.

Evaluating Heart Sounds: S3 & S4

• S3: Related to diastolic pressures; sounds like "Kentucky" or "Slosh-ING in." Best assessed over left heart ventricles; can be physiological (normal in younger populations) or pathophysiologic (indicative of heart failure).

• S4: Related to increased resistance to filling; resembles "Tennessee" or "a-STIFF wall." Indicates possible pathologies, typically abnormal, reflecting poor ventricular compliance.

Cardiac Sound Cycle

• S3: Suggests turbulence due to rapid ventricular filling; assesses fluid overload or heart function.

• S4: A pathological finding that indicates decreased compliance or stiff ventricular walls.

Erb’s Point & Murmurs

• Erb’s Point: Vital for hearing both aortic and pulmonic murmurs, providing insight into valve disorders.

• Innocent Murmur: Always Systolic phase. Common in asymptomatic individuals; reflects normal physiology or developmental adaptations.

Heart Murmurs

• Murmurs arise from turbulent blood flow; can be categorized as either innocent or pathologic.

  • Types of Murmurs:

    • Systolic: Associated with obstruction of outflow from semilunar valves.

    • Diastolic: Spells incompetence of semilunar valves.

    • Continuous: Audibility throughout both phases, indicating pathology.

Hearing a Bruit or Feeling a Thrill

• Auscultating a Bruit: A blowing/swishing sound over vessels; indicates obstructed peripheral blood flow, significant in diagnosing vascular issues. Auscultated over vessels  (Not the heart)

• Palpating a Thrill: A palpable vibration indicating turbulent blood flow, often accompanies murmurs or structural malformations of the heart. Over chest, over abdominal vessels.

• Heaves or Lift: A noticeable movement felt over the chest; indicative of powerful heart contractions, often assessed during the physical examination.

Pleural Rub vs. Pericardial Rub

• Pleural Rub: Occurs in inflammation between visceral and parietal linings of lungs; creates low-pitched sounds with breathing; patients often report localized pain. Sound stops when patient holds their breath .

• Pericardial Rub: Involves inflammation of visceral and parietal linings of the pericardium; generates low-pitched, coarse rubbing sounds; patients may experience positional pain (leaning forward may alleviate pain, if pericarditis).Sound does not stop when patient holds their breath.

Physical Assessment of Heart and Periphery

Key tools for examination include:

• Light / penlight

• Stethoscope

• Good room lighting for visibility

• Privacy for patient comfort.

General Appearance Inspection

• Assess skin color, swelling, respiratory effort, and overall posture for indications of cardiac or respiratory distress.

General Assessment

• Evaluate patient alertness levels, anxieties, and signs of dyspnea to gauge cardiac function.

  • Inspect the chest/thorax for structural abnormalities, jugular vein distention (JVD) , and vascular alterations.

  • Palpate the skin over the thorax…Crepitus?

Jugular Vein Pressure (JVD…Jugular Vein Distention)

• JVD indicates right atrial failure; evaluated by head elevation and observing vein distention. Elevate head of bed to 30-45 degrees. Turn chin/head away from examiner

  • NORMAL: Visible pulsations, indicative of healthy pressure;

  • ABNORMAL: Distended veins revealing potential heart failure issues.

Carotid Pulse Assessment

• Palpate LIGHTLY carotid arteries one side at a time to measure rate and amplitude; auscultate for bruits indicating potential vascular compromise (Whooshing, swishing sound)-Always compare bilaterally .

• palpate on one side and then the other – to prevent stimulation lowering blood flow to the brain.

Apical Pulse

• Identify the Point of Maximal Impulse (PMI) for accurate pulse measurement; auscultation for a full minute is indicated for heart rate assessment.

• *may use this time to preform an Apical Radial Deficiet pulse

Auscultation of Heart Sounds…APE To Man

• Begin with diaphragm for high-pitched sounds: aortic (S2), pulmonic (S2), Erb’s Point, tricuspid (S1), and mitral (S1)…( Listen for he NORMAL Sounds and Murmurs)

• Transition to bell for low-pitched sounds: Aortic – S3 after the S2, Pulmonic – S3 after the S2, Erb’s  - deeper/lower pitch murmurs, Tricuspid  - S4 before the S1, Mitral   - S4 before the S1

  • (abnormal S3, S4, and murmurs) to identify any abnormalities in heart physiology or structure. (Listen for Abnormal Sounds & Murmurs)

Auscultate: Normal, Splits, & Murmurs

APE To Man: Diaphram – high pitch

•Aortic: S2 @ the Rt side, 2nd ICS/Rt sternal boarder

•Pulmonic valve: S2 @ the 2nd lft ICS / Lt sternal boarder

•Erb’s Point:   The Lft 3rd ICS  - the center of the heart mass.  

•Tricuspid valve: S1 @ the 4th lft ICS – Lt. Sternal boarder

•Bicuspid / Mitral valve: S1 @ the lft 5th ICS / Mid clavicular AKA PMI/Apex of heart

Auscultate Abnormal:  S3, S4, & Murmurs

APE To Man:  WITH BELL – LOW PITCH

•Aortic: S2 @ the 2ND ICS RT. Sternal boarder

•Pulmonic valve: S2 @ the 2nd lft ICS / Lt sternal boarder

•Erb’s Point:   The Lft 3rd ICS  - the center of the heart mass.  

•Tricuspid valve: S1 @ the 4th lft ICS – Lt. Sternal boarder

•Bicuspid / Mitral valve: S1 @ the lft 5th ICS / Mid clavicular AKA PMI/Apex of heart