Cardiovascular Dr. Reem ali

Cardiovascular Dr. Reem ali
Fall Semester

Fetal Circulation Foramen ovale: is anatomical opening between the right atrium and left atrium which closes shortly after birth. Higher pressure in the left atrium due to increased pulmonary blood flow cause the foraman ovale to close. Ductus arteriosus: A vessel that connects the main pulmonary artery to the aorta The ductus arteriosus should functionally close within 15 hours and structurally within a few weeks (in mature infants) Higher concentrations of oxygen in the blood, decreased prostaglandin levels and decreased pulmonary vascular resistance closes the ductus arteriosus.

Functions of Cardiovascular System
The cardiovascular system is responsible for circulating blood throughout the body A healthy cardiovascular system is vital to supplying the body with oxygen and nutrients

Assessment of Cardiac Function
History: parents usually report Poor weight gain, poor feeding habits, fatigue during feeding, sweating with feeding. Frequent respiratory infections and difficulties (tachypnea, dyspnea, shortness of breath, persistent cough). Cyanosis Evidence of exercise intolerance

History A previous cardiac defects in a sibling Maternal rubella infection during pregnancy, The use of medications or chemicals during pregnancy chronic illness Children with chromosomal abnormalities are likely to have associated congenital heart defects. A history of viral infection or toxic exposure (myocardities) A history of streptococcal infection (Rheumatic fever)

Physical Examination; Vital signs tachycardia or bradycardia may indicate cardiac disease. Tachypnea may indicate congestive heart failure Hypertension; Differences in BP between the upper and lower extremities may indicate coarctation of the aorta

Physical Exam; Inspection Skin color: cyanosis: central cyanosis increased deoxyhemoglobin content (greater than 5 g%) reducing oxygen available for delivery to the tissues ruddy (أحمر داكن) complexion) Position of comfort (e.g a squatting position وضع القرفصاء) Presence of clubbing Orthopnea (difficult for people to breathe while lying down ) is a sign in children , Lethargy Nutritional status Edema ; it first appears periorbitally,

Physical Exam; Palpation The point of maximum intensity (PMI; at 3rd or 4th intercostal space, just left of midclavicular line) and the apical impulse The presence of a thrill/murmur should be noted. The quality and symmetry of all pulses Warmth of extremities, capillary refill, and presence or absence of edema Locating the hepatic and splenic borders (normally liver edge should not be more than 1–2 cm below the costal margin.

Physical Exam; Auscultation heart sounds, heart rate and rhythm. The presence of additional heart sounds, such as a murmur, is noted. Lung sounds

Murmurs Innocent murmurs vs. Organic murmurs
produced as a result of turbulent blood flow across the heart valve An innocent or functional heart murmur Not resulting from heart disease This is the most common type of heart murmur May be caused by fever, anemia, or a thin chest Organic murmur Indicates abnormality in the heart or a major artery May be caused by a narrow valve, a leaking valve, or a hole in the heart

Murmurs How to assess murmurs Organic murmurs are
Position in cardiac cycle Duration & location Quality; pitch, intensity Whether there is a thrill Whether the murmur changes with position change Organic murmurs are either systolic or diastolic long, harsh or blowing, loud constant heard no matter what position the child is in

Cardiac Catheterization
A diagnostic/therapeutic invasive procedure catheter is inserted through a peripheral blood vessel (femoral, radial artery) into the heart, to visualize the structures inside & function Other purpose to obtain cardiac tissue samples for biopsy. close small holes inside the heart place wire devices, called stents, in narrowed arteries to keep them open Heart X-ray film

Classification of Congenital Heart Disease
Acyanotic Increased pulmonary blood flow Atrial septal defect * Ventricular septal defect * Patent ductus arteriosus * Atrioventricular canal Obstruction to blood flow from ventricles Coarctation of aorta * Aortic stenosis * Pulmonic stenosis* Cyanotic Decreased pulmonary blood flow Tetralogy of Fallot * Tricuspid atresia Mixed blood flow Hypoplastic left heart syndrome Truncus arteriosus Transposition of great arteries *

Congenital heart disease: Increased pulmonary blood flow
Atrial Septal Defect (ASD) *

Congenital heart disease: Increased pulmonary blood flow:ASD
CM Many children have no symptoms and seem healthy If the opening is large S& S of CHF may develop and increased the risk of endocarditis. Harsh systolic Murmur over 2nd or 3ed ICS Atrial dysrhythmias Pulmonary vascular obstructive diseases and emboli formation later in life enlarged right side and increased pulmonary circulation

Congenital heart disease: Increased pulmonary blood flow: ASD
Treatment of ASD ASD may close spontaneously as the child grows Some children may need medication such as digoxin and diuretics Control infection Catheterization may be needed to close the septum

Ventricular Septal Defect (VSD) * Most common congenital heart defect

Congenital heart disease: Increased pulmonary blood flow: VSD
CM Fatigue Sweating Rapid, heavy, congested breathing Disinterest in feeding Poor weight gain Murmurs May lead to hypertrophy and enlargement of the right atrium CHF is common Treatment: Surgical repair

Atrioventricular Canal (AV) Incomplete fusion of endocardial cushions defect involves the valves Common defect in children with down syndrome

Patent Ductus Arteriosus (PDA) * CM In premature infant Asymptomatic or signs of CHF Murmurs A widened pulse pressure & bounding pulses At risk for endocarditis & pulmonary vascular obstructive disease Treatment Prostaglandin inhibitor Surgical repair

Acyanotic Increased pulmonary blood flow Atrial septal defect Ventricular septal defect Patent ductus arteriosus Atrioventricular canal Obstruction to blood flow from ventricles Coarctation of aorta Aortic stenosis Pulmonic stenosis Cyanotic Decreased pulmonary blood flow Tetralogy of Fallot Tricuspid atresia Mixed blood flow Hypoplastic left heart syndrome Truncus arteriosus Transposition of great arteries

Congenital heart disease: Obstructive Defects
Coarctation of the Aorta (COA) * Narrowing anywhere in the aorta Increased pressure proximal to the defect Restricts the amount of oxygenated blood to lower part LT ventricle has to work harder Risk for endocarditis Coronary arteries may narrow due to high pressure

Congenital heart disease: Obstructive Defects:COA
CM High BP and bounding pulse in arms Low BP & Absent femoral pulse and cool extremities Headaches, dizziness , fainting & epistaxis cramps in the legs Pt at high risk for hypertension, ruptured aorta and stroke Kidneys’ function may be altered ( decrease urine ) Treatment Enlargement of constricted section (surgical or nonsurgical (Balloon angiplasty))

Aortic Stenosis (AS) * Narrowing or stricture of the aortic valve Types of AS: Valvular stenosis The most common caused by malformed cusps resulting in a bicuspid rather than tricuspid valve or fusion of the cusps. Subvalvular stenosis is a stricture caused by a fibrous ring below a normal valve. Supravalvular stenosis

Congenital heart disease: Obstructive Defects: AS
Extra workload on the left ventricle causes hypertrophy which causes an increase in the left atrium pressure in turn increases the pressure in the pulmonary veins AS is progressive, associated with sudden episodes of myocardial ischemia Sudden death is possible CM Faint pulses, hypotension , tachycardia & poor feeding Chest pain , Dizziness when standing Murmurs Treatment Balloon dilatation (via cardiac catheterization) Valvotomy involves a surgical removal of adhesion that preventing valve leaflets from opening Aortic valve replacement

Pulmonary Stenosis (PS) * Narrowing at the entrance of the pulmonary artery When RT ventricular failure develops this causes an increase in the RT atrial pressure The accelerating pressure reopen the foramen ovale causing systemic cyanosis In severe cases CHF occurs

Congenital heart disease: Obstructive Defects: PS
CM Mild cases are asymptomatic Cyanosis in severe cases Murmurs Cardiomegaly (chest X-ray) Treatment Depends on the degree of the stenosis may wait for a few years Relieve stenosis or valve adhesion by balloon angioplasty

Acyanotic Increased pulmonary blood flow Atrial septal defect Ventricular septal defect Patent ductus arteriosus Atrioventricular canal Obstruction to blood flow from ventricles Coarctation of aorta Aortic stenosis Pulmonic stenosis Cyanotic Decreased pulmonary blood flow Tetralogy of Fallot Tricuspid atresia Mixed blood flow Hypoplastic left heart syndrome Truncus arteriosus Transposition of great arteries

Congenital heart disease Decreased Pulmonary Blood Flow: Tetralogy of Fallot (TOF)
The classic form includes four defects: Ventricular septal defect Pulmonic stenosis Overriding aorta: the aorta is shifted towards the right side of the heart so that it sits over the ventricular septal defect Right ventricular hypertrophy

Congenital heart disease Decreased Pulmonary Blood Flow: Tetralogy of Fallot (TOF)
In mild right ventricle obstruction, the pressure in the right ventricle can be slightly higher than the left, thus some of the deoxygenated blood in the right ventricle will pass through the VSD to the left ventricle thus a child may not appear blue In severe obstruction in the RT ventricle the large amount of de-oxygenated blood passes via VSD into the LT ventricle thus these children appear blue Tetralogy of Fallot occurs in about two out of every 10,000 live births. It makes up about 8 percent of all cases of congenital heart disease.

Congenital heart disease Decreased Pulmonary Blood Flow: TOF
CM Infants may be acutely cyanotic at birth; others have mild cyanosis CM progresses over the first year of life as the pulmonic stenosis worsens Murmur Acute episodes of cyanosis and hypoxia, called blue spells or "TET spells". Anoxic spells occur when the infant's oxygen requirements exceed the blood supply (crying, tighter pulmonary artery ) Children with cyanosis may have clubbing nail, squatting position, poor growth TOF children at risk for cerebrovascular disease and sudden death Polycythemia Treatment: primarily palliative shunt then complete repair (such as closure of VSD)

Congenital heart disease Decreased Pulmonary Blood Flow
Tricuspid Atresia (TA) Failure of the tricuspid valve to develop so there is no communication from the right atrium to the right ventricle Blood flows through an atrial septal defect or a patent foramen ovale to the left side of the heart and through a VSD to the right ventricle associated with pulmonic stenosis and transposition of great arteries. complete mixing of deoxygenated and oxygenated blood in the left side of the heart, resulting in systemic cyanosis

Congenital heart disease Decreased Pulmonary Blood Flow: TA
CM Cyanosis Tachycardia & dyspnea Clubbing nail Children with TA at risk for stroke Treatment Prostaglandin Palliative treatment; shunt to increase blood flow to the lungs Surgical treatment

A cyanotic Increased pulmonary blood flow Atrial septal defect Ventricular septal defect Patent ductus arteriosus Atrioventricular canal Obstruction to blood flow from ventricles Coarctation of aorta Aortic stenosis Pulmonic stenosis Cyanotic Decreased pulmonary blood flow Tetralogy of Fallot Tricuspid atresia Mixed blood flow Hypoplastic left heart syndrome Truncus arteriosus Transposition of great arteries

Congenital heart disease Mixed Defects
Transposition of Great Arteries/Vessels (TGA/V) * The pulmonary artery leaves the left ventricle, and the aorta exits from the right ventricle, with no communication between the systemic and pulmonary circulation Deoxygenated blood returns via misconnected aorta to the body Oxygenated blood goes back to lungs

Congenital heart disease Mixed Defects (TGV/A)
Often associated with septal defects PDA, VSD, patent foramen ovale CM Severe cyanosis May have signs of CHF Cardiomegaly a few weeks after birth Treatment Surgical (arterial switch procedure)

Truncus arteriosus (TA) A single vessel arising from the heart that forms the aorta and pulmonary arteries. Large Ventricular septal defect accompanies TA

Hypoplastic left heart syndrome (HLHS) Is a combination of abnormalities of the heart and the great vessels In HLHS most structures on the left side of the heart are small & underdeveloped Mitral valve, left ventricle, aortic valve & aorta are involved.

Acquired Cardiovascular Disorders
Rheumatic Heart Disease (RHD) Congestive Heart Failure (CHF)

Acquired Cardiovascular Disorders :RHD
Permanent damage to the heart valves is caused by RF It develops after an infection of the upper RT with group A β- hemolytic streptococci The antigens of group A Streptococci bind to receptors in the heart, muscle, brain & synovial joints, causing an autoimmune response The antigens produced by Streptococci are similar to the body’s own antigens thus antibodies may attack healthy body cells RF forms Aschoff bodies(inflammatory lesions) that causes swelling and alterations in the connective tissue

RF major criteria Rheumatic Carditis Polyarthritis Erythema marginatum Subcutaneous nodules chorea

Rheumatic Carditis Involves endocardium, pericardium & myocardium CM: valvulitis Myocardities Pericarditis: muffled heart sound due to pericardial effusion, chest pain, pericardial friction rub Murmur Tachycardia especially during sleep Polyarthritis Joints such as knees, elbows, hips, shoulders & wrists Joints are swollen, hot, red & painful

Erythema marginatum Erythematous macule mostly found on the trunk & extremities Subcutaneous nodules Nontender swellings mostly found on the bony prominences areas such as feet, hands vertebrae Chorea Sudden & aimless irregular movements of the extremities Involuntary facial, grimaces Speech disturbances Emotional liability Muscle weakness Other minor criteria: arthralgia (joint pain), fever, fatigue and elevated ESR

Diagnostic test Throat culture-group a beta hemolytic streptococcal Increased ESR Increased in WBC Increased in C-reactive protein

Treatment Bed rest until ESR decreases Antibiotics (penicillin, erythromycin) x 10 days Reduce inflammation (Salicylates: aspirin) Corticosteroids (if not responding to aspirin alone) Phenobarbital for chorea Treatment of heart failure Prophylactic antibiotics (benzathine penicillin G) for 5 years or until 18 to prevent recurrence Prevention of RHD by Treating streptococcal throat infections with a full course of antibiotic Complications of RHD Mitral valve damage Congestive heart failure Hypoxemia

Acquired Cardiovascular Disorders :CHF
CHF: is a condition in which the heart cannot pump enough oxygenated blood to meet the need of the body organs CHF often occurs in children with congenital heart defects Medical problems that may lead to CHF are Rheumatic fever Endocarditis or valuvlitis Cardiac arrhythmias Cardiomyopathy Chronic lung disease Hypertension hemorrhage

Causes of CHF Volume overload Pressure overload which is caused by obstructive lesion, stenosis or coarctation of the aorta Decreased contractility which may be caused by myocardial ischemia due to Severe anemia Asphyxia Acidemia Low level of K, glucose, Ca , Mg High cardiac output (such in sepsis, hyperthyroidism or severe anemia)

Right side failure Right side is unable to pump blood to the lungs Due to the congestion in the right side of the heart the blood flow begins to back up into the veins which causing fluid retention Edema can be seen in the feet, ankles, eyelids Left side failure Left side is unable to pump much blood to the body Blood begins to back up into the vessels in the lungs, thus lungs become stressed (increased RR and labored breathing) Fatigue and poor growth

Symptoms of CHF Impaired Myocardial Function
Tachycardia Dec. urine output Fatigue & weakness Sweating restlessness Anorexia Pale & cool extremities Weak peripheral pulses Decreased BP Gallop rhythm cardiomegaly Pulmonary Congestion Tachypnea Retractions Flaring nares Exercise intolerance Orthopnea (breathlessness) Cough, hoarseness Cyanosis Wheezing Grunting Systemic Venous Congestion Weight gain Hepatomegaly Edema (is a late sign in children and it shows up as periorbital edema) other sites includes feet, ankles, face and abdomen) Ascites Neck vein distension

Therapeutic Management of CHF
Improve cardiac function Digitalis (digoxin) Angiotensin- converting enzyme (ACE) Remove accumulated fluid & sodium Diuretics Urine output 30ml/hour Decrease cardiac demands Neutral thermal environment Treat existing infections Reducing the effort of breathing Sedation & rest Improve tissue oxygenation & decrease oxygen consumption Improving myocardial function Oxygen supplement

Improve cardiac function Digitalis glycosides have three actions Increase the force of contraction (increase cardiac output & decrease venous pressure) Decrease the HR & slow the conduction of the impulses through the AV node Increase renal perfusion (enhance diuresis) Digoxin (Lanoxin) is used for children because of rapid onset and decreased risk of toxicity Digoxin level 0.8 – 2.0 u/L S&S of Toxicity includes nausea, vomiting, anorexia, slow HR Hold digoxin dose If HR less than 100 for infant If HR less than 80 for older children If HR less than 60 for adolescents

Improve cardiac function Angiotension-converting enzyme (ACE) inhibitors Reduces the afterload on the heart Vasodilatation results in decreased pulmonary and systemic vascular resistance, dec. BP& dec. in right and left atrial pressures Renal flow improved which enhances diuresis Capoten (captopril) most commonly used Side effect include hypotension, renal dysfunction

Remove accumulated fluid & sodium (decrease preload) Use of diuretics; lasix , diuril aldactone, Bumex, Zaroxolyn Potassium supplements when Lasix is used Low level of K enhances the effect of digoxin thus increases the risk of digoxin toxicity High level of K diminishes the effect of digoxin Fluid & sodium restriction

Decrease Cardiac Demands (lessen heart workload) Using easy-to-suck nipples increase the frequency and decrease the amount of each feeding neutral thermal environment Treating any existing infections Reducing the effort of breathing (semi-fowler position) Sedation if necessary Rest Improve tissue oxygenation and decrease oxygen consumption In addition to the previous management Oxygen supplement

Decreased cardiac output related to congenital structural defect
Goal : pt will exhibit improved cardiac output Interventions Administer digoxin Prevent digoxin toxicity Ascertain accurate rout and dose Check the pulse before administering drugs Withhold digoxin if pulse is less then (infants), (older children)

Decreased cardiac output related to congenital structural defect
Goal : pt will exhibit improved cardiac output Interventions Recognise digoxin toxicity Nausea, vomiting, anorexia, Bradycardia and dyshrythmia Ensure adequate K intake Observe signs of hypokalemia/hyperkalemia Monitor electrolytes level Check BP Expected outcomes: heartbeat is strong, regular & within normal ranges

Activity Intolerance Related to Imbalance between Oxygen Supply and demand
Goal : pt will exhibit no additional respiratory or cardiac stress Interventions Neutral thermal environment Treat fever promptly Small frequent feedings Timely arranged nursing care to avoid much disturbing to the pt Promptly respond to anxiety, crying Expected outcomes: pt rests quietly

Common Nursing Diagnosis
Altered tissue perfusion related to inadequate cardiac output Knowledge deficit related to care of the child pre- and postoperatively Fear related to lack of knowledge about child’s disease Altered family processes related to stresses of the diagnosis and care responsibilities Ineffective individual or family coping related to lack of adequate support Altered parenting related to inability to bond with critically ill newborn

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