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Module 5 Cardiac

Module 5 Cardiac. CARDIAC ANATOMY. CARDIAC CYCLE. TRANSITION FROM FETAL CIRC. Blood flow from placenta to fetus through the umbilical vein to the ductus venosus and into the right atrium of the heart No need for blood to travel to the lungs, though some does just by way of pressure gradients

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Module 5 Cardiac

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  1. Module 5 Cardiac

  2. CARDIAC ANATOMY

  3. CARDIAC CYCLE

  4. TRANSITION FROM FETAL CIRC. • Blood flow from placenta to fetus through the umbilical vein to the ductus venosus and into the right atrium of the heart • No need for blood to travel to the lungs, though some does just by way of pressure gradients • Majority of blood passes through patent ductus arteriosus, the vascular channel between the pulmonary artery and the aorta

  5. Newborn must adapt to receiving oxygen from the lungs • Transition from fetal to pulmonary circulation occurs in just a few hours • Increase in pressure in the left atrium stimulates closure of the foramen ovale • In response to higher oxygenation satruationsductousarteriosus closes within 10-15 hours after birth • Permanent closure occurs by 10-21 days after birth unless sats remain low

  6. PEDIATRIC DIFFERENCES • More sensitive to fluid volume changes • Less cardiac muscle compliance • Inability to regulate stroke volume until muscle fibers fully developed at around 5 years of age • Increased metabolic rate and increased oxygen demand • Little cardiac output reserve • H & H concentrations are higher as appropriate for age necessary for oxygen transport • Persistent desaturation/hypoxia can lead to increased H & H from bone marrow response

  7. CARDIAC ASSESSMENT • Comprehensive History • Has your child ever had a change in skin color during feeding or crying? • Does your child tire easily during physical activities? • Has anyone ever told you that your child has a heart murmur? • Does your child seem to assume a squatting position frequently?

  8. PHYSICAL ASSESSMENT • Inspection • Palpation • Auscultation • Vital signs

  9. INSPECTION • General appearance • Note size for age • Activity • Level of consciousness • Skin color • Muscle tone • Nail beds • Edema

  10. Skin and mucous membranes • Color and skin temperature • Pink • Pale • Mottled • Dusky • Moist or dry • Edema

  11. COLOR CHANGES Dusky skin tones

  12. COLOR CHANGES Mottled Skin

  13. COLOR CHANGES Note the pallor of extremities compared to trunk

  14. COLOR CHANGES Skin color; watch for changes in perfusion when crying or agitated

  15. COLOR CHANGES Pale or dusky undertones

  16. INSPECTION • Pink mucous membranes • Nutritional status • Excessive perspiration • Neck vein distention • Retractions

  17. PALPATION • Assess pulses for rate, rhythm, and volume • Apical • Radial • Brachial • Femoral

  18. Grading of pulses 0 = absent 1 = weak, thready 2 = normal 3 = full 4 = bounding

  19. Capillary refill • Normal time < 2 seconds • Fontanel • Indicates fluid status • Hepatosplenomegaly

  20. AUSCULTATION • Heart sounds are the refection of the heart’s functioning, the intensity varies with age, thickness of chest wall and cardiac output. • S1: Closure of mitral and tricuspid valves, producing the first heart sound “lub” of “lub-dub.” This is the beginning of systole • S2: Closure of aortic and pulmonic valves, the second heart sound “dub.” This is the beginning of diastole.

  21. MURMURS • Innocent murmurs are those that occur in the absence of significant heart disease or structural abnormality of the heart. • Innocent murmurs are rarely heard in newborns and should be evaluated. • Approximately 30% of children beyond the neonatal period are found to have an innocent murmur.

  22. Diastolic murmurs are always pathologic • Graded on a scale of 1-6 • Clinical assessments must be correlated with murmurs

  23. CLINICAL ASSESSMENT • Monitor vital signs • Heart rate • Blood pressure • Respirations • Pulse oximetry • Interpret lab values • Maintain strict intake and output

  24. DIAGNOSTIC STUDIES • Chest X-ray • Electrocardiogram (ECG/EKG) • Echocardiogram • Cardiac catheterization • Arterial blood gases

  25. CONGESTIVE HEART FAILURE • Is the pathophysiologic state in which the heart is unable to pump sufficient blood to meet the metabolic demand of the body. • Volume overload • Pressure overload • Myocardial dysfunction: Problems with contractility • High cardiac output demand

  26. RIGHT SIDED FAILURE • Effects of increased ventricular pressure - Wall stress and attempts by heart to pump better • Effects of increased volume - Dilation of the chamber - Regurgitation back into the atrium

  27. CLINICAL MANIFESTATIONS • Tachycardia • Muscle failure – poor contractility • Marginal B/P • Change in pulses • Diaphoresis • Poor feeding • Pale color • Hepatomegaly

  28. LEFT SIDED FAILURE • Increased pressure in left ventricle • Increased volume in left ventricle • Increased pressure in pulmonary veins • High pulmonary artery wedge pressure

  29. HYPOPLASTIC LEFT HEART LILY NEWBORN PRE OP LILY ONE DAY OLD POST OP

  30. LILY 4 YEARS OLD LILY 5 YEARS OLD

  31. CLINICAL MANIFESTATIONS • Effects of increased pressure • Muscle failure as on the right • Effects of increased volume • Ventricular dilation and worsening of muscle failure • Poor contractility • Marginal blood pressure • Tachycardia

  32. Volume and pressure overload • Backward failure • Tachypnea • Increased work of breathing • Moist rales • Signs and symptoms of pulmonary hypertension

  33. Failure on either side • Poor perfusion • Capillary refill is delayed • Extremities are cool • Gallop heart sound • Tachycardia • Failure on either side • Peripheral edema • Diaphoresis • Loss of appetite

  34. CLINICAL MANAGEMENT • Fluid restriction to help with congestion • Diuretic therapy to help manage excess body water • Nutritional support, either NGT or IV therapy • Oxygen for the heart muscle

  35. Medication to assist with contractility • Digoxin • Dopamine IV • Medication to aid perfusion • Captopril PO • Milrinone IV • Treat underlying cause

  36. MEDICATIONS-what and why? • Diuretics • Cardiac glycosides • ACE • Inhibitors/Antihypertensive agents • Antibiotics • Analgesics • Salicylates • Oxygen • Gamma Globulin

  37. CONGENITAL DEFECTS • Atrial Septal Defect • Ventricular Septal Defect • Patent Ductus Arteriosus • Hypoplastic Left Heart • Transposition of the Great Arteries • Tetralogy of Fallot

  38. ACQUIRED DEFECTS • Kawasaki Disease • Acute systemic inflammatory illness • Leading cause of acquired heart disease in children • Usually preceded by URI • Rheumatic Heart Disease • Damage occurs, usually to valves, following rheumatic fever • More prevalent in 3rd world countries • Inflammatory disease affecting heart, joints, CNS • Inflammatory disease that occurs after infection with beta hemolytic strep pharyngitis

  39. CASE STUDY • Sara is an 18-year-old first-time mom. She brings her 3-week-old baby Adam into the ER for a check because his color did not look right today. She tells you that he is a good baby, he sleeps all the time, he never wakes up to eat, she wakes him up • What else do you want to ask?

  40. What else do you want to ask? • What was Adam’s birth weight? Mom reports 7 lbs., 9 oz. • What is his current weight? You weigh him today at 7 lbs., 1 oz. • How much is he eating? He eats about 3 oz. every four to six hours. • Number of wet diapers a day? He has a wet diaper about every six hours. • Ask mom to describe the scenario about the color changes. Mom states he was feeding today and he looked a little blue.

  41. You ask the mom whether Adam had a murmur at birth and mom says no. The ER doctor examines him and tells Sara he believes that Adam has a VSD Why would his murmur be heard now at 3 weeks of age?

  42. Why would his murmur be heard now at 3 weeks of age? • A VSD is a hole between the ventricles. At birth the pressure in both sides of the heart is equal. As the baby grows, the pressure in the left side of the heart increases, forcing blood back into the right side of the heart and backing up into the lungs, which causes respiratory distress and poor feeding. It also results in an audible murmur.

  43. What tests would be ordered and what would be in Adam’s plan of care?

  44. What tests would be ordered and what would be in Adam’s plan of care? • Tests: • Chest X-ray to look for cardiomegaly, pulmonary edema. • ECG for rhythm disturbances. • Echocardiogram to confirm the VSD and look for other structural abnormalities and to determine the size of the VSD. • Adam’s plan of care will include oxygen, feeding support with smaller, more frequent feeds with a special nipple, and higher calorie formula. The food might be delivered via nasogastric feeds. Treatment will be based on the size and location of the VSD. It can be surgical or conservative

  45. MODULE 5 WORKSHEET • Complete MODULE 5 WORKSHEET • Know which medications are used for which purpose in children with cardiovascular compromise

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