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PECULIAR ANATOMIC AND PHYSIOLOGICAL FEATURES OF CARDIOVASCULAR SYSTEM IN CHILDREN <ul><li>LECTURES FOR FOREIGN STUDENTS OF...
The main functions of the organs of CARDIOVASCULAR SYSTEM IN CHILDREN <ul><li>  consist in maintaining the homeostasis of ...
Embryogenesis of cardiovascular system <ul><li>In the course of embryogenesis of cardiovascular system, the vessels are fo...
Continuation  <ul><li>The development of the heart from the part of the mesoderm begins since the third week of the embryo...
Continuation <ul><li>The external layer develops later into the muscular layer or   myocardium, and the external envelope,...
Continuation <ul><li>The tube grows intensively within the third week of the embryonic development bending into S-shape.  ...
Continuation <ul><li>Throughout Weeks 4-5, the partitioning of the atrium begins with the appearance of the interatrial se...
Continuation <ul><li>Meanwhile, in the embryonic heart, the additional bundles of the conducting system are found out: </l...
Continuation <ul><li>All these additional bundles degenerate before the birth.  </li></ul><ul><li>Meanwhile, in 0.2% of th...
Continuation <ul><li>Within the 5th week of the embryonic development, the interventricular septum is formed growing from ...
Continuation <ul><li>Within the 7 th  week, the partition of the ventricles comes to an end.  </li></ul><ul><li>At the sam...
Continuation <ul><li>The formation of the valves of the heart follows the formation of the septa.  </li></ul><ul><li>The v...
Continuation <ul><li>At the end of Weeks 7-8, the heart has the four-chamber structure. </li></ul><ul><li>Since the 8th we...
The peculiarities of the fetal blood circulation <ul><li>Throughout the fetal stage of development, the maternal blood sup...
Continuation <ul><li>Several specific paths of blood circulation exist in the fetus, in particular ductus arteriosus (Bota...
Placental blood circulation of fetus <ul><li>The arterial blood collecting from the villi of placenta enters the body of t...
Continuation <ul><li>The umbilical vein runs to the hilus of liver and divides into two branches.  </li></ul><ul><li>One o...
Continuation <ul><li>The blood from inferior vena cava enters the right atrium. The blood from the head and the upper limb...
Continuation <ul><li>The blood from the right atrium enters the aorta by two paths: </li></ul><ul><li>a) through the oval ...
Continuation <ul><li>b) a portion of blood (about 10%) runs from the right atrium to the right ventricle and then to the p...
Continuation <ul><li>The blood directing to the lower part of the body and the lower limbs runs through the celiac arterie...
Continuation <ul><li>The first contraction of the fetal heart takes place in the 4-th week of the intrauterine development...
Continuation <ul><li>The liver, the head, and the upper part of fetal body obtain the blood, which is more saturated with ...
Peculiar features of newborn  blood  circulation <ul><li>The placental blood circulation finishes. </li></ul><ul><li>The f...
Newborn blood circulation <ul><li>Soon after the birth, the blood circulation system rearranges. </li></ul><ul><li>The vas...
Continuation <ul><li>An increased amount of blood flows from the right atrium to the right ventricle and into the pulmonar...
Continuation <ul><li>The flow of the blood from the right atrium to the left one terminates.  </li></ul><ul><li>Within two...
Continuation <ul><li>Sometimes, the foramen ovale is present anatomically for a long period: in 50% of the children up to ...
Continuation <ul><li>Within the first minutes after birth, Arantius' duct is closed. </li></ul><ul><li>Nevertheless, the c...
Continuation <ul><li>Meanwhile, ductus arteriosus operates throughout first eight hours of the postnatal life providing fo...
Anatomical features of heart in children <ul><li>The heart of the newborn makes up to 0.8% of body mass (in adults only 0....
Continuation <ul><li>When the child growth, the left ventricle becomes the predominated one with the ratio of right to lef...
Continuation <ul><li>At the age of 8 months the two-fold increase of heart mass is recorded; at the age of three years the...
Continuation <ul><li>The growth of different divisions of the heart is not uniform. </li></ul><ul><li>Up to the age of two...
Continuation <ul><li>Up to the age of six years, the heart is round in the shape.  </li></ul><ul><li>Later on, the shape o...
Continuation <ul><li>At the age of 3-4 years, the thoracic cavity increases, the diaphragm descends, and the thymus reduce...
Continuation <ul><li>Due to the change in the shape and the position of the heart, the apical impulse shifts with the age....
Continuation <ul><li>At the age of 3-7 years, the position of the apical impulse shifts to the fifth intercostals space, 1...
Main features of the internal structure of heart in the children <ul><li>Myocardium in the newborns follows the embryonic ...
Functions of heart <ul><li>The heart pumps the blood to the aorta, the pulmonary artery, the systemic and the pulmonary ci...
Continuation <ul><li>The connective tissue in the myocardium is poorly developed </li></ul><ul><li>The elastic fibers are ...
Continuation <ul><li>The myocardium of the atria consists of two layers of the muscular fibers: circular and elongated. </...
Continuation <ul><li>The conducting system is not yet perfect. </li></ul><ul><li>The myocardium differentiate substantiall...
Functions of heart <ul><li>The heart pumps the blood to the aorta, the pulmonary artery, the systemic and the pulmonary ci...
Continuation <ul><li>The stroke volume increases with the age due to increasing capacity of the myocardium of the left ven...
Table 1. The systolic (stroke)   volume and the cardiac output of the heart in the children (after A.V. Mazurin, I.V. Voro...
Functions of heart <ul><li>The second function of the heart, contractile one, is characterized by the heart rate.  </li></...
Continuation <ul><li>The high values of heart rate in the children result from domination of the sympathetic heart innerva...
Continuation <ul><li>Such a phenomenon is the result of the increasing vagal tonus in the course of the inspiration and vi...
Heart cycle <ul><li>The heart cycle is defined as the set of the electrophysiological, biochemical and biophysical process...
Continuation <ul><li>The length of the heart cycle is the newborn is 0.4-0.5 s.  </li></ul><ul><li>Later on, the length of...
Anatomical and physiological features of blood vessels in the children <ul><li>The arteries in the children are wider than...
Anatomical and physiological features of blood vessels in the children <ul><li>With the age, the veins grow faster than th...
Continuation <ul><li>In the newborns, the walls of the blood vessels are thin. </li></ul><ul><li>The muscular and elastic ...
Continuation <ul><li>Up to the age of 5 years, the muscular layer of the vascular walls grows faster; </li></ul><ul><li>at...
Continuation <ul><li>The capillaries in the children are well developed.  </li></ul><ul><li>The capillaries in the guts, t...
Continuation <ul><li>The shape of the capillaries is not regular: they are short and twisted.  </li></ul><ul><li>The capil...
The functional indices of the blood circulation in the children <ul><li>are the circulation rate, the spread of the pulse ...
The circulation rate in the children <ul><li>The circulation rate in the children is faster than in adults due to increase...
The spread of the pulse wave <ul><li>The spread of the pulse wave in the children is slower than in the adults due to the ...
The arterial blood pressure in the children <ul><li>The arterial blood pressure in the children is lower than in the adult...
The arterial blood pressure in the children <ul><li>In the newborn systolic arterial pressure in 76 mm Hg; its monthly inc...
The arterial blood pressure in the children <ul><li>At the age of one year, the systolic arterial pressure is around 90 mm...
Clinical Examination of cardiovascular system <ul><li>The clinical examination of cardiovascular system comprises the comp...
Complaints <ul><li>1. The fatigue upon the physical exercises (walking, games, ascending the staircase etc.) </li></ul><ul...
Complaints <ul><li>6. The edema in the lower limbs, the waist, the face. </li></ul><ul><li>7. The palpitations (the subjec...
Complaints <ul><li>11. The delay in the physical development, especially in the young children without the overt constitut...
Visual examination <ul><li>The severity of the conditions  </li></ul><ul><li>The delay in the physical development </li></...
Visual examination <ul><li>Tachipnea (the frequent superficial respiration: more than 60 breathings per minute in the chil...
Visual examination <ul><li>The paleness or cyanosis of the skin  </li></ul><ul><li>The subcutaneous blood vessels in the t...
Visual examination <ul><li>The  pulsation of the carotid arteries  </li></ul><ul><li>Gibbus cardiacus  </li></ul><ul><li>T...
Palpation <ul><li>The heart impulse </li></ul><ul><li>The arterial pulse. </li></ul><ul><li>The phenomen of  &quot;cat mur...
Heart percussion <ul><li>The percussion of the heart allows one to assess the size of the heart, its configuration and pos...
The techniques of percussion : <ul><li>Direct percussion  is performed only with one flexed finger. This technique is the ...
The techniques of percussion : <ul><li>Indirect percussion  is performed with two hands, namely the finger of one hand str...
The techniques of percussion : <ul><li>Orthopercussion  is performed for assessing the left boundary of the heart.  </li><...
Major guidelines of percussion <ul><li>1 . For assessing the relative borders of the heart, the subtle percussion should b...
Major guidelines of percussion <ul><li>3. The relative border of the heart is assessed by the external edge of the finger,...
Auscultation <ul><li>For auscultation in the children, the special pediatric stethoscope is used with the diameter of the ...
Auscultation <ul><li>The following order of heart auscultation is operative: </li></ul><ul><li>Point 1. Apex of the heart ...
Auscultation <ul><li>Point 4. The lower third of sternum at the base of the xiphoid process attachment, slightly to the ri...
Laboratory examination <ul><li>General blood analysis  </li></ul><ul><li>Biochemistry of blood serum   </li></ul><ul><li>I...
Instrumental methods of examination <ul><li>X-ray examination of the chest </li></ul><ul><li>Electrocardiography (ECG),  <...
<ul><li>To sum up, the complex of examination techniques, namely visual examination, palpation, percussion, auscultation a...
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Bohomolets Pediatric Lecture of Cardiovascular

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By Prof. T.V. Pochinok from Pediatric department in 3rd year

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Bohomolets Pediatric Lecture of Cardiovascular

  1. 1. PECULIAR ANATOMIC AND PHYSIOLOGICAL FEATURES OF CARDIOVASCULAR SYSTEM IN CHILDREN <ul><li>LECTURES FOR FOREIGN STUDENTS OF THE THIRD YEAR OF STUDY </li></ul><ul><li>Prof. T.V. Pochinok </li></ul><ul><li>National Ukrainian O.O. Bohomolets Medical University </li></ul>
  2. 2. The main functions of the organs of CARDIOVASCULAR SYSTEM IN CHILDREN <ul><li> consist in maintaining the homeostasis of the body, supplying the organs and the tissues with the oxygen and the nutrients, and eliminating carbon dioxide and the products of the metabolism. </li></ul>
  3. 3. Embryogenesis of cardiovascular system <ul><li>In the course of embryogenesis of cardiovascular system, the vessels are formed the first. </li></ul><ul><li>Within the second week of the embryonic development, the clusters of the cells known as blood islands, which later give the origin to the blood vessels appear in mesoderm. </li></ul>
  4. 4. Continuation <ul><li>The development of the heart from the part of the mesoderm begins since the third week of the embryonic development. </li></ul><ul><li>In the presumptive region of the neck, two primary endocardial tubes are formed. </li></ul><ul><li>The growing endocardial tubes approach one another and finally fuse, the septum between them resolves resulting in the tubular primitive heart structure. </li></ul><ul><li>The internal layer of the tube is referred to as endocardium, the external layer – epimyocardium. </li></ul>
  5. 5. Continuation <ul><li>The external layer develops later into the muscular layer or myocardium, and the external envelope, epicardium. </li></ul><ul><li>The internal layer gives rise to endocardium. </li></ul><ul><li>The broadened caudal end of the heart tube forms the venous sinus receiving the primary veins. </li></ul><ul><li>Cranial part of the heart tube is named as the cardiac bulb, from which later the arterial trunk originates. </li></ul><ul><li>The middle part of the heart tube dilates generating the ventricles and the atria. </li></ul>
  6. 6. Continuation <ul><li>The tube grows intensively within the third week of the embryonic development bending into S-shape. </li></ul><ul><li>The heart turns around the axis approaching the frontal one. </li></ul><ul><li>The part of the heart between the atrium and the ventricle narrows initiating the formation of the atrioventricular orifice. </li></ul><ul><li>In the middle of Week 4, two primordial chambers of the heart are generated. </li></ul>
  7. 7. Continuation <ul><li>Throughout Weeks 4-5, the partitioning of the atrium begins with the appearance of the interatrial septum with the oval foramen. </li></ul><ul><li>The oval foramen contains the valve on its left side. </li></ul><ul><li>Since the 4th week, the conducting system of the heart begins to generate with its major structures, namely sinoatrial (Keith-Flack's) node, atrioventricular (Aschaff-Tawara) node, atrioventricular (His) bundle, and Purkyne fibers. </li></ul>
  8. 8. Continuation <ul><li>Meanwhile, in the embryonic heart, the additional bundles of the conducting system are found out: </li></ul><ul><li>left and right Kent's bundles between the atria and the ventricles; </li></ul><ul><li>James bundle connecting the atria with the atrioventricular node; </li></ul><ul><li>Mihime's bundle connecting the atrioventricular node with the myocardium of the ventricles. </li></ul>
  9. 9. Continuation <ul><li>All these additional bundles degenerate before the birth. </li></ul><ul><li>Meanwhile, in 0.2% of the adults these embryonic conducting paths partially preserve. </li></ul><ul><li>The preservation of the embryonic elements of heart conducting system may be the cause of the paroxysmal tachycardia and arrhythmia in the children. </li></ul>
  10. 10. Continuation <ul><li>Within the 5th week of the embryonic development, the interventricular septum is formed growing from the apex towards the atrium. </li></ul><ul><li>For some time, the foramen between the ventricles exists. </li></ul><ul><li>Later on, the interventricular foramen overgrows with the connective tissue. </li></ul>
  11. 11. Continuation <ul><li>Within the 7 th week, the partition of the ventricles comes to an end. </li></ul><ul><li>At the same time, the common arterial trunk separates to aorta and the pulmonary trunk. </li></ul>
  12. 12. Continuation <ul><li>The formation of the valves of the heart follows the formation of the septa. </li></ul><ul><li>The valves grow as the duplicators of the endocardial layer. </li></ul>
  13. 13. Continuation <ul><li>At the end of Weeks 7-8, the heart has the four-chamber structure. </li></ul><ul><li>Since the 8th week, the heart descends from the germinal position in the presumptive neck region into the thoracic cavity. </li></ul>
  14. 14. The peculiarities of the fetal blood circulation <ul><li>Throughout the fetal stage of development, the maternal blood supplies the fetus with oxygen and nutrients and carries away carbon dioxide through the placental blood circulation. </li></ul><ul><li>The fetal tissues are supplied with the mixture of arterial and venous blood. </li></ul>
  15. 15. Continuation <ul><li>Several specific paths of blood circulation exist in the fetus, in particular ductus arteriosus (Botallo's duct), ductus venosus (Arantius' duct), and the oval foramen. </li></ul><ul><li>The pulmonary circuit is absent in fetus. </li></ul><ul><li>The period of the placental blood circulation begins at the end of the second – at the beginning of the third months of the fetal stage of development. </li></ul>
  16. 16. Placental blood circulation of fetus <ul><li>The arterial blood collecting from the villi of placenta enters the body of the fetus via the umbilical vein </li></ul><ul><li>The length of the umbilical cord at the end of the fetal stage of development amounts to 50 cm. </li></ul>
  17. 17. Continuation <ul><li>The umbilical vein runs to the hilus of liver and divides into two branches. </li></ul><ul><li>One of them, Arantius' duct joins the inferior vena cava. There, the oxygenated blood from the placenta is mixed with the deoxygenated venous blood from the lower parts of the body. </li></ul><ul><li>Another branch that joins the portal vein carries the oxygen-saturated blood diluted partially by the venous blood to the liver. </li></ul><ul><li>Then the blood flows to inferior vena cava via the hepatic vein. </li></ul>
  18. 18. Continuation <ul><li>The blood from inferior vena cava enters the right atrium. The blood from the head and the upper limbs also enters the right atrium via superior vena cava. </li></ul>
  19. 19. Continuation <ul><li>The blood from the right atrium enters the aorta by two paths: </li></ul><ul><li>a) through the oval foramen from the right atrium to the left one, and then to the left ventricle and the ascending aorta; </li></ul>
  20. 20. Continuation <ul><li>b) a portion of blood (about 10%) runs from the right atrium to the right ventricle and then to the pulmonary trunk. Since the pulmonary circuit in fetus does not operate and the pulmonary blood vessels have a high resistance to flow, this portion of the blood is directed from the pulmonary trunk to the arterial arch via ductus arteriosus (Botallo's duct). </li></ul>
  21. 21. Continuation <ul><li>The blood directing to the lower part of the body and the lower limbs runs through the celiac arteries; </li></ul><ul><li>The blood outflows from the body of the fetus via the arterial arteries comprising the umbilical cord, and returns to the placenta. </li></ul><ul><li>About 65% of blood returns to the placenta. </li></ul>
  22. 22. Continuation <ul><li>The first contraction of the fetal heart takes place in the 4-th week of the intrauterine development. </li></ul><ul><li>First, the fetal heart rate is rather low – 15-35 beats per minute. </li></ul><ul><li>As soon as the placental circulation is formed, the heart rate increases up to 125-130 beats per minute. </li></ul><ul><li>Such a rhythm is rather stable in normal gestation while in pathological conditions the deceleration or the acceleration of the fetal heart rate is possible. </li></ul>
  23. 23. Continuation <ul><li>The liver, the head, and the upper part of fetal body obtain the blood, which is more saturated with oxygen and the nutrients providing for more intensive development of these parts of the body as compared with the pelvic organs and the lower limbs. </li></ul>
  24. 24. Peculiar features of newborn blood circulation <ul><li>The placental blood circulation finishes. </li></ul><ul><li>The fetal blood communications are closed. </li></ul><ul><li>The pulmonary circuit becomes operative in full extent. </li></ul><ul><li>The vascular resistance of the pulmonary blood vessels decreases 5-10 fold. </li></ul><ul><li>The systemic vascular pressure increases. </li></ul>
  25. 25. Newborn blood circulation <ul><li>Soon after the birth, the blood circulation system rearranges. </li></ul><ul><li>The vascular resistance of the pulmonary blood vessels decreases 5-fold by the first and 10-fold by the second month of the postnatal life. </li></ul>
  26. 26. Continuation <ul><li>An increased amount of blood flows from the right atrium to the right ventricle and into the pulmonary arteries. </li></ul><ul><li>The increased left atrial pressure and decreased right atrial pressure causes the closure of the foramen ovale by the valve. </li></ul>
  27. 27. Continuation <ul><li>The flow of the blood from the right atrium to the left one terminates. </li></ul><ul><li>Within two weeks after the birth, the foramen ovale is joined with the valve resulting in the anatomical closure of the foramen within 5-7 months after the birth. </li></ul>
  28. 28. Continuation <ul><li>Sometimes, the foramen ovale is present anatomically for a long period: in 50% of the children up to the end of the first year of life; in 15 - 30% of persons, the foramen ovale is present throughout the life. </li></ul><ul><li>The open foramen ovale may be the cause of the congenital heart defects. </li></ul>
  29. 29. Continuation <ul><li>Within the first minutes after birth, Arantius' duct is closed. </li></ul><ul><li>Nevertheless, the complete obliteration of ductus venosus occurs within 8 weeks. </li></ul><ul><li>With the first breath of the newborn child, the spasm of ductus arteriosus occurs. </li></ul>
  30. 30. Continuation <ul><li>Meanwhile, ductus arteriosus operates throughout first eight hours of the postnatal life providing for two-side outflow of the blood from aorta to the pulmonary artery. </li></ul><ul><li>The anatomical obliteration of ductus arteriosus completes within 6-8 weeks of the postnatal life. </li></ul><ul><li>Sometimes, ductus arteriosus as well as other fetal blood communication do not completely close resulting in formation of the congenital heart defects. </li></ul>
  31. 31. Anatomical features of heart in children <ul><li>The heart of the newborn makes up to 0.8% of body mass (in adults only 0.4%). </li></ul><ul><li>The atria and the cardinal vessels in the newborns are somehow larger than the ventricles. </li></ul><ul><li>In the newborns, the right ventricle is the same by its size as the left one, with the thickness of the walls being of 5 mm. </li></ul>
  32. 32. Continuation <ul><li>When the child growth, the left ventricle becomes the predominated one with the ratio of right to left ventricle shifting in the following way: 1:1.5 at the age of one year; 1:2 – at the age of five years; 1:2.76 at the age of 14. </li></ul><ul><li>The thickness of the wall in the left ventricle increases 3-fold with the age while the thickness of the wall in the right ventricle increases only by a third. </li></ul>
  33. 33. Continuation <ul><li>At the age of 8 months the two-fold increase of heart mass is recorded; at the age of three years the heart increases 3-fold, and at the age of 15, the heart increases ten-fold. </li></ul><ul><li>The minimal ratio of heart mass to body mass is evident at the age of 5-6 months, in boys at the age of 8 years and in girls at the age of 12 years. Therefore, at the periods indicated, the heart is maximally vulnerable to the physical and psychoemotional loads. </li></ul>
  34. 34. Continuation <ul><li>The growth of different divisions of the heart is not uniform. </li></ul><ul><li>Up to the age of two years, the atria grow more intensively. </li></ul><ul><li>After 10 years the ventricles grow predominantly. </li></ul><ul><li>The size of the heart in boys is superior to that in girls except for the age of 13-15 when the girls overrun the boys in their growth . </li></ul>
  35. 35. Continuation <ul><li>Up to the age of six years, the heart is round in the shape. </li></ul><ul><li>Later on, the shape of the heart becomes oval. </li></ul><ul><li>Up to the age of 2-3 years, the position of the heart on the diaphragm is horizontal. </li></ul><ul><li>The right ventricle is adjacent to the thoracic wall generating for the most part the apical impulse of the heart. </li></ul>
  36. 36. Continuation <ul><li>At the age of 3-4 years, the thoracic cavity increases, the diaphragm descends, and the thymus reduces in size. </li></ul><ul><li>As a result, the heart occupies the oblique position turning around its long axis, the left ventricle forward. </li></ul><ul><li>At this time, the heart impulse is generated mainly by the left ventricle. </li></ul><ul><li>Later on, the heart occupies the vertical position in the thoracic cavity. </li></ul>
  37. 37. Continuation <ul><li>Due to the change in the shape and the position of the heart, the apical impulse shifts with the age. </li></ul><ul><li>In the newborn, the apical impulse is assessed in the fourth intercostals space, 2 cm outwards from the left middle clavicular line. </li></ul>
  38. 38. Continuation <ul><li>At the age of 3-7 years, the position of the apical impulse shifts to the fifth intercostals space, 1 cm outwards from the left middle clavicular line. </li></ul><ul><li>At the age of 7-12 years, the apical impulse is assessed in the fifth intercostals space, 0.5 cm inwards from the left middle clavicular line. The same position is in adults. </li></ul>
  39. 39. Main features of the internal structure of heart in the children <ul><li>Myocardium in the newborns follows the embryonic patterns of the structure representing undifferentiated symplast rich in vacuoles. </li></ul><ul><li>The muscular fibers of the myocardium are thin </li></ul><ul><li>The longitudinal fibrillarity and the transverse striation are not pronounced, </li></ul><ul><li>The number of nuclei is high, while the nuclei are small and low differentiated, therefore the myocardium does not look as a compact structure. </li></ul>
  40. 40. Functions of heart <ul><li>The heart pumps the blood to the aorta, the pulmonary artery, the systemic and the pulmonary circuits of circulation. </li></ul><ul><li>The indices of the pumping function of the heart are the systolic (stroke) volume and the cardiac output. </li></ul><ul><li>The stroke volume increases with the age due to increasing capacity of the myocardium of the left ventricle. The increase in the cardiac output is less intensive because the heart rate decreases with the age </li></ul>
  41. 41. Continuation <ul><li>The connective tissue in the myocardium is poorly developed </li></ul><ul><li>The elastic fibers are practically absent (they appear at the age of 7 years). </li></ul><ul><li>The vascularity of the myocardium is well developed, later on the vasculature of the myocardium decreases. </li></ul>
  42. 42. Continuation <ul><li>The myocardium of the atria consists of two layers of the muscular fibers: circular and elongated. </li></ul><ul><li>The myocardium of the ventricles consists of three layers of the muscular fibers: two spiral, shared for two ventricles and one circular, separate for each ventricle. </li></ul>
  43. 43. Continuation <ul><li>The conducting system is not yet perfect. </li></ul><ul><li>The myocardium differentiate substantially with the age, the connective tissue develops intensively, the muscular fibers thicken. </li></ul><ul><li>The development of the myocardium finishes at the beginning of the pubertant period. </li></ul>
  44. 44. Functions of heart <ul><li>The heart pumps the blood to the aorta, the pulmonary artery, the systemic and the pulmonary circuits of circulation. </li></ul><ul><li>The indices of the pumping function of the heart are the systolic (stroke) volume and the cardiac output. </li></ul>
  45. 45. Continuation <ul><li>The stroke volume increases with the age due to increasing capacity of the myocardium of the left ventricle. </li></ul><ul><li>The increase in the cardiac output is less intensive because the heart rate decreases with the age </li></ul>
  46. 46. Table 1. The systolic (stroke) volume and the cardiac output of the heart in the children (after A.V. Mazurin, I.V. Vorontsov, 1999) 92 4425 1,2 59,0 13 - 16 85 3075 1,15 41,0 12 85 1955 1,0 23,0 7 117 1173 1,0 10,2 1 120 420 0,9 3,0 newborn ml/kg ml ml/kg ml Cardiak output Systolic volume Age
  47. 47. Functions of heart <ul><li>The second function of the heart, contractile one, is characterized by the heart rate. </li></ul><ul><li>The heart rate decreases with the age: = in the newborns the heart rate is 140-160 per min; </li></ul><ul><li>= at the age of 6 months – 130-135 per min; </li></ul><ul><li>= at the age of one year – 120-125; </li></ul><ul><li>= at the age of 5 years – 100; = at the age of 10 years – 80-85; = at the age over 12 years – 70-75; = in the adults – 65-75 per min. </li></ul>
  48. 48. Continuation <ul><li>The high values of heart rate in the children result from domination of the sympathetic heart innervation. </li></ul><ul><li>For young children, the sinus arrhythmia is typical expressing as the deceleration of heartbeats at the moment of breathing-out and its acceleration at the moment of breathing-in. </li></ul>
  49. 49. Continuation <ul><li>Such a phenomenon is the result of the increasing vagal tonus in the course of the inspiration and vice versa. </li></ul><ul><li>The high values of heart rate in the newborns and infants result in diminishing length of the heart cycle. </li></ul>
  50. 50. Heart cycle <ul><li>The heart cycle is defined as the set of the electrophysiological, biochemical and biophysical processes in the heart occurring within one heart contraction. </li></ul><ul><li>The start of the heart cycle is marked by P wave in electrocardiogram. </li></ul>
  51. 51. Continuation <ul><li>The length of the heart cycle is the newborn is 0.4-0.5 s. </li></ul><ul><li>Later on, the length of the heart cycle decreases. At the age of 10 years, the length of the heart cycle is 0.7 s. In adults, the length of the heart cycle is 0.77-0.8 s </li></ul>
  52. 52. Anatomical and physiological features of blood vessels in the children <ul><li>The arteries in the children are wider than in the adults. </li></ul><ul><li>The diameter of the arteries in the newborns and the young children is superior to that of the veins. </li></ul>
  53. 53. Anatomical and physiological features of blood vessels in the children <ul><li>With the age, the veins grow faster than the arteries. As a result, at the age of 16, the diameter of the veins is twice as wide as that of the arteries. </li></ul><ul><li>The growth of the arteries and the veins does not correspond to that of the heart: the circumference of the aorta at the age of 15 increases three-fold, while the volume of the heart – seven-fold. </li></ul>
  54. 54. Continuation <ul><li>In the newborns, the walls of the blood vessels are thin. </li></ul><ul><li>The muscular and elastic fibers of the blood vessels are not developed sufficiently. </li></ul><ul><li>With the age, the vascular walls are differentiated and the percentage of the muscular and elastic fibers increases. </li></ul>
  55. 55. Continuation <ul><li>Up to the age of 5 years, the muscular layer of the vascular walls grows faster; </li></ul><ul><li>at the age of 5-8, the growth rate of all the layers is uniform; </li></ul><ul><li>at the age of 8-12, the connective tissue is differentiated and the intima of the vascular walls grow predominantly; </li></ul><ul><li>at the age of 12 years, the structure of the vascular walls is the same as in the adults. </li></ul>
  56. 56. Continuation <ul><li>The capillaries in the children are well developed. </li></ul><ul><li>The capillaries in the guts, the kidneys, the skin, and the lungs are wider than that in the adults, both in absolute and in relative values. </li></ul><ul><li>The shape of the capillaries is not regular; they are short and twisted. The capillary permeability in the children is higher than in the adults. </li></ul><ul><li>– At the age of 12-13, the formation of the vasculature of the body is completed. </li></ul>
  57. 57. Continuation <ul><li>The shape of the capillaries is not regular: they are short and twisted. </li></ul><ul><li>The capillary permeability in the children is higher than in the adults. </li></ul><ul><li>At the age of 12-13, the formation of the vasculature of the body is completed. </li></ul>
  58. 58. The functional indices of the blood circulation in the children <ul><li>are the circulation rate, the spread of the pulse wave, and the arterial blood pressure. </li></ul>
  59. 59. The circulation rate in the children <ul><li>The circulation rate in the children is faster than in adults due to increased heart rate, the relatively high volume of the circulating blood, the relatively short length of the vasculature, and the high intensity of the metabolism. </li></ul><ul><li>The time of full blood circulation in the newborn is 12 s, in the adult – 22 s. </li></ul><ul><li>As a result, the blood supply in the children is higher than in the adults. </li></ul>
  60. 60. The spread of the pulse wave <ul><li>The spread of the pulse wave in the children is slower than in the adults due to the decreased percentage of the elastic fibers in the arterial walls. </li></ul>
  61. 61. The arterial blood pressure in the children <ul><li>The arterial blood pressure in the children is lower than in the adults due to decreased pumping and contractile capacities of the heart, the relatively higher diameter of the arteries, and the insufficient development of the elastic fibers in the arterial walls. </li></ul>
  62. 62. The arterial blood pressure in the children <ul><li>In the newborn systolic arterial pressure in 76 mm Hg; its monthly increment is 2 mm Hg. </li></ul><ul><li>At the age below one year, the following formula of the systolic arterial pressure is valid: 76+2n, where n – the age of the child in months. </li></ul>
  63. 63. The arterial blood pressure in the children <ul><li>At the age of one year, the systolic arterial pressure is around 90 mm Hg with its further annual increment of 2 mm Hg. Therefore, the following formula of the systolic arterial pressure may be used: 90+2n, where n – the age of the child in years. </li></ul><ul><li>The diastolic blood pressure equals 1/2–1/3 of the systolic one. </li></ul>
  64. 64. Clinical Examination of cardiovascular system <ul><li>The clinical examination of cardiovascular system comprises the complaints, the anamnesis, the visual examination, the palpation, the percussion, the auscultation. </li></ul>
  65. 65. Complaints <ul><li>1. The fatigue upon the physical exercises (walking, games, ascending the staircase etc.) </li></ul><ul><li>2. The dyspnea at the rest or in the movements. </li></ul><ul><li>3. The difficulties in breast-feeding </li></ul><ul><li>4. The cyanosis of the lips, the nails, the mucosa; the cyanotic skin at rest or in the movements. </li></ul><ul><li>5. The paleness of the skin. </li></ul>
  66. 66. Complaints <ul><li>6. The edema in the lower limbs, the waist, the face. </li></ul><ul><li>7. The palpitations (the subjective feelings of the heartbeats). </li></ul><ul><li>8. The pains in the heart. </li></ul><ul><li>9. The headaches </li></ul><ul><li>10. The sudden fainting for several seconds. </li></ul>
  67. 67. Complaints <ul><li>11. The delay in the physical development, especially in the young children without the overt constitutional and alimentary factors. </li></ul><ul><li>12. The frequent bronchitis and pneumonia, especially with the congestive symptoms. </li></ul><ul><li>13. The frequent anginas. </li></ul><ul><li>14. The noises in the heart. </li></ul><ul><li>15. The disturbed heart rhythm </li></ul>
  68. 68. Visual examination <ul><li>The severity of the conditions </li></ul><ul><li>The delay in the physical development </li></ul><ul><li>The position of the patient in bed </li></ul><ul><li>The stigmas of dysembriogenesis </li></ul><ul><li>The deformities of thorax in the area of the heart (gibbus cardiacus) </li></ul>
  69. 69. Visual examination <ul><li>Tachipnea (the frequent superficial respiration: more than 60 breathings per minute in the children below 2 months; more than 50 – in the children aged 2-12 months; more than 40 – in the children aged 1-3 years; more than 30 – in the children aged 3-7 years; more than 25 – in the children at the age above 7) or dyspnea (deep respiration with normal or slightly increased rate) </li></ul>
  70. 70. Visual examination <ul><li>The paleness or cyanosis of the skin </li></ul><ul><li>The subcutaneous blood vessels in the thorax </li></ul><ul><li>The edema and the pastosity </li></ul><ul><li>The phalanges of the fingers in the patients with heart diseases have sometimes the appearance of the &quot;drumsticks&quot;, the nails may look as the &quot;watch glasses&quot;. </li></ul>
  71. 71. Visual examination <ul><li>The pulsation of the carotid arteries </li></ul><ul><li>Gibbus cardiacus </li></ul><ul><li>The apical heart impulse or the impulse of the base of heart </li></ul>
  72. 72. Palpation <ul><li>The heart impulse </li></ul><ul><li>The arterial pulse. </li></ul><ul><li>The phenomen of &quot;cat murmurs&quot; </li></ul>
  73. 73. Heart percussion <ul><li>The percussion of the heart allows one to assess the size of the heart, its configuration and position as well as the width of the vascular bundle. </li></ul><ul><li>The percussion is performed in the supine position of the patient. </li></ul>
  74. 74. The techniques of percussion : <ul><li>Direct percussion is performed only with one flexed finger. This technique is the most adequate one for examining the children whatever age. </li></ul>
  75. 75. The techniques of percussion : <ul><li>Indirect percussion is performed with two hands, namely the finger of one hand striking the back surface of distal or middle phalange of the finger-pleximeter, the latter placed on the skin. This technique is possible to use for examining the children of relatively elder age. </li></ul>
  76. 76. The techniques of percussion : <ul><li>Orthopercussion is performed for assessing the left boundary of the heart. </li></ul>
  77. 77. Major guidelines of percussion <ul><li>1 . For assessing the relative borders of the heart, the subtle percussion should be used. For assessing the absolute borders of the heart, the percussion should be the most subtle. </li></ul><ul><li>2. The heart percussion should be performed along the intercostals spaces in the direction from the lungs to the heart </li></ul>
  78. 78. Major guidelines of percussion <ul><li>3. The relative border of the heart is assessed by the external edge of the finger, the absolute one – by the internal edge of the finger. </li></ul><ul><li>4. The heart percussion is performed in specified sequence: First, the right border is assessed, then, the left border, and finally, the upper border. </li></ul><ul><li>5. Prior to the assessment of the right border of the heart, the height of the diaphragm is assessed </li></ul>
  79. 79. Auscultation <ul><li>For auscultation in the children, the special pediatric stethoscope is used with the diameter of the diaphragm no more than 20 mm. </li></ul><ul><li>Auscultation is performed in the different positions of the patient: supine, lateral, sitting, standing, prior to and after the physical exercises, at the maximum of breathing-in, upon the arrest of the breathings, upon the complete breathing-out. </li></ul>
  80. 80. Auscultation <ul><li>The following order of heart auscultation is operative: </li></ul><ul><li>Point 1. Apex of the heart (sounds of mitral valve). </li></ul><ul><li>Point 2. The second intercostal space near the right edge of sternum (sounds of the aortal valves). </li></ul><ul><li>Point 3. The second intercostal space near the left edge of sternum (sounds of the valves of the pulmonary artery). </li></ul>
  81. 81. Auscultation <ul><li>Point 4. The lower third of sternum at the base of the xiphoid process attachment, slightly to the right from the middle sternal line (sounds of the tricuspid valve). </li></ul><ul><li>Point 5 (Botkin-Naunin-Erb point). This is the point of the intersection of the left edge of sternum with the line drawn from the second intercostal space on the right from the edge of sternum to the apex of the heart (sounds originating from all the valves of the heart). </li></ul>
  82. 82. Laboratory examination <ul><li>General blood analysis </li></ul><ul><li>Biochemistry of blood serum </li></ul><ul><li>Immunologic status </li></ul><ul><li>Bacterial analysis of the blood </li></ul>
  83. 83. Instrumental methods of examination <ul><li>X-ray examination of the chest </li></ul><ul><li>Electrocardiography (ECG), </li></ul><ul><li>phonocardiography (PCG), </li></ul><ul><li>echocardiography (Echo-CG), Dopplerography of the peripheral blood vessels, </li></ul><ul><li>magnetic resonance tomography (MRT). </li></ul>
  84. 84. <ul><li>To sum up, the complex of examination techniques, namely visual examination, palpation, percussion, auscultation and the techniques of laboratory and instrumental examination provides for diagnosing various diseases of cardiovascular system in the children. </li></ul>

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