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According to the book "Pediatrics (management): Diseases of a respiratory organs and cardiovascular system" / Under the editorship of R. E. Berman, V. K. Vogan; The Lane from English G. M. Alekhina, K. G. Ryabova. — Moscow: Medicine, 1988. It is devoted to questions of physiology and pathology of cardiovascular system. Much attention is paid to congenital anomalies of development and infectious diseases of the newborn and children of more advanced age.
CORDIAL AND VASCULAR
ASSESSMENT OF THE CONDITION OF CORDIAL AND VASCULAR SYSTEM
- COLLECTING ANAMNESIS AND PHYSICAL INSPECTION
At an assessment of a condition of children with suspicion on cardiovascular diseases the collected anamnesis and data of physical inspection are of great importance. Only taking into account them the issue of need of further laboratory diagnosis and purpose of the corresponding treatment will be resolved, or relatives of the patient will be told that his state does not inspire fears.
There is a number of questions on which it is necessary to pay special attention when collecting the anamnesis at suspicion on a heart disease. Parents who see the child daily usually do not notice emergence at it of cyanosis or consider that it has "a swarty skin" — subjective option of norm. Much more often attentive parents notice cyanosis of integuments at the child at an exercise stress. As for fatigue of children of advanced age, it is necessary to find out how they transfer rise on a ladder, walking to different distances, driving the bicycle, etc.; it is necessary to specify also whether arises at the child of an orthopnea, or an asthma at night. When collecting the anamnesis of the child of chest age it is necessary to pay the main attention to behavior it when feeding. Having heart disease, as a rule, exhausts the smaller volume of milk for feeding, at suction it quite often has a short wind and plentiful sweating. The child who was tired after feeding quickly falls asleep, however through a short period, having got hungry, wakes up. This symptom which is periodically repeating during the day should be differentiated from displays of intestinal colic and other digestive disturbances.
Physical inspection should be begun with an assessment of length of a body and a constitution. A number of heart diseases conducts to an arrest of development that is shown by decrease in rates of increase in body weight while its length increases according to age. The baby with congestive heart failure can seem longer and gipotrofichny in comparison with the peer having the compensated heart disease of blue type with which quite often length and body weight remain within norm. Special attention at survey should be paid on such signs as rattles in lungs, peripheral hypostases, increase in a liver and spleen. The unhealthy type of the child, insufficient increase in body weight, a tachypnea and increase in the sizes of a liver belong to the main displays of heart failure. To be a precursory symptom of a disease, cyanosis can be too poorly expressed, and fingers of hands and legs take a form of drum sticks usually not earlier than at the end of the 1st year of life even at the expressed undersaturation of an arterial blood oxygen. Cyanosis is swept usually most of all up in a nail bed, on lips and visible mucous membranes. Cyanosis around a mouth or in frontal area can be caused by rather expressed venous network, than undersaturation by oxygen of an arterial blood.
Table 11 — 1. Average heart rate (in 1 min.) at rest
The Heart Rate (HR) at newborns is very high and subject to considerable fluctuations (tab. 11 — 1). It averages 120 — 140 blows in 1 min. and can increase to 170 during the crying or concern or to decrease to 70 — 90 in 1 min. during a dream. In process of growth of the child of ChSS it urezhatsya, reaching 40 in 1 min. at athletically the developed teenagers. At constant tachycardia (ChSS exceeds 200 in 1 min. at newborns, 150 at babies and 120 at children of more advanced age), bradycardia or the wrong rhythm of reductions which is not caused by a sinus arrhythmia inspection of the child for the purpose of an exception of pathological character of the last can be required.
Establishment of nature of pulse — an important early stage in diagnosis of inborn heart diseases. With the high pulse pressure which is combined with the jumping pulse it is possible to assume sharp fluctuations of a blood-groove in an aorta, for example at a patent ductus arteriosus, aortal insufficiency or various arteriovenous shunts. Weakening of pulse can be caused by heavy congestive heart failure, a cardiac tamponade or a myocardiopathy.
The Arterial Pressure (AP) should be measured not only on hands, but also standing, at least if it is necessary to exclude coarctations) aortas. Decrease in a pulsation of a pas of a femoral artery or artery of a dorsum of foot in itself does not form the sufficient basis for diagnosis of this pathology. For measurement of the ABP at children of advanced age it is possible to use the mercury sphygmomanometer with the cuff taking about 2/3 forearms or hips. Use of too narrow cuff will inevitably lead to overestimate of the measured parameters while at too wide they will be a little underestimated. For measurement of the ABP most of children have usually enough set of cuffs 3, 5, 7, 12 and 18 cm wide. Emergence of the I tone of Korotkov corresponds to systolic pressure on a scale. At gradual pressure decrease in a cuff tones before a total disappearance become usually weaker. It is possible to take pressure for the size of diastolic pressure at the moment both easing of tones (preferably), and their disappearances; usually in the first case it is higher, and in the second — below true. For definition of the ABP on a leg a stethoscope have over a popliteal artery. As a rule, measured by means of a cuff, it approximately on 100 mm of mercury. exceeds the ABP, measured on a hand.
At children of early age of the ABP it is possible to define auskultativno, palpatorno or an inflow method. The last is most convenient for use for uneasy children. A cuff of the corresponding size have on a forearm or the child's hip. Fast inflating of air in it squeeze an extremity before blanching its distalny cuffs, then slowly release the last. Indications of the manometer at the time of reddening of distal part of an extremity by the little below the indications of systolic pressure received at a direct bloody method or auskultativny definition. Exact data on size ABP at children of both early, and more advanced age receive also by means of ultrasonic research (doppler sonography).
Size ABP changes in process of growth of the child; it depends on length and body weight. In the pubertal period of the ABP significantly raises and undergoes a number of temporary changes before relative stabilization on reaching mature age. At an exercise stress, excitement, cough and an overstrain it can increase by 40 — 50 mm of mercury. from usual level. At children of one age group with a similar constitution of the ABP can vary therefore at inspection of the patient with arterial hypertension it is always necessary to take repeated measurements it (fig. 11 — 1 and 11—2).
At quiet children at research of a venous pulse obtain information on venous pressure and pressure in the right auricle. Inspection of veins should be performed, having given to the patient a sitting position at an angle 90 °. In similar conditions if venous pressure is not increased, the outside jugular vein should not act over a clavicle. The increased venous pressure is transferred to an internal jugular vein and can be shown by increase of venous pulse without noticeable stretching of a vascular wall; such pulsation is not observed at healthy children in position of a body having leaned back at an angle 45 °.
Fig. 11 — 1. Arterial pressure (in pertsentilyakh) at boys in a sitting position (from: Report of the Task Force on Blood Pressure Control in Children. — National Heart, Lung and Blood Institute. — Pediatrics (Suppl.) 59:803, 1977. Copyringht Academy of Pediatrics).
On the phlebogram of a jugular vein or at a direct lead from upper hollow three positive components corresponding to each cardial cycle normal are defined; they are called respectively "and", "with" also by "V" (fig. 11 — 3). The wave "and" appears at the time of an auricular systole, and a wave "with" — at the time of an early ventricular systole. As large veins are in direct link with the right auricle, changes of pressure and a krovenapolneniye of cardial cavities are transferred to veins. Let's review the following examples.
- At congestive heart failure increase of pressure in the right auricle is followed by its increase in cervical veins. The main pulse wave in upper part of the place of discrepancy of these veins arises at the time of an early diastole.
- The heart prelum at exudative or chronic cardial compression leads to increase in pressure in system of jugular veins, however amplitude of a venous pulse is small.
Fig. 11 — 2. Arterial pressure (in pertsentilyakh) at girls in a sitting position (from: Report of the Task Force on Blood Pressure Control in Children, National Heart, Lung and Blood Institite. — Pediatrics (Suppl.) 59:803, 1977. Copyright Academy of Pediatrics).
- The expressed degree of a stenosis of a pulmonary artery can be followed by increase of diastolic pressure in a right ventricle. Emptying of the right auricle during its systole happens in the conditions of excessive diastolic pressure in it. At the same time the atypical presystolic wave is registered "and". Similar waves can arise also with not changed end diastolic pressure in a right ventricle, for example at patients with a stenosis of a pulmonary artery in combination with a hypertrophy of a right ventricle; the mechanism of their emergence is connected with restretching of walls of a ventricle in a diastole phase.
- Emergence of a presystolic wave "and" can be connected with a stenosis or an atresia of the three-leaved valve; by its transfer on lower hollow and hepatic veins the presystolic pulsation in a liver appears.
- At insufficiency of the three-leaved valve the part of excessive pressure in a right ventricle is transferred to the right auricle; as a result in a phase of a systole the expressed atypical venous pulsation leading to influence of waves "with" and "V" is registered.
- At a full cross heart block the possibility of emergence of a pulsation of cervical veins depends on position of the three-leaved valve at the time of an auricular systole. Reduction of the right auricle at the closed three-leaved valve is followed by emergence of the expressed pulsation of cervical veins.
- At obstruction of an upper vena cava, despite increase of pressure in system of jugular veins, the pulsation of veins is not noted.
Fig. 11 — 3. Phase analysis of cordial activity.
Inspection of the child for the purpose of definition of function of heart. It is necessary to determine function of heart by a certain scheme, paying attention to each symptom. Some data can be received even at the general survey of the child to auscultation. The protrusion in precardiac area to the left of a breast which is followed by the strengthened pulsation can suggest an idea of increase in the sizes of heart. The retrosternal (cordial) push demonstrates increase in a right ventricle, at a hypertrophy of left the high apical beat is defined. Two of these signs can be combined. The hyper dynamic type of a precardiac pulsation assumes loading volume, for example at the expressed shunt from left to right. Contrary to it lack of a precardiac pulsation, at hardly defined apical beat, is a sign of a pericardiac exudate or far come cardiomyopathy. The localization of a cardiac impulse in relation to the median and clavicular line defined at the child in a sitting position also helps at size discrimination of heart; at increase in a left ventricle the cardiac impulse is defined lateralny. Trembling of a thorax call the noise felt at a palpation in heart; their localization always has to match sites of the greatest intensity auskultativno of the revealed noise. It is very important to propalpirovat area of a nadgrudinny pole and a neck for the purpose of identification of the aortal noise testimonial of an aortal stenosis which are carried out on vessels or, at their smaller expressiveness, about a stenosis of a pulmonary artery. Rough systolic noise in the field of bottom edge of a breast or a top of heart testify respectively to defect of an interventricular partition or mitral insufficiency. At a stenosis of the atrioventricular valve diastolic trembling (a symptom of cat's purring) is palpatorno defined. It is necessary to fix accurately the place of localization and a phase of trembling.
In art of auscultation of much it is possible to reach practice and persistence. For the most adequate auscultation of high-tone sounds the stethoscope membrane is densely pressed to a chest wall, low-tone — pressed slightly. Listen to each sound component separately, at the same time in the beginning characterize cordial tone, and then — noise. It is necessary to allocate characteristic signs of each tone and noise. The first cardiac sound is caused by closing of atrioventricular valves (mitral and three-leaved), the II tone — closing of semi-lunar valves. During a breath the krovenapolneniye of the right departments of heart increases, time of emptying of a right ventricle is extended and the closing time of valves of a pulmonary artery is slowed down. Some splitting of tones appearing at the same time normal is connected with a breath phase (fig. 11 — 4).
Fig. 11 — 4. Physiological splitting of II toua hearts at the child at the age of 5 flyings with innocent systolic noise.
The phonocardiogram which is written down on a pulmonary artery (A), a top of heart (B), a pulse curve on a carotid artery (V), the electrocardiogram (). One division of a scale corresponds to 0.04 pages.
Figures noted cardiac sounds.
Fig. 11 — 5. The phonocardiogram which is written down on a pulmonary artery (A), and a top of heart (B). Figures noted cardiac sounds.
It is more preferable to auscultate the I cardiac sound on a top, the II tone — at the left upper edge of a breast. The child at the same time has to be in a quiet state lying on spin. Normal splitting of the II tone appears at breath height at once, the II tone comes to an end with the termination of an exhalation. In diagnosis the fact of splitting of tone, than its intensity is more important. The last varies depending on age of the patient, thickness of a chest wall and cordial emission. Physiological splitting of the II tone testifies to lack of defect of an interatrial partition, the defects which are followed by development of pulmonary hypertensia, the expressed stenosis of valves of a pulmonary artery and some other diseases.
It is more preferable to define the third cardiac sound in a mesodiastole, having placed a stethoscope funnel on area of a top of heart (fig. 11 — 5). In a presystole, just before the I tone, the IV tone matching an auricular systole sometimes is defined. At the teenager with relative bradycardia the III tone can be manifestation of norm, however at the patient with clinical signs of congestive heart failure and tachycardia it is followed by a cantering rhythm; at it merge III and IV tones is possible. The cantering rhythm is explained with insufficient distensibility of walls of a ventricle, at the same time the III top amplifies that is connected with filling of ventricles.
The exile clicks listened in an early systole are caused by an aortectasia and a pulmonary artery or increase of pressure in them. The moment of their emergence is so close by the time of the tone termination I that they can mistakenly be taken for splitting of the last. Aortal systolic clicks most accurately are determined by the bottom left edge of a breast and are continuous. They accompany the morbid conditions which are followed by an aortectasia (for example, at an aortal stenosis, Fallo's tetrad, the general arterial trunk). The clicks of opening of a pulmonary artery connected with its stenosis are heard in an average third of a breast on the left edge more accurately. They change on intensity during a respiratory cycle, disappearing on a breath. At identification on a top of mesosystolic click which protodiastolic noise follows it is possible to suspect a prolapse of the mitral valve.
Noise are characterized on intensity, height, the relation to a phase of cordial activity (systolic or diastolic), to the place of the most accurate localization and carrying out. On time of their emergence in relation to I and II cardiac sounds distinguish ejection murmurs. The systolic ejection murmur appears after accurately listened I tone, gradually increases to a maximum, and then decreases. However it disappears prior to the beginning of the II tone, however patients with the expressed degree of a stenosis have mouths of an aorta or valves of a pulmonary artery long noise can be imposed on the 1st component II of tone, thereby shading it. Pansystolic noise begin almost along with the I tone and continue during all systole, sometimes gradually decreasing. In general it is possible to tell that emergence of the expressed ejection murmur, as a rule, is connected with increase in a blood-groove in the field of semi-lunar valves of an aorta or their stenosis while pansystolic noise is characteristic of patients with defects of an interventricular partition or insufficiency of atrioventricular valves (mitral or three-leaved). Long call the systolic noise continuing to a diastole or "joining" it. It should be distinguished from two-component noise at which the systolic component comes to an end by the time of emergence of the II tone or to it, and after closing of semi-lunar valves there is a diastolic noise. Late systolic call the noise beginning right after the first noise and continuing until the end of a systole. At a prolapse of the mitral valve they are defined after click in the middle of a systole.
Allocate several types of diastolic noise:
- high-tone blowing, determined by the left edge of a breast, since the second mezhreberye, it is caused by aortal insufficiency or, with a high pressure in a small circle of blood circulation, insufficiency of valves of a pulmonary artery;
- early low-tone protodiastolic in a middle part of the left edge of a breast and on its upper edge it is connected with insufficiency of valves of a pulmonary artery (as a rule, it appears after surgical recovery of an output path of a pulmonary artery, for example after operation for Fallo's tetrad);
- early diastolic, localized in a middle part of a breast on its left edge and under a xiphoidal shoot, it is caused by increase in a blood-groove in the right atrioventricular opening or (more rare) a stenosis of the three-leaved valve; 4) scraping mesodiastolic on a top, defined after
- tone, it is connected with the increased krovenapolneniye of a left ventricle at the diseases which are followed by development of massive shunts from right to left; 5) long scraping on a top, accruing by the end of a diastole (with strengthening in a presystole), confirms an anatomic stenosis of the mitral valve.
Many noise are not caused by the expressed disturbances of a hemodynamics. Them call functional, accidental, insignificant or innocent (the last name is more preferable). At periodic auscultation in free selection innocent noise is revealed more than at 30% of children; their percent increases if children are inspected in unusual conditions (increase in cordial emission at high temperature of a body, infectious process, nervousness, etc.) . From innocent noise the srednetonalny, vibrating, rather short systolic ejection murmur more accurately listened in average and lower parts of the left edge of a breast without essential irradiation most often is defined on a top, the basis of heart or to the interscapular area. To another often meeting, but to insignificant noise, the short systolic ejection murmurs localized at the heart basis and continuous wine noise belong. Children at the age of mainly 3 — 7 years quite often have at the time of exile of musical character Graham Steel's noise reminding sometimes vibration of a tuning fork. It is short, usually amplifies in position of the child sitting, is more intensive at high temperature of a body, excitement or an exercise stress. The innocent pulmonic murmur often occurs at children and teenagers. It is caused by a blood whirl at its exile in a pulmonary artery that does not represent an aberration. It is the high-tone, blowing noise arising in an early systole, intensity of 1 — 3/6 degree defined in the second mezhreberye at the left in position of the child lying. Wine is other example of innocent noise at children. It is caused by a turbulent blood flow in system of jugular veins, does not belong to pathological and is more often localized in a neck or an upper part of a front surface of a thorax. In the form of a soft nun's murmur he is listened in time both systoles, and diastoles. At change of position of the head or easy
prelum of area of jugular veins on a neck it can amplify or, on the contrary, disappear. In the similar simple way it is possible to distinguish wine noise from the noise arising at organic lesions of cardiovascular system, in particular at a patent ductus arteriosus.
Parents should explain value of innocent noise. It is important to calm them because the doubts remaining with them influence education of the child, being usually expressed in hyper guardianship. The subconscious alarm of parents can make negative impact on development of consciousness of the child and to some extent on formation of his personality. In this regard in conversation with parents the doctor has to emphasize that innocent noise does not mean any serious anomaly. In order that it is final to make sure of it, it is necessary to hold repeated consultations periodically.