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RNC Cardiac Review

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RNC Cardiac Review RNC cardiac review Elizabeth Rex, MS, NNP - BC NCC Cardiac Content ♥ Congestive Heart Failure ♥ Transition to extrauterine life ♥ Hypertension ♥ PDA ♥ Shock ♥ CV Assessment BP CVP ♥ Cardiac Tamponade EKG Monitoring ♥ Anomalies (Cyanotic / Acyanotic) Lines AV Canal ♥ Cyanosis Coarctation of aorta Central / Peripheral HLHS Cardiac / Pulmonary Pulmonary stenosis/atresia TOF ♥ Arrhythmias TGA TAPVR Fetal Circulation 3 fetal shunts Ductus venosus Foreman ovale Ductus arteriosus Embryonic Development Cardiac septation : begins middle of the 4 th week and complete by end of 5 th week Defects arising from problems in septation : VSD, ASD, endocardial cushion defect (AV canal), malformation of tricuspid and mitral valves Great Vessel Development Happens simultaneously with septation Defects that occur with great vessel development: Truncus Arteriosus TOF Pulmunary and Aortic valve malformations Transposition DORV Cardiovascular Transition ♥ 10 min = PaO2 50 mm hg ♥ 1 hr = PaO2 62 mm hg ♥ 2 days PaO2 75 - 85 mm hg 24 hours after birth: ♥ Oxygen consumption triples ♥ Significant increase in cardiac output ♥ Left ventricle must remodel and hypertrophy Respiratory Assessment ♥ Normal Rate: 30 - 60, easy effort ♥ Increased WOB: tachypnea, GFR, gasping ♥ S aturations: Pre and post Heart Rate Assessment ♥ Normal rate 120 - 160 (may range 80 - 200) ♥ Normal sinus rhythm Bradycardia Underlying causes ♥ Vagal response ♥ Apnea ♥ Hypoxemia ♥ Asphyxia ♥ H ypotension ♥ Acidosis ♥ Digoxin toxicity ♥ Central line in right atrium Evaluate for shock ♥ HR < 70 is usually pathologic ♥ D ifferentiate Sinus bradycardia - QRS complex follows each p wave ♥ Complete heart block Complete Heart Block ♥ Ventricular rate 45 - 89 beats/min ♥ P wave unrelated to QRS ♥ I ncreased incidence with maternal lupus erythematosus ♥ If hydroptic at birth, will be critically ill Tachycardia ♥ Abnormal tachycardia sustained HR>180 - Assess for shock, CHF - Evaluate resp status, perfusion, pulses, BP ♥ Most common: Sinus tachycardia sustained HR 180 - 220 Sympathetic stimulation Fever SVT Supraventricular Tachycardia Sustained HR > 220 ♥ Usually well tolerated initially unless associated with: Structural CHD Hydrops SVT - 15 lead EKG - Run while doing tx - Vagal maneuvers - Stimulate a gag - Suction nasopharynx - Ice to nose and forehead - Adenosine - Initial dose 100 mcg/kg - Rapid IV push over 1 - 2 seconds followed by flush - No response in 2 minutes increase dose 50 - 100 mcg/kg - Cardiover sion - 0.5 joules/kg Heart Auscultation ♥ First heart sound – S1 Closure of mitral and tricuspid valves End of atrial systole S1 Accentuated, may mean: Increased CO PDA, VSD, TAPVR, TOF AVM Anemia Fever Diminished, may mean: CHF Myocarditis Heart Auscultation Second heart sound – S2 Closure of aortic and pulmonic valves End of ventricular systole Split S2 is a normal finding and just reflects the aortic valve closing before the pulmonic valve. S2 First 48 hours Normal to hear single S2 in first two days of life because of increased PVR. If you hear a split S2 at birth, could indicate abnormalities of P or A valves or alterations in PVR and SVR. • After 48 hours • S2 split elongated • ASD, TAPVR, TOF, Ebstein’s anomaly • Absent split • Aortic stenosis, PPHN, TGA, TA S3 & S4 S3: O nly heard in left to right shunts and mitral valve insufficiency S4: Should not be heard in newborn. If so, indicates decreased ventricular compliance Ejection clicks: Abnormal after 24 HOL and heard after S1. Associated with dilation of great vessels or malformation of PV and AV Heart Murmur Sound caused by turbulent blood flow ♥ Blood forced through narrowed areas ♥ Regurgitation through incompetent or abnormal valves ♥ Increased flow across normal structures Heart Auscultation Murmurs Location Transmission Intensity Timing Quality Grading I - VI Heart Murmur Intensity Grade I - barely audible Grade II - soft but audible Grade III - moderately loud, no thrill Grade IV - loud, assoc. with thrill Grade V - audible with stethoscope barely touching chest Grade VI - audible with stethoscope not touching chest Heart Murmur Timing ♥ Systolic Heard between S1 and S2 of same beat S1 (murmur) S2 S1 (murmur) S2 ♥ Diastolic Heard between S2 and S1 of next beat S1, S2 (murmur) S1, S2 (murmur) ♥ Continuous Starts in systole and extends into diastole Normal/Innocent Murmurs Up to 50% of neonates can have a murmur in the first 48 hours of life ♥ Continuous systolic/Crescendo systolic murmur ( L R flow through PDA) ♥ Early soft midsystolic ejection murmur aka Peripheral pulmonic stenosis (PPS) Grade I - II/VI (no thrill) upper left sternal border, radiates to axilla and back ♥ Systolic ejection murmur (turbulence of blood flow across pulmonary valve) Grade I - II/VI may be heard 1 st week of life as PVR decreases and PDA closes Pathologic Heart Murmur ♥ > Grade 3 murmur within hours of birth SYSTOLIC • Pan systolic murmur • Mitral or tricuspid regurgitation • VSD DIASTOLIC • Aortic or pulmonic valve regurgitation Continuous murmur PDA, AVM, aortopulmonary window Pathologic Heart Murmur ♥ Central cyanosis ♥ Respiratory distress ♥ Abnormal heart silhouette ♥ ↑ or ↓ pulmonary vascularity on CXR ♥ Gallop CHF Assessment - Obeservation ♥ Skin: color, temperature, diaphoresis, edema ♥ Precordium: quiet, visible, heave, thrill PMI - LLSB 5 th intercostal space PMI shifted to the right: Dextrocardia Tension pneumothorax Diaphragmatic hernia PMI shifted to the left Tension right pneumothorax Assessment - Palpation ♥ Pulses: compare upper to lower extremities and side to side (if not equal, could mean LOTO) R Brachial and femoral equal in strength (R brachial = R subclavian = pre - ductal) Pedal pulses palpable Weak: LOTO, myocardial failure or shock Bounding (=“aortic runoff”): PDA, aortic insufficiency, systemic to pulmonary shunt ♥ CFT: press for 5 seconds, release < 3 seconds normal Assessment Auscultation Bruits ♥ Liver ♥ Anterior fontanelle ♥ M ay indicate AVM arteriovenous malformation Cyanosis - Peripheral Results from sluggish movement of blood to the extremities and increased tissue oxygen extraction ♥ Acrocyanosis Bluish discoloration hands and feet No mucous membrane involvement Often resolves by 48 hours of age Rule out hypothermia Cyanosis - Peripheral ♥ Circumoral cyanosis Bluish discoloration around the mouth Often associated with feeding R/O central cyanosis Cyanosis - Central = deoxygenated blood leaving the ♥ Bluish discoloration of tongue and mucous membranes ♥ Caused by desaturation of arterial blood. Hemoglobin carrying no O2 appears purple. ♥ At least 5g of desaturated hemoglobin/dl is necessary before you can observe cyanosis. ♥ Also influenced by presence of anemia or polycythemia ♥ Indicates cardiac or respiratory dysfunction Cyanosis - Pulmonary / Cardiac Pulmonary Cardiac Cyanosis Yes Yes Respiratory Rate Increased Increased – often tachypneic no GFR Infant looks comfortable if no C HF Work of breathing Increased Easy effort unless CHF – then GFR Acid/Base Balance Increased PCO2 Decreased PCO2 with tachypnea Respiratory acidosis Metabolic acidosis Mixed resp/metabolic if pulmonar y disease CXR Asymmetric pattern of Increased or decreased infiltrates or other pulmonary vasculature pulmonary disease Heart silhouette normal abnormal Size/shape/location O2 Challenge test PO2> 150 PO2 < 150 for cyanotic CHD Blood pressure Methods for measuring Arterial: ♥ Umbilical artery ♥ PAL Radial ♥ PAL Posterior tibialis Discrepancies in upper and lower BPs Coarctation of the aorta Any type of arch abnormality PDA Hypertension ♥ Systolic or mean arterial BP > 95 th percentile for birth weight, gest age, and post - natal age 95 th percentile for systolic BP = 65 mmHg at 24 wks. 95 th percentile for BP = 90/60 mmHg at 40 wks post conception. Renal abnormalities most common cause Hypertension Treatment ♥ V aries with cause of hypertension ♥ T x etiology if possible ♥ A nti - hypertensive only if hypertension immediately life threatening CVP ♥ In most cases the trend in CVP is more helpful than absolute value ♥ CVP may be difficult to interpret because it is affected by several factors: hypervolemia myocardial failure excessive ventilatory pressures grunting respirations tension pneumothorax pleural effusion UVC tip in portal system Cardiac Cycle Systole & Diastole Adult Systole is contraction of the ventricles Diastole is the relaxation and filling of the ventricles followed by a small atrial contraction Cardiac Cycle average neonate’s cardiac cycle is ≈ 0.4 secs, based on a HR of 150 Supraventricular tachycardia HR 230 60 ÷ 230 = 0.26 secs HR 300 60 ÷ 300 = 0.2 secs C ardiac Output The volume of blood pumped by the left ventricle in 1 min 120 - 200 ml/kg/min CO = stroke volume x HR Cardiac Output I nfluenced by changes in HR, pulmonary vascular resistance, and systemic vascular resistance to flow A lso influenced by the amount of blood returning to the heart Stroke Volume R elatively fixed at 1.5 ml/kg Factors that affect SV ♥ Preload ♥ Afterload ♥ Contractility Preload T he volume of blood in the ventricle before contraction (or at the end of diastole – aka end diastolic pressure) C linically, a measure of pressure rather than volume Dependent upon venous return to the heart An ↑↓ in preload can significantly affect CO in the neonate’s non compliant heart Preload Changes ↓ ♥ Hypovolemia ♥ Intrapartum blood loss ♥ Peripheral pooling secondary to bacterial sepsis ↑ ♥ Fluid overload ♥ Left to right shunt thru PDA, VSD, PFO Contractility S peed of ventricular contraction
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