Heart and Neck Vessels

1
Heart and Neck Vessels

• Week 8

2
Introduction

• Heart normally pumps between 4 6 L of
  blood/minute cardiac output (CO)
• CO SV X R e.g. 5.6 L 70 mL X 80 bpm
• Heart can alter CO to adapt to metabolic needs of
  body
• Preload afterload affect hearts ability to ?
  CO.  

3
Circulation
Figure 17-1. p. 498.
4
The Precordium
5
Internal Anatomy of the Heart
6
Direction of Blood Flow (19-5)
7
Internal Position/Surface Landmarks of the Heart
8
Preload Afterload

• Preload is a function of
• Volume of venous return
• Length to which ventricular muscle is stretched
  at end of diastole
• Starlings Law gt the stretch gt contraction
• Heart muscle contractility
• Afterload is a function of
• Opposing pressure ventricle must generate to open
  aortic valve against higher intraaortic pressure
• Resistance from PVS that ventricle must pump
  against.

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Preload and Afterload
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Cardiac Cycle

• Blood fills ventricles - pressure ?
• Atria contract - AV valves slam shut
• Ventricle contracts bl. forced into PA aorta
• Pressure ? in those vessels SL valves shut
• All 4 valves are closed ventricles relax,
  meanwhile atria have been filling with bl.
• Atrial pressure becomes gt than ventricular AV
  valves open
• Blood fills ventricles pressure ? ...

11
The Cardiac Cycle During Diastole and Systole

• http//www.coursewareobjects.com/objects/hao/anim/
  13-001ap.htm

12
The Cardiac Cycle
13
Events of the Cardiac Cycle

• http//www.coursewareobjects.com/objects/hao/anim/
  13-002ap.htm

14
Heart Sounds

• S1 caused by closure of AV valves loudest at
  apex
• S2 caused by closure of SL valves loudest at
  base
• S3 caused by ventricular vibrations during
  early diastole due to resistant ventricles
  occurs immediately after S2
• S4 caused by ventricular vibrations at end of
  diastole due to noncompliant ventricles occurs
  just before S1.

15
Heart Sounds
16
Murmurs

• Turbulent blood flow result in gentle blowing,
  swooshing sound
• Causes
• Velocity of blood increases
• Viscosity of blood decreases anemia
• Structural defects
• Characteristics of Sound
• Frequency, intensity, duration, timing.

17
Conduction

• Automaticity - SA node
• SA node ? R L atria ? AV node ? Bundle of His ?
  R L bundle branches ? Purkinje fibres ?
  ventricles
• ECG Waves
• P wave atrial depolarization
• PR interval
• QRS complex ventricular depolarization
• T wave ventricular repolarization.

18
Cardiac Electrical Activity

• http//www.coursewareobjects.com/objects/hao/anim/
  13-005ap.htm

19
Conduction System of the Heart
20
Aging Changes

• Systolic BP ?
• L ventricle wall thickness ?
• ? in pulse pressure as systolic BP ?
• No change in resting HR
• Cardiac output at rest is not changed
• ? ability of heart to alter CO on demand
• ? in arrhythmias ectopic beats more common
• Tachycardic rhythms less tolerated
• Incidence of cardiovascular disease ?.

21
Subjective Data Collection

• Chest pain
• Dyspnea
• Orthopnea
• Cough
• Fatigue
• Cyanosis or pallor

• Edema
• Nocturia
• Past cardiac history
• Family cardiac history
• Personal habits (cardiac risk factors)
• Medications.

22
Objective Exam

• Start with general survey - general physical
  appearance skin colour, body structure,
  mobility (position, posture gait), behaviour
  (distress, pain)
• Take pulse and BP
• Start from periphery move towards heart
• Perform PVS assessment starting with arms (will
  take next)
• Assess neck vessels
• Assess precordium.

23
Neck Vessels Exam

• GENTLY palpate carotid artery on both sides
• Auscultate carotid artery on both sides
• Inspect jugular veins for distention
• Position person supine at 30 to 45 degree angle
• Remove pillow to avoid neck flexion, turn head
  slightly away, direct strong light towards side
  of neck to highlight pulsations
• Note external jugular veins overlying the
  sternomastoid muscle pulsations should flatten
  disappear at about 45o angle
• Note pulsation of internal jugular at sternal
  notch.

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Blood Vessels of the Neck (19-10)
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Precordium

• Inspect precordium, inspect apical impulse
• Palpate apical impulse
• Palpate across precordium for unusual pulsations,
  thrills, vibrations
• Auscultate.

26
Taking a Carotid Pulse
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Palpate Apical Impulse
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Point of Maximal Impulse (PMI)

• http//www.coursewareobjects.com/objects/hao/anim/
  13-006ap.htm

29
Auscultation of Heart

• Auscultate in Z pattern including
• Aortic valve area 2nd R intercostal space
• Pulmonic valve area 2nd L intercostal space
• Tricuspid valve area L lower sternal border 5th
  intercostal space
• Mitral valve area L midclavicular line, 5th
  intercostal space
• Listen to S1 and S2 at all locations, one sound
  at a time.

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Aucultatory Areas
31
Cardiac Ausculatory Landmarks

• http//www.coursewareobjects.com/objects/hao/video
  /13-0041vp.htm

32
Auscultation of Heart Valves

• http//www.coursewareobjects.com/objects/hao/anim/
  13-009ap.htm

33
Cardiac Auscultation with Diaphragm and Bell
http//www.coursewareobjects.com/objects/hao/video
/13-0061vp.htm http//www.coursewareobjects.com/o
bjects/hao/video/13-0071vp.htm
34
On Auscultation

• Note rate and rhythm any pulse deficit
• Identify S1 and S2
• Assess S1 and S2 separately
• S1 louder at Apex
• S2 louder at Base
• Listen for extra heart sounds S3 or S4
• Listen for murmurs.

35
The Third Fourth Heart Sounds (Abnormal S3 S4)

• http//www.coursewareobjects.com/objects/hao/audio
  /13-005sp.htm
• http//www.coursewareobjects.com/objects/hao/audio
  /13-007sp.htm

36
Stenotic and Regurgitant Valvular Defects

• http//www.coursewareobjects.com/objects/hao/anim/
  13-010ap.htm
• http//www.coursewareobjects.com/objects/hao/anim/
  13-011ap.htm

37
Blood Work Associated with Heart Function
Oxygenation

• Hb or Hgb
• female 120 160 g/L
• male 140 180 g/L
• Hct
• female 0.36 0.46
• male 0.37 0.49
• RBC
• female 3.8 4.8
• male 4.2 5.4

• pH 7.35 7.45
• pO2 75 100
• pCO2 35 45
• SaO2 96 100
• Cl 100 106 mmol/L
• Na 135 145 mmol/L
• K 3.5 5.0 mmol/L.

38
Dev. Considerations - Aging

• Rise in systolic BP
• Widening of pulse pressure
• Increase in orthostatic hypotension
• Care when palpating carotid artery
• More difficult to palpate apical pulse
• S4 more common without disease
• Systolic murmurs common
• Occasional premature beats common.

39
Clinical Portrait of Congestive Heart Failure