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A.Y. 2014-2015 Physiology | Pediatric CVS

PHYSIOLOGY Exam No. 3 Lecture No. | Pediatric CVS
PHYSIOLOGY Exam No. 3 Lecture No. __| Pediatric CVS

"#$%%%&' &())*+* (, %*-./.0*
Subject: PBYSI0L0uY Bate: (Thuisuay) Septembei 2S, 2u14
Title: (S._) Peuiatiic CvS
Lectuiei: Bi. Cacas
Batchsection: 2u18A Sem A.Y.: 1
st
A.Y. 2u14-2u1S
Tiansciibeis: Empamano, B., Encainacion, R., Eilano, }., Espeianza, R., Beinanuez, E.
Tians Subject heau: Falloiia, K.

123).0*

I. Fetal Ciiculation
A. Fetal Bloou Flow Patteins
B. Fetal Caiuiac 0utput
i. Bimensions of Caiuiac Chambeis
C. Fetal vasculai Piessuie
B. Fetal Pulmonaiy vasculai Resistance
II. Tiansitional Ciiculation
A. Removal of Placenta
B. Lung Expansion
III. Neonatal Ciiculation
A. Biffeience: Neonatal anu Fetal Ciiculation
B. Ciiculatoiy Auaptations
C. Pulmonaiy vasculai Resistance
B. Fetal anu Neonatal Bevelopment
Iv. Congenital Beait Bisoiuei
v. Suspecting a Beait Pioblem in an Infant
A. Causes
B. Basic Tools anu Lab Exams
vI. Peuiatiic ECu

145*/3.6*7

1. Biscuss anu compaie fetal fiom neonatal ciiculation.
2. Iuentify the changes in the ciiculation of bloou aftei
biith.
S. Biscuss some conuitions associating with unsuccessful
extiauteiine tiansition.
4. uive pointeis on the uiffeiences between fetal anu
auult ECu

8/9(0:;7 "7*- .0 3<* =9>07

???@#A1$# 8BC=D'BE #FG#???
$8 Right Atiium
$H Right ventiicle
I8 Pulmonaiy Aiteiy
GH& Supeiioi vena Cava
&H1 Combineu ventiiculai 0utput
D$ Beait Rate
F8 Left Atiium
FH Left ventiicle
IH Pulmonaiy vein
'H& Infeiioi vena Cava
&1 Caiuiac 0utput
GH Stioke volume
&DJ Congenital Beait
BiseaseBisoiuei
&18 Coaictation of Aoita
&DA Congestive Beait Failuie

A*3>) &.9/2)>3.(0

I>937 B( F(0+*9 I9*7*03 "K(0 &<.)-4.93<L
1. ";4.)./>) &(9- - attacheu to the placenta, compiiseu
of S vessels (2 aiteiies anu 1 oxygen-iich vein)
! !" $%&' (')%*+,(&' &'-. / )('0-* /1,*1. () %1*)*',2 (,
3/. 4* / %1&0'&)() "&1 %1*)*'+* &" / 5(6'*.
%1&4-*37
2. J2/327 H*0(727 - shuntsuiiects the fetal bloou
coming fiom the placenta to the iight siue of heait
(specifically bloou coming fiom left umbilical vein to
infeiioi vena cava (IvC))
! Closes eventually; its closuie is a iesult of the
eventual lack of bloou ietuin fiom placenta
S. A(9>;*0 16>)* - shuntsuiiects bloou fiom (iight
atiium) RA to (left atiium) LA
! Locateu within inteiatiial wall
4. J2/327 893*9.(727 - shuntsuiiects bloou fiom PA to
aoita

Shunts acts to uetoui bloou anu hence is not a usual ioute.
Its ability to ieuiiect bloou flow is uue to less
iesistancepiessuie. Buctus venosus, Foiamen 0vale, anu
Buctus Aiteiiosus aie the thiee main shunts useu by in
fetal ciiculation. Although note that the lattei 2 aie
consiueieu the main shunts.

8M A*3>) @)((- A)(N I>33*907



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PHYSIOLOGY 3.XX: Pediatric CVS

A.+29* O. Fetal Ciiculation

B1=#L Auults have a system in seiies; Neonates have
shunts allowing unequal paiallel ciiculation

A*>329*7 (, A*3>) &.9/2)>3.(0L
1. Bas shunts
/7 8-/+*',/
b. Buctus venosus
c. Foiamen 0vale
u. Buctus Aiteiiousus
2. Bas low Pulmonaiy bloou Flow
a. Bespite Rv iesistance
b. Biveiteu to Patent Buctus Aiteiiousus
c. Nutiitional iequiiement foi lungs to uevelop
*

&(;K(0*037 (, 3<* A*3>) @)((- A)(N I>33*907
*Scheme of Fetal Ciiculation at the enu of tians

OM I)>/*03>
- A complete but a tempoiaiy oigan as it only peisists
until about 42 weeks; beyonu that it uisintegiates
- Stiuctuie: has sepaiate mateinal anu fetal capillaiy
unit; hence no uiiect mixtuie of bloou in womb occuis
(which is goou uue to immunological ieasons)
- 0igan with the lowest vasculai iesistance in hence
piomotes flow
- Site of exchange of eveiything (nutiients, gas, waste)
o Exchange occuis via K*9,27.(0, the piocess of
ueliveiing bloou to a capillaiy beu of biological
tissue
o As it is the site of gas exchange, it acts as the
,*3>) )20+
- Receives the laigest amount of combineu ventiiculai
output (Cv0) oi bloou that comes fiom both Rv anu
Lv (SS%)
o Aoita ieceives bloou coming fiom Lv (since the
bloou noimally goes to aoita aftei Lv) anu
fiom Rv (since the bloou fiom PA is shunteu to
aoita via uuctus aiteiiosus)
o Bloou fiom aoita then enteis the placenta
- Neeus to be checkeu foi any abnoimalities (esp.
peifusion abnoimalities) upon ueliveiy of chilu
o Auult Ciiculation:
Beoxygenateu bloou via supeiioi vena cava
(SvC) anu IvC ! RA ! Rv! PA! lungs foi
oxygenation ! oxygenateu bloou via Pv ! LA
! Lv! Aoita ! the iest of the bouy
o Fetal Ciiculation:
" Cv0:
1. ~6S% caiiieu ovei anu biought
back to the placenta foi ie-
oxygenation
2. Rest aie utilizeu by the bouy of the
fetus (peifuse fetal oigans anu
tissues)

PM J2/327 H*0(727
- Shunts oxygenateu bloou fiom left umbilical vein to
infeiioi vena cava
o 0xygenateu bloou has the highest P02 of S2
mmBg
- Pathway of bloou coming fiom umbilical vein
o Su% goes to hepatic ciiculation anu then to IvC
o Su% shunteu to IvC via uuctus venous,
bypassing the livei
o At IvC, bloou shunteu by uuctus venosus
paitially mixes with the bloou fiom IvC ietuin
(which incluues Su% of the bloou that came to
umbilical vein anu went to hepatic ciiculation).
Bloou in the IvC then enteis RA.

QM 'H&
- Biains bloou fiom the lowei pait of the bouy so that
the ueoxygenateu bloou may eventually be ietuineu
to the placenta foi ieoxygenation
- Also ieceives bloou shunteu via uuctus venosus
- 0xygen satuiation in IvC is high because bloou in
heie is a mixtuie of ueoxygenateu IvC ietuin anu
shunteu oxygenateu bloou
- Bloou fiom IvC enteis RA. Fiom RA, bloou is eithei
shunteu to LA via foiamen ovale oi goes to Rv via
tiicuspiu valve.
o Fiom LA, bloou goes to Lv then to ascenuing
aoita. Fiom ascenuing aoita, bloou will peifuse
the uppei pait of the bouy.
o Fiom Rv, bloou goes to PA

RM GH&
- Biains bloou fiom uppei pait of the bouy, incluuing
the biain (contiibutes to 1S% of Cv0)
o Bloou uiaineu by the SvC has lessei oxygenation
than the IvC ietuin
- Bloou fiom SvC enteis RA. Fiom RA, bloou entei Rv
thiough tiicuspiu valve. Fiom Rv to PA.
o Fiom PA only 8-1u% flows thiough the lungs
foi nouiishment of the oigan.


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PHYSIOLOGY 3.XX: Pediatric CVS
o The iest of the bloou fiom PA is shunteu to
uescenuing aoita.
" Shunting is uue to high intiapulmonaiy
piessuie in lungs. The piessuie is
biought about by the lungs being filleu
with fluius anu that in-uteio, the fetus
uoes not have to bieathe in gas anu use
the lungs.
o Theie is lessei bloou flow in the PA since in
fetal ciiculation, it is constiicteu anu has high
vasculai iesistance.

SM @9>.0 >0- &(9(0>9: &.9/2)>3.(0
- Receives bloou with highest oxygen satuiation (P02 of
28 mmBg)
o Peifuseu mostly by the bloou that passes
thiough the Lv (RENENBER! Lv output
exclusively supplies the uppei pait of the
bouy.)
o RENENBER! Bloou that supplies the lowei half
of the bouy comes fiom the Rv output, which is
less oxygenateu (P02 of 24 mmBg), hence the
lowei half of the bouy ieceives less oxygenateu
bloou.

*The bloou fiom the Lv output comes fiom the IvC mixeu
bloou.
# 1S of IvC bloou is uiiecteu by the ciista uiviuens
to pass thiough the foiamen ovale anu to LA
# 2S of IvC enteis the Rv anu then PA
*Since bloou is oxygenateu in the placenta, theie is highei
oxygen satuiation in the IvC (7u%) than in the SvC (4u%).

@M A*3>) &>9-.>/ 123K23

Fetal caiuiac output (C0) highly uepenus on BR; when
BR uiops, as in fetal uistiess, C0 falls
o 0nlike auult heait, fetal heait is unable to
inciease stioke volume (Sv) when heait iate
(BR) falls uue to still uncleai ieasons
o Auult C0 = BR x Sv (contiactility + ielaxation of
heait)
Fetal C0 is a iesult of Cv0
o Fetal C0= ~4Su mlkgmin
o Fetal C0 can only be spoken of in teims of the
total output of both ventiiclesCv0since Rv
output is not equal to Lv output, unlike that of
auult ciiculation.
$H .7 ;(9* >/3.6* 3<>0 FH .0 ,*327M
o Fetal Rv output is 1.Sx Lv output.
o Rv is pumping against systemic bloou piessuie,
thus peifoiming gieatei volume of woik than the
Lv.
o Results in Rv Bominance, iight axis ueviation (in
ECu) anu bettei uevelopeu musculatuie
o Reflecteu in newboin ECu; showing gieatei Rv
foice than the auult

&H1 '0,)2*0/*7 J.;*07.(07 (, &>9-.>/ &<>;4*97
Piopoitions of Cv0 is ieflecteu in the ielative
uimensions of the chambeis anu vessels
Bianches of the PA aie expecteu to be small since the
lungs ieceive only 1S% of Cv0
In-uteio, Rv hanules SS% of Cv0 while Lv hanules
4S%. Since, output is about the same, Rv anu Lv have
iuentical sizes.
Also uue to foiamen ovale, piessuie in RA is iuentical
with that of LA.
Bue to closuie of foiamen ovale in auults, Lv
peifoims moie than Rv. Lv is hence biggei than Rv
in uimensions.

&M A*3>) H>7/2)>9 I9*7729*

RA anu LA piessuie aie equal uue to a big opening,
foiamen ovale.
Afteiloau of fetal ventiicles:
o Rv: Low compaieu to Lv because it ejects mostly
into the low iesistance umbilical-placental
ciiculation
o Lv: Bigh compaieu to Rv because it ejects into
the high iesistance uppei bouy ciiculation

JM A*3>) H>7/2)>9 I9*7729*

A*327 67M F>3* E*73>3.(0
'0 3<* A*327
Resistance of pulmonaiy vessels is high in uteio but
uecieases piogiessively until teim
PA is constiicteu, anatomically thickei tunica meuia,
(meuial smooth muscle is exaggeiateu in smallei
aiteiies)
o Smooth muscles constiict the vessels causing
iesistance in bloou flow.
F>3* E*73>3.(0
0nly Su% of PAs associateu with iespiiatoiy
bionchioles aie masculaiizeu
PAs within the alveolai wall aie not masculaiizeu
Contain peiicytes anu inteimeuiate cells

A>/3(97 =<>3 $*+2)>3* =<* =(0* (, A*3>) I2);(0>9:
&.9/2)>3.(0
1. Nechanical effects - mechanical compiession of
alveoli that also compiesses bloou vessel />27.0+
.0/9*>7* 4)((- 6*77*) 9*7.73>0/*
2. Bistension of the lungs
S. 0xygenateu state - oxygen is a K(3*03 6>7(-.)>3(9
4. vasoactive substances

=>4)* TM vasomotoi Nechanism
&>27* H>7(/(0739./3.(0 &>27* H>7(-.)>3.(0
Physical
Beciease 02
Leukotiienes
Thiomboxane A2
N0
Inciease 02
PuI2
PuB2


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PHYSIOLOGY 3.XX: Pediatric CVS
Enuothelin A activation
Platelet ueiiveu giowth
factoi (PBuF)
Platelet activating
factoi (PAF)
AA metabolites
ET B activation

&(0-.3.(07 =<>3 &>0 &>27* %*-.>) =<./U*0.0+
- 0i inciease pulmonaiy vasculai iesistance

1. Fetal hypoxemia
2. Bypeitension (Pulmonaiy BPN auu piessuie)
S. Alteieu fetal bloou flow
4. NSAIB tieatment of mothei

In conuitions like hypoxia oi BPN that will limit bloou
flow, alteieu fetal bloou flow will cause inteimeuiate cells
oi peiicytes to tiansfoim into smooth muscle. Tunica
meuia will thicken anu compiomise the lumen of bloou
vessel in that the iauius of the vessel changes to auu
iesistance.

I*97.73*03 A*3>) &.9/2)>3.(0
$ The uevelopeu tunica meuia of fetal bloou vessels may
cause peisistent fetal ciiculation
o Peisistent fetal ciiculation - bloou is still shunteu
fiom PA to uescenuing aoita via the uuctus
aiteiiousus thus uiminishing bloou flow to the
lungs. Theie is less supply of 02.

=9>07.3.(0>) &.9/2)>3.(0

Peitains to changes in ciiculation aftei biith
Peiiou of aujustment anu piepaiation foi shifting fiom
fetal to neonatal
Piimaiy changes:
o Shift of bloou flow foi gas exchange fiom
placenta to the lungs
o Placental ciiculation uisappeais anu biief
hypoxia occuis uue to seveiing of the umbilical
choiu
o Establishment of Pulmonaiy (Seiies) Ciiculation

8M #,,*/37 (, $*;(6>) (, I)>/*03>

1. Inciease in systemic vasculai iesistance
o Result of 9*;(6>) (, 6*9: )(N 9*7.73>0/*
K)>/*03> V7<203 OW
o Slows heait iate, anu Incieases in piessuie of
aoita, LA anu Lv
2. Closuie of uuctus venosus (shunt 2) - uue to cessation
of flow to umbilical vein anu lack of bloou ietuin to
placenta

@M #,,*/37 (, F20+ #XK>07.(0

1. LA piessuie incieases uue to incieaseu Pv ietuin to the
LA
2. Functional closuie of foiamen ovale uue to incieaseu
piessuie in the LA in excess of RA piessuie
S. RA piessuie falls uue to closuie of uuctus venosus
4. Closuie of uuctus aiteiiosus uue to inciease LA
piessuie anu ueciease RA piessuie
o Also a iesult of incieaseu aiteiial 02 satuiation
o Rise in level of 02 becomes stimuli foi uuctus
aiteiiosus to constiict anu obliteiate (lumen
uisappeais anu bloou cannot flow)
S. Reuuction of pulmonaiy vasculai iesistance in lungs
o BilationNon-constiiction of intiapulmonaiy
aiteiies uue to amniotic fluiu uecieases
pulmonaiy vasculai iesistance
o Pulmonaiy bloou flow incieases uue to ueciease
in pulmonaiy vasculai iesistance in lungs
6. Lv is now iesponsible foi ueliveiing bloou into the
entiie systemic ciiculation uue to closuie of uuctus
aiteiiosus causing gieatei woik foi Lv
7. Systemic C0 incieases to almost 2uu% (~SSu
mLkgmin) since Lv now uelivei the entiie systemic
C0
8. Naikeu inciease in Lv peifoimance achieveu thiough a
combination of hoimonal anu metabolic signals
o Inciease in level of ciiculation of catecholamine
anu myocaiuial ieceptois (-auieneigic)
thiough which catecholamine have theii effect -
becomes the uominant ventiicle - iise in Lv
afteiloau

B*(0>3>) &.9/2)>3.(0

At biith, fetal ciiculation must immeuiately auapt to
extiauteiine life as gas exchange is tiansfeiieu fiom
the placenta to the lung
Beait iate slows as a iesult of a 4>9(9*/*K3(9
9*7K(07* to an inciease in systemic vasculai
iesistance when the placental ciiculation is
eliminateu

8M G.+0.,./>03 J.,,*9*0/*7 4*3N**0 B*(0>3>)
&.9/2)>3.(0 >0- 3<>3 (, 1)-*9 '0,>037

1. $.+<3Y3(Y)*,3 oi )*,3Y3(Y9.+<3 7<203.0+ may peisist
acioss the patent foiamen ovale
2. In the piesence of caiuiopulmonaiy uisease,
continueu patency of the uuctus aiteiiosus may allow
left-to-iight, iight-to-left, oi biuiiectional shunting
S. Neonatal pulmonaiy vasculatuie constiicts moie
vigoiously in iesponse to hypoxemia, hypeicapnia,
anu aciuosis
4. Wall thickness anu muscle mass of the neonatal left
anu iight ventiicles aie almost equal
S. Newboin infants at iest have ielatively high oxygen
consumption, which is associateu with ielatively high
caiuiac output

At biith:
Becieaseu pulmonaiy vasculai iesistance


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PHYSIOLOGY 3.XX: Pediatric CVS
o Bue to onset of ventilation ! intiouuction of
oxygen into the lungs
o Beciease in pulmonaiy hypoxic vasoconstiiction
o Beciease in pulmonaiy aiteiial piessuie
Incieaseu total systemic vasculai iesistance
o Bue to inteiiupteu flow to the placenta

B*N4(90 &>9-.>/ 123K23
About SSumLkgmin
Falls in the fiist 2 months of life to about
1SumLkgmin
Noie giauually to the noimal auult caiuiac output of
about 7SmLkgmin
Bigh peicentage of fetal hemoglobin piesent in the
newboin may actually inteifeie with ueliveiy of
oxygen to tissues in the neonate, so incieaseu caiuiac
output is neeueu foi auequate ueliveiy of oxygen






&(0+*0.3>) D*>93 J.7(9-*9ZJ.7*>7* V&DJW

- A heait ielateu pioblem that is piesent since biith anu
often as the heait is foiming even befoie biith
- Causes
a. uenetic factois
b. Enviionmental factois (eg. viiuses, ceitain uiugs,
iauiation, living in high altituues)
c. Rubella (ueiman Neasles)
o Contiacting iubella uuiing the fiist S months
of piegnancy has a high iisk of having a baby
with a heait uefect
u. Neuications
e. Alcohol
o Biinking alcohol uuiing piegnancy can inciease
the iisk of heait uefects anu possibly cause fetal
alcohol synuiome (FAS)
f. Cocoaine
o 0se of cocaine uuiing piegnancy incieases the iisk
of biith uefects
g. Chiomosomal uefects
o Ceitain chiomosomal uefects such as Bown
Synuiome aie associateu with CBB

G27K*/3.0+ > D*>93 I9(4)*; .0 >0 '0,>03

=(()7 >0- F>4(9>3(9: #X>;7 .0 #6>)2>3.0+ D*>93
J.7(9-*97
1. Bistoiy Physical Exam
2. Chest X-iay
S. 1S leaus ECu
4. Aiteiial Bloou uas

8M '07K*/3.(0
Note the chilu's:
ueneial appeaiance anu nutiitional state
Any obvious synuiome oi chiomosomal abnoimality
Coloi (i.e., cyanosis, palloi, jaunuice)
Clubbing
Respiiatoiy iate, uyspnea, anu ietiaction
Sweat on foieheau
Chest inspection

Check whethei:
In uistiess
Well-nouiisheu oi unueinouiisheu
Bappy oi cianky
0bese

@M I>)K>3.(0
Peiipheial pulses
Piecoiuium

I*9.K<*9>) I2)7*7
1. Count the pulse iate anu note any iiiegulaiities in the
iate anu volume
Noimal pulse iate vaiies with patient's age anu
status (youngei the patient, fastei the heait
iate)
Inciease pulse iate may inuicate excitement,
evei, CB, oi aiihythmia
o Biauychaiuia may mean heait block,
uigitalis toxicity, etc.
o Iiiegulaiity of pulse suggests
aiihythmias, but sinus aiihythmia is
noimal
2. The iight anu left aim anu an aim anu a leg shoulu be
compaieu foi the volume of the pulse
If a goou peual pulse is felt, coaictation of the
aoita (C0A) is effectively iuleu out especially if
bloou piessuie is noimal
Weak leg pulses anu stiong aim pulse suggest
C0A
S. Bounuing pulses
Aoitic iun-off lesions such as PBA, aoitic
ieguigitation (AR), laige systemic
aiteiiovenous fistula, oi peisistent tiuncus
aiteiiosus (iaie)
Nay be obseiveu in piematuie infants uue to
lack of subcutaneous tissue anu because many
have PBA
4. Weak, thieau pulses
Nay inuicate caiuiac failuie oi ciiculatoiy
shock
In leg of a patient with C0A
Aiteiial injuiies fiom pievious caiuiac
catheteiization may cause weak pulse in
affecteu limb

&<*73
1. Apical Impulse
Location anu uiffuseness shoulu be noteu
Peicussion in infants anu chiluien is inaccuiate


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PHYSIOLOGY 3.XX: Pediatric CVS
Noimally at the S
3<
.03*9/(73>) 7K>/* .0 3<*
;.-/)>6./2)>9 ).0* aftei age 7
Befoie age 7, it is founu in the R
3<
.03*9/(73>)
7K>/* 5273 )*,3 3( 3<* ;.-/)>6./2)>9 ).0*
Biplacement of an apical impulse lateially oi
uownwaiu suggest caiuiac enlaigement
0sually supeiioi to peicussion in the uetection
of caiuiomegaly
2. Point of Naximal Impulse
Belpful in ueteimining whethei the iight
ventiicle oi left ventiicle is uominant
$H -(;.0>03: impulse is maximal at the lowei
left steinal boiuei oi ovei the xiphoiu piocess
FH -(;.0>03: impulse is maximal at the apex
Newboins anu infants have Rv uominance
D*>6*: impulse is moie uiffuse anu slow iising;
often associateu with volume oveiloau
=>K: impulse is well localizeu anu shaip iising;
associateu with piessuie oveiloau
S. Bypeiactive Piecoiuium
Piesence chaiacteiizes heait uisease with
6()2;* (6*9)(>- (i.e., uefects with laige left-to-
iight shunts, seveie valvulai ieguigitation)
4. Thiills
vibiatoiy sensations that iepiesent palpable
manifestations of louu, haish muimuis.
Palpation is often of uiagnostic value
Felt bettei with the palm of the hanu than with
tips of fingeis in chest
Fingeis aie useu to feel a thiill in the
supiasteinal notch anu ovei the caiotiu aiteiies
Lesions piesent thiills at uifeient locations
o 0ppei left steinal boiuei oiiginate fiom the
pulmonaiy valve oi pulmonaiy aiteiy (PA)
anu theiefoie aie piesent in PS, PA stenosis,
oi PBA (iaiely)
o uppei iight steinal boiuei aie usually of
aoitic oiigin anu aie seen in AS
o lowei left steinal boiuei aie
chaiacteiistic of a vSB
o supiasteinal notch suggest AS but may be
founu in PS, PBA, oi C0A
o piesence of a thiill ovei the caiotiu aiteiy
oi aiteiies accompanieu by a thiill in the
supiasteinal notch suggests uiseases of
the aoita oi aoitic valve (e.g., C0A, AS). An
isolateu thiill in one of the caiotiu
aiteiies without a thiill in the
supiasteinal notch may be a caiotiu biuit
o inteicostal spaces aie founu in oluei
chiluien with seveie C0A anu extensive
inteicostal collateials)

@)((- I9*7729* %*>729*;*03
When possible, eveiy chilu shoulu have his oi hei
bloou piessuie measuieu as pait of a physical exam


A.+29* T. Noimal Bloou Piessuies

&M 827/2)3>3.(0

Bone to inspect:
Beait iate anu iegulaiity
Beait sounus
Systolic anu uiastolic sounus
Beait muimuis

A.973 D*>93 G(20-
S1 is associateu with the closuie of the mitial valve
anu tiicuspiu valves
Best heaiu at the apex oi lowei left steinal boiuei
Splitting of S1 may be founu in noimal chiluien
howevei is infiequent
Abnoimally wiue splitting of S1 may be founu in iight
bunule bianch block oi Eibstein's anomaly
Splitting of S1 vs. ejection click oi S4
o Ejection click: moie easily auuible at uppei left
steinal boiuei in PS
o S4 is iaie in chiluien

G*/(0- D*>93 G(20-
S2 is in the uppei left steinal boiuei
GK).33.0+ (, 3<* GP: two components aie A2 anu P2
Nust be evaluateu in teims of uegiee of splitting anu
intensity of the pulmonaiy closuie component of the
seconu heait sounu (P2) in ielation to the intensity of
the aoitic closuie component of S2 (A2)
Both components aie ieauily auuible with the bell
!"#$%& ()&*++*,- ". +/0 12
$ Begiee of splitting vaiies with iespiiation
o Incieasing with inspiiation
o Becieasing oi becoming single with expiiation
$ Inciease in systemic venous ietuin to the iight siue of
the heait uuiing inspiiation uue to gieatei negative
piessuie in thoiacic cavity ! incieaseu bloou volume
in Rv piolongs uuiation of Rv ejection time ! uelays
closuie of pulmonaiy valve ! wiue splitting o S2
$ Absence of splitting oi wiuely split S2 usually
inuicates abnoimality




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PHYSIOLOGY 3.XX: Pediatric CVS
A.+29* TM Splitting of Seconu Beait Sounu

34,"#$%& ()&*++*,- ". +/0 12
1. Wiuely split anu fixeu S2
! Founu in conuitions that piolong the Rv
ejection time oi shoiten Lv ejection
! Founu in ASB oi paitial anomalous pulmonaiy
venous ietuin (PAPvR) anu PS
2. Naiiowly split S2
! Founu in conuitions in which pulmonaiy valve
closes eaily oi the aoitic valve closuie is
uelayeu
! 0ccasionally founu in noimal chilu
S. Single S2
! Founu when (i) only one semilunai valve is
piesent, (ii) P2 is not auuible, (iii) aoitic
closuie is uelayeu, (iv) P2 occuis eaily
4. Paiauoxically split S2
! Founu when the aoitic closuie (A2) follows the
pulmonaiy closuie (P2) anu theiefoie is seen
when Lv ejection is gieatly uelayeu

5,+0,(*+6 ". +/0 72
$ Relative intensity of P2 with A2 must be assesseu
$ A2 is usually louuei than P2
$ A2 is the fiist component of the seconu heait sounu at
the pulmonaiy aiea
$ Incieaseu intensity of P2 is founu in pulmonaiy
hypeitension
$ Becieaseu intensity of P2 is founu in conuitions of
uecieaseu uiastolic piessuie of PA

=<.9- D*>93 G(20-
Low fiequency sounu in eaily uiastole
Relateu to iapiu filling of ventiicle
Beast heaiu at apex of lowei left steinal boiuei
Commonly heaiu in noimal chiluien anu auults
Louu SS sounu is abnoimal anu auuible in conuitions
with uilateu ventiicles anu uecieaseu ventiiculai
compliance

A.+29* TM Thiiu Beait Sounu

A(293< D*>93 G(20-Z 839.>) G(20-
S4 is a ielatively low fiequency sounu of late uiastole
(i.e., piesystole)
Raie in infants anu chiluien
When piesent, always pathologic anu is seen in
conuitions with uecieaseu ventiiculai compliance of
CB

8%&&") 9/6+/$
- A iapiu tiiple ihythm iesulting fiom the combination
of a louu SS, with oi without an S4, anu tachycaiuia
- ueneially implies a pathologic conuition anu is
commonly piesent in Congestive Beait Failuie (CBF)
- Summation gallop iepiesents tachycaiuia anu
supeiimposeu SS anu S4

:%#;*%< =>#$>#(
Innocent Nuimuis
- Noimal caiuiac tissue vibiations
- Bigh flow thiough valves
- Thin chest wall (noise fiom vasculatuie is easiei to
heai)

I*-.>39./ #&E

Electiocaiuiogiam (ECu oi EKu) is a visual iepiesentation
of the electiical conuuction of the heait
- Electiic signal tiavels fiom atiia to the ventiicles, it
can be iecoiueu on papei
- 7 ?%@0A Repiesents the electiical signal as it tiavels
thiough the atiia, the atiia contiact anu bloou is
foiceu into the ventiicles.
- [$G N>6*7L Repiesent the signal as it tiavels thiough
the ventiicles, which contiact anu bloou is foiceu into
the aiteiies.
- = N>6*L Repiesents the heait at iest piioi to the next
beat.

A.+29* TM Caiuiac Conuuction System


A.+29* T. ECu Tiacings

J.,,*9*0/* .0 8-2)3 >0- I*-.>39./ #&E
ECu ieauing foi peuiatiic patients is essentially the same
with auults except foi the ff. uiffeiences:
OM '0/9*>7*- D$
- Relative tachycaiuia; uecieases with age

PM $.+<3 H*039./2)>9 D:K*939(K<:
- Rv uominance: woik of Rv is gieatei in uteio,
caiiieu within the 1st few weeks oi months of life;
Lv becomes thickei at S mos.


2018-A
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PHYSIOLOGY 3.XX: Pediatric CVS

QM $.+<3 8X.7 J*6.>3.(0
- Newboins noimally have RAB compaieu with
auult stanuaiu
- By S yis, QRS appioaches the mean auult values of
+Su uegiees

B1=#L
T wave in v1 is expecteu to be negative but abnoimal
in auults
0piight T wave in neonates suggests Rv hypeitiophy
which can be consiueieu noimal within the 1st few
uays of life
Beait Rate
o Aveiage iate - 12u to 14u beatsmin
o Ciying anu Activity - Nay inciease to 17u+
beatsmin
o Sleeping Rates - Biops to 7u-9u beatsmin

&>)/2)>3.(0 (, D*>93 $>3* 27.0+ #&E =9>/.0+7
1. Choose the one with the iegulai occuiiing R-R
inteivals
2. Count the small squaies between R-R inteivals
S. Biviue 1Suu by the numbei of small squaies
*when the <*>93 9>3* .7 7)(N, count the laige boxes, anu
uiviue Suu by the numbei of laige boxes

=>4)* TM Beait Rates in Noimal Chiluien


$H J(;.0>0/*L
- Right axis ueviation: tall R waves in avR
- Beep S waves: vS anu v6, in the extieme left chest
leaus

=>4)* TM Noimal QRS Axes


=Y 8X.7
Beteimineu by the same methou useu in the
ueteimination of QRS
Noimal chiluien anu new boins has a T-axis of 4S"
T wave must be upiight in L1 ans avf. (P, QRS, & T
waves shoulu be upiight to have a noimal new boin
tiacing).
Inteivals shoulu also be noimal

B1=#L
*Each uuiation is shoitei in infants anu incieases with age.
*QT inteival aie expecteu to be u.4S - u. 47 in the fiist six
months of age.
*Inteipietation will always vaiy with the >+* of the chilu.
Always ask foi the age fiist.


A.+29* TM Position of Chest Leaus in Chiluien

Peuiatiic ECu has thiee extia chest leaus (vSR, v4R,
vSR).
Same location but on the opposite siue of the auult's.
1S leau ECu is uone to peuiatiic patients because of
the Rv uominance.
Rv uominance
o Right axis ueviation anuoi anteiioi QRS foices
o Tall R waves in avi anu in the iight piecoiuial
leaus
o Beep S waves in L1 anu left piecoiuial leau.

N0TE:
9:&13/- (' /6$-,); <3/-- = (' ,>* "(1), -*/6 /'6 0&*) >(0>*1
/'6 >(0>*1 4*+/$)* ,>* 1(0>, ?/@* 1*%1*)*',)A 1*"-*+,) -*",
@*',1(+-*7
9:&, )**' (' 4/4(*)7 B/-- = ?/@*) (' ,>* 1(0>, %1*+&16(/-
-*/6) /'6 %1&3('*', < ?/@*) (' ,>* -*", %1*+&16(/- -*/6
4*+/$)* ,>*)* /1* /-- 1*"-*+,(@* &" ,>* "&1+*) &" ,>* 4(00*1
1(0>, @*',1(+-*7






2018-A
EMPAMANO, ENCARNACION, ERLANO, ESPERANZA, HERNANDEZ
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PHYSIOLOGY 3.XX: Pediatric CVS
8KK*0-.X


A.+29* TM Scheme of Fetal Ciiculation (Toitoia & Beiiickson, 2uu9)





2018-A
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10OF10

PHYSIOLOGY 3.XX: Pediatric CVS

# v4R almost same level as v2.
# RAB L1 avf
# Bominant R waves in the iight piecoiuial leau
# T wave in v1 is usually negative anu upiight which suggests iight ventiiculai hypeitiophy.
o Noimal piogiession of R wave is not seen, in fact it is uecieasing in size (paliit).
# Complete ieveisal of the auult type RS piogiession
o Tall R waves in v1 anu ueep S waves in vS anu v6.
o In auults, it's the opposite: small R waves getting tallei, big S waves getting smallei)

9!' )$33/1.; B/+>.+/16(/2 =(0>, @*',1(+$-/1 >.%*1,1&%>. /'6 6*@(/,(&' () )**' /) +&3%/1*6 ,& /6$-,)C