CARDIOVASCULAR SYSTEM

DEVELOPMENT OF THE HEART

The heart begins to emerge from the mesoderm at the 3rd week of intrauterine
development. Single-layer cardiac tube is formed from two tabs of the heart. From the
inner part of the endocardial heart tube is formed endocardium, and from
mioepikardialnoy plate - myocardium and epicardium. During the 4 th week of gestation,
primary heart tube lengthens and S-shaped bends, turning in the heart of a sigmoid shape.
At its caudal far end stands a venous sinus (it flow into the large veins), is cranial extension,
which forms the atria. Part of the heart tube, curved in the form of a loop, forms a common
ventricle, narrower and rolling in the arterial trunk (cone). Narrow section of the heart
tube, located between the primary ventricle and atrium called the atrioventricular canal. In
the channel walls having pre-serdno-ventricular endocardial ridges, from which
subsequently formed two-and tricuspid valves. Since the end of 4 th to 6 th week of
gestation is a division of the heart on the right and left halves. At the cranial wall of the
atrium begins to form the primary mezhpred-serdnaya wall, which remains the primary
interatrial opening. At the 7 th week in the right atrium formed secondary mezhpred-
serdnaya partition.

Primary interatrial septum fuses with endocardial cushions, leading to the closure of the
primary hole. Simultaneously in the cranial division of the primary partitions formed
secondary hole - the oval window.

The remnants of the primary interatrial septum covering the foramen ovale in the
secondary atrial septum, form the valve distributing blood between the atria. Blood flow is
possible only in one direction - from the right atrium to the left, which is determined by the
higher pressure in the right atrium.

After the birth of a higher pressure in the left atrium tightly to each other, both walls of
the heart, they fused with each other, closing the foramen ovale and atrial septal forming
the final.

Of primary ventricular wall from top to atrial septal grows in its upper part remains
interventricular opening, the site of which later arises connective membrane.
Simultaneously, arterial trunks have two longitudinal folds that grow in the sagittal plane
towards each other, as well as down - in side of the interventricular septum. joined
together, these folds form a barrier separating the ascending part of the aorta from the
pulmonary trunk.

Since the emergence of interventricular and aortolegochnoy partitioning embryo formed a

four-heart. Valvular apparatus of the heart occurs after the formation of the partitions on
the 7 th week of prenatal development and is formed by the development of endocardial
projections.
By the 8-10-weeks ending formation of all regions of the heart, which coincides with the
formation of the placenta and the emergence of the placental circulation. Complete
separation of blood flow of right and left heart occurs only in the postnatal period.

If you violate the normal course of development of the heart may be the formation of
congenital malformations.

The most common incomplete imperforate atrial and (rarely), interventricular walls, as
well as a violation of aortolegoch-term partitioning, leading to incomplete separation of the
arterial trunk to the ascending part of the aorta and pulmonary trunk, and sometimes - a
narrowing or complete closure (atresia), pulmonary trunk.

Direct line growth aortolegochnoy partitions (instead of the normal spiral) leads to the
transposition of great vessels. In this case, the aorta moves away from the right ventricle
and pulmonary artery - from the left.

Perhaps cleft arterial duct between the aorta and pulmonary trunk.

Due to abnormal development of endocardial ridges may form defects of heart valves.

Cardiomyocytes conduction system appear simultaneously with the workers and are
located along the length of the cardiac tube. Abbreviations hearts appear on the 22 th day
of intrauterine development, first with a frequency of 15-35 per minute. By 6 th week,
heart rate increases to 112 per minute, for 8-9-th - to 165-175 per minute, and then
somewhat decreased.

A normal pregnancy fetal heart rate is very stable, but the disease can dramatically slow
down or accelerate.

In response to hypoxia in the fetus developed bradycardia, increased cardiac output

occurs and the reduction of blood vessels of the kidneys, gastrointestinal tract and skin.

FETAL CIRCULATION

In the placenta, chorionic villus capillary network merges into the umbilical vein that runs
in the umbilical cord and carrying oxygenated and nutrient-rich blood to the fetus (Figure
2-12).

The body of the fetal umbilical Vienna goes to the bottom edge of the liver and at its gate is
divided into two branches: one branch flows into the portal vein, the second - venous
(arantsiev) canal - one of the hepatic veins or inferior vena cava. Thus, the liver, serving
from the fruit body of hematopoiesis, receives the most oxygenated blood of the umbilical
vein, somewhat diluted venous blood portal vein.
In the inferior vena cava oxygen-rich blood mixes with venous blood flowing from the
lower body of the fruit, and enters the right atrium. Through the oval window atrial septal
mixed blood enters the left atrium, directs the development of the fetus valve of the inferior
vena cava (eustachian valve). From the left atrium the blood enters the left ventricle, and
then - in the aorta. The upper half of the body of the fruit

The upper hollow Vienna

Nv
Oval hole \

Lower hollow Vienna

Venous duct

Portal sine

Gate Vienna

Umbilical Vienna

Pulmonary trunk

Umbilical artery

Placenta

Hypogastric artery

- Oxygenated blood f - Neoksigenirovannaya blood

Fig. 2-12. Blood circulation of the fetus.

(including brain) supply blood to the branches of the aortic arch (common carotid and
subclavian arteries), departing from it to the confluence of the arterial duct, which provides
better oxygenation.

Blood with a high concentration of C0 2 from the upper part of the body of the fruit enters
the right atrium on the upper vena cava. Through the right atrioventricular orifice that
blood passes into the right ventricle, and then - in the pulmonary trunk. Due to the high
vascular resistance of the pulmonary circulation of the blood enters the pulmonary artery
is not easy, but in the arterial (arterial) duct and then - in the descending aorta below place
a discharge from her left subclavian artery. In the aorta of mixed blood, received from the
left ventricle, added new portions of the venous blood, then this mixed blood to the organs
and body wall of the fetus. All the organs of the fetus are mixed blood, with the more
oxygenated blood enters the liver, brain and upper limbs, less oxygenated - in the lungs and
the lower half of the body. Blood of the descending aorta in umbilical arteries back to the
capillary network of chorionic villi.

Thus, the fetal circulatory system - a vicious circle, isolated from the circulatory system
pregnant. Movement of fetal blood occurs at the expense of his heart. From 11-12-th week
of the blood circulation contribute to the respiratory movements of the fetus, as
encountered in these periods of negative pressure in the chest cavity with the lungs
neraspravivshihsya promote the flow of blood from the placenta in the right half of the
heart.

The most important features of fetal circulation:

presence of placental blood;

nonfunctioning pulmonary circulation;

blood flow in the systemic circulation, bypassing the two small right-left shunt
(communication between the left and right halves of the heart and major blood vessels);

significant excess of the minute volume of the systemic circulation (the presence of right-
left shunts), minute volume of the pulmonary (non-functioning lungs);

ensuring that all organs of the fruit mixed with blood (over-oxygenated blood to Nye in
the liver, brain and upper extremities);

almost the same (low) blood pressure in the pulmonary artery and aorta. Adaptation to
the conditions of fetal placental blood flow during

all prenatally provide the following factors:

increase in respiratory surface of the placenta;

increase in blood flow velocity;

increase the content of hemoglobin and red blood cells the fetus;

presence of HbF, having a greater affinity for oxygen;

low need for fetal tissues for oxygen.

CIRCULATION BORN

Childbirth is a significant restructuring of the circulatory system (Figure 2-13).

 Terminated placental blood circulation, providing its vessels (umbilical Vienna, venous
duct, two umbilical arteries) cease to function, gradually turning into a ligament.

Being shut down fetal holes (ductus arteriosus, the oval window).

Begin to operate pulmonary arteries and veins.

Simultaneous reduction of atrial switch to sequential.

Due to the increased oxygen demand increases cardiac output and systemic blood
pressure.

After giving birth, as its adaptation to vneutrobnym conditions of life, there are substantial
changes in blood circulation, take several hours or days.

Following an initial decline, increases the pressure in the vessels of the systemic
circulation while reducing the heart rate, due to an increase in vascular resistance after
cessation of placental circulation.

The upper hollow Vienna

Closed foramen ovale

Lower hollow Vienna

Venous ligament (obliteri-stimulated venous duct)

Round ligament of liver (obliterated umbilical Vienna)

Arterial ligament / (U obliterated ductus arteriosus)

Aorta

Gate Vienna

Navel

t - t oxygenated blood

f - Neoksigenirovannaya blood

Umbilical ligament (obliterated umbilical artery)

Fig. 2-13. Blood circulation of the newborn.

 With the beginning of pulmonary respiration bloodstream through the lungs increases by
about 5 times. No. 2: the fifth month of life 5-10 times reduced vascular resistance in the
lesser circulation. A light begins to pass the entire volume of cardiac output (in utero
period, only 10%). This increases venous return to the left of the heart and, consequently,
increased left ventricular ejection. At the same time, the pulmonary vessels of newborn
retain the ability to taper sharply in response to hypoxemia, hypercapnia or acidosis.

After the start of pulmonary respiration (in a healthy newborn to 10-15-th hour of life)
due to contraction of smooth muscles is functionally closed ductus arteriosus, and later (in
90% of children by about 2 months) is his anatomical closure. Small and large circles of
blood begin to function separately.

Closure of the arterial duct and a decrease in pulmonary vascular resistance accompanied
by a decrease in pressure in the pulmonary artery and right ventricle.

Due to redistribution of pressure in the atria fail to perform the oval window. About 3
months is its functional closure of the existing valve, valve and then grows to the edges of
the oval window. Formed an integral interatrial septum. Full closure of the oval window is
usually the end of the first year of life, but about 50% of children and 10-25% of adults in
atrial septal detect hole overlooking the thin probe, which has no significant effect on
hemodynamics.

Venous duct and umbilical vessels are overgrown by the end of 2 nd week of life.

Anatomic and physiologic features CARDIOVASCULAR SYSTEM IN

CHILDREN

Size and weight of the heart

The magnitude of the heart in the newborn is relatively greater than in adults, and is 20-24
g, ie 0,8-0,9% of body weight (adult 0,4-0,5%). The increase in heart size occurs most
intensely during the first 2 years of life, in 5-9 years and during puberty.

The mass of the heart is doubled by the end of the first year of life, tripled to 2-3 years to
6 years of increases 5-fold and 15 years' increases in 10-11 times, compared with the
newborn .

Linear dimensions of the heart to 2 years increased in 1,5 times, to 7 years - in 2 times,
and for 15-16 years - 3 times. Growth of the heart in length faster than the width: length is
doubled to 5.6 years, and the width - to 8.10 years. The volume of the heart from the
neonatal period up to 16 years of age increases in 3-3,5 times.

The right and left ventricles in neonates are approximately equal in size, their wall
thickness is about 5 mm, and the walls of the atria - about 2 mm. In a subsequent left
ventricular myocardium is growing faster than the right. Stimulators of growth of the left
ventricle are increasing vascular resistance and blood pressure. Weight of the right
ventricle in the first months of life may be reduced due to reduction of resistance in the
vessels of the lungs and the closure of the arterial duct.

By the end of the first year of life left ventricular mass in 2,5 times exceeds that of the
right ventricle, and a teenager - in 3,5 times.

By 12-14 years of left ventricular wall thickness reaches 10-12 mm, and the right to
increase only by 1-2 mm, the atria - to 1 mm.

Different departments of the heart grow unevenly: up to 2 years more intensively grow
atrium, with 2 to 10 years - all the heart in general, after 10 years of increases mainly
ventricles.

The shape of the heart

The shape of the heart in newborn spherical, due to the underdevelopment of the ventricles
and the relatively large size of the atria. Ears are large and cover the atria of the heart
foundation. The top of its rounded. Trunk blood vessels also have relatively large

in

Fig. 2-14. The boundaries of absolute and relative cardiac dullness in children of different ages: a - up
to 2 years, b - 2 to 7 years, - from 7 to 12 years. (From: Dombrovskaya YF et al. Propedeutics
childhood diseases, MA, 1953.)

The lower boundary of the heart in infants and children in the first year of life is one
intercostal gap is higher than in adults. The top of the heart in infants is projected in the
fourth left intercostal interval, outwards from sredneklyuchichnoy line and is formed by
two ventricles, and from 6 months - only the left ventricle. The upper limit of the heart in
infants is at the level of the first intercostal space, and for the first month of life falls to the
edge II. Projection of valves is higher than in adults. Printmarge heart goes
sredneklyuchichnuyu line, and the right - for the right edge of the sternum, anatomically its
axis is horizontal.

At the end of the first year of life status of the heart begins to change, and at 2-3 years is
gradually transformed into a fiber bundle, which is associated with a lowering of the
diaphragm,
size compared with the ventricles. After 6 years form the heart closer to the oval (pear),
typical of adults. The relative size of the atria decrease ventricles stretch and become more
massive.

Regulation heart

The heart of a newborn is located high and lies transversely (Figure 2-14). The projection
of the heart to the spinal column is localized between T 1V and T vm.

increase in the lungs and chest, as well as a decrease in the size of the thymus gland.
Gradually, the projection of the apex of the heart to 1,5-2 year shifts in the fifth intercostal
space, the upper limit is reduced to 2 years up to the second intercostal space, from 7 to 12
years - up III edges.

The structure of the heart

In the myocardium of the newborn Connective, including elastic, the fabric is poorly
developed. Muscle fibers are thin, and are close enough delimited from each other, contain
a large number of nuclei. Longitudinal fibrillar muscle fibers is weak, and the transverse
ischerchen-ness is virtually absent. Well developed network of blood vessels (especially
arterioles).

During the first 2 years of life occur intensive growth and differentiation of the
myocardium: increased thickness and number of muscle fibers, relatively fewer nuclei of
muscle cells, appear septal walls. After a year of becoming an express cross-striation of
muscle fibers, forming subendokardialny layer. In the period from 3 to 7-8 years at a
relatively slow growth of body weight, the final differentiation of heart tissue, to 10 years in
its histological structure is similar to that of adults.

Babies on the inner surface of the ventricles are already tra-bekuly, showing small
papillary muscles of different shapes. In children, the first year of life fleshy trabeculae
cover almost the entire inner surface of both ventricles, the worst they have developed in
adolescence.

Endocardium generally distinguished by a loose structure, relatively low content of elastic

elements. Newborns and children of all age groups atrioventricular valves are elastic, with
bright sashes. In the subsequent (to 20-25 years) leaf valves are sealed, their edges are
jagged.

Pericardium neonatal fits snugly heart, movable, as coarse-Dino-pericardial ligaments are

weak. The volume of pericardial cavity is negligible. Dome of the pericardium is high - on
the line connecting the sternoclavicular articulation. The lower boundary of the
pericardium is held at the middle of the fifth intercostal space. Only a 14-year relationship
with the pericardial organs of the mediastinum are similar to those in adults.
Cardiac conduction system

During the first six months of intense development of life and increase in diameter of
cardiac conducting myocytes (Purkinje fibers). In early childhood home of the conduction
system is located deep in the muscular part of interventricular septum (mural type), and
adolescents - in the membranous part (septal type) . The development of histological
structures and wire system of the heart ends only 14-15 years.

Action potentials in Purkinje fibers occur in children at lower values of membrane resting
potential than in adults, and repolyari-tion is much faster.

Nervous regulation of the cardiovascular system

Innervation of the heart through the superficial and deep plexus formed by fibers of the
vagus nerve and cervical sympathetic nodes in contact with the ganglia of sinus and atrial-
zheludoch-arms units in the walls of the right atrium.

In neonates persists loose type of innervation characteristic fetus: the nerve trunks and
branches are in the thick of the myocardium in the form of a large number of beams, not
forming a small wreath. With 5 years of age is further differentiation of the nervous tissue
of the heart: in the nodes there is a well-developed okolokletochny layer, formed of tiny
bundles of nerve fibers and loop end plexuses. Differentiation is mainly completed by
school age.

Babies and young children of the central regulation of cardiovascular system to a greater
extent realized through the sympathetic, to a lesser - via the vagus nerve, so the heart rate
in infants is much greater. Premature and immature children retained fetal-tion type of
reaction to hypoxia, clinically manifested by periods of apnea and bradycardia. The
prevailing role of the vagus nerve in the regulation of cardiac rhythm is established in the
later stages of development, as myelination of its branches is only 3-4 years. Under the
influence of the vagus nerve decreases heart rate, sinus arrhythmia may occur (like
breathing) and some so-called "vagal impulses "- dramatically lengthened the intervals
between heart contractions.

Such myocardial function, as automatism, excitability, conductivity, contractility and

tonicity are similar to those in adults.

Blood vessels

Newborn thin-walled blood vessels, muscle and elastic fibers in them are weak. Arteries is
relatively broad and roughly equal to the clearance of veins. In a subsequent veins grow
faster than the arteries, and by age 16, their clearance is 2 times larger than that of the
arteries. After birth, increasing the length of intra-vessels, their diameter, the number of
mezhsosudistyh anastomoses, the number of vessels per unit volume of body. Most
intensively this process takes place in the first year of life and at the age of 8-12 years. For
12 years the structure of the vessels is the same as in adults. Differentiation of arterial and
venous networks is the development of collateral vessels, occurs valvular apparatus in the
veins, increasing the number and length of the capillaries. arteries.

- The walls of the arterial bed, in contrast to venous blood, at the time of birth have three
membranes (outer, middle and internal). Peripheral resistance, blood pressure and blood
flow velocity in healthy children during the first years

life is less than in adults. With age, increasing the circumference, diameter, thickness and
length of the arteries. Thus, the area of the lumen of the ascending aorta increases from 23
mm 2 in newborns up to 107 mm 2 in 12-year-olds, which correlates with an increase in
heart size and volume of cardiac output. The thickness of the ascending aorta rapidly
increased to 13 years.

-- Change the level of a discharge of certain branches of the great arteries and type of
branching. In newborns and children from a discharge of the great arteries are located
proximally, and angles at which these vessels departed, more than adults.

-- Changing the radius of curvature of the arcs formed vessels. Thus, newborns and
children under 12 years of aortic arch has a larger radius of curvature than in adults.

-- With age, there is a partial change in the topography of the vessels. In particular, the
older the child, the lower is aortic arch: in newborns is higher than the T, and for 17-20
years - at the level of T ".

Vienna. With age, increasing the diameter of veins and their length. After birth, changing
the topography of the surface veins of the body and limbs. Babies are well-developed thick
subcutaneous venous plexus against the background of large veins are not konturiruyutsya.
They clearly stand out only to 1-2 years of life.

Capillaries in children are broad, irregularly shaped (short and convoluted), their
permeability is higher than in adults, but the absolute number is lower.

The growth rate of major vessels in comparison with the heart more slowly. Thus, if the
volume of the heart to 15 years increased by 7 times, then the circumference of the aorta -
only 3 times. Over the years, somewhat reduced the difference in the size of the lumen of
the pulmonary artery and aorta. The birth of the width of the aorta is 16 mm, pulmonary
artery - 21 mm to 10.12 years compared to the lumen, while adult aorta has a larger
diameter.

The arteries and veins of the lungs most intensively developed during the first year of life,
due to the emergence of respiratory function and obliteration of the arterial duct. In
children, the first weeks and months of life, muscle layer of pulmonary vessels less
pronounced than that due to the lower response of children to hypoxia. Significant
strengthening of the development of pulmonary vascular mark and during puberty.

Coronary vessels. The peculiarity of the coronary system in children - an abundance of

anastomoses between the left and right coronary artery. Newborn to four muscle fibers
have a single tube, and by age 15 - 1 capillary for 2 fiber. Coronary vessels of up to 2 years
divided by type of loose, then - according to a mixed, and by 6.10 years formed the trunk
type. The most intensive growth capacity of coronary vessels occurs in the first year of life
and in puberty. Abundant vascularization and loose cellular tissue surrounding the vessels,
creating a predisposition to the inflammatory and dystrophic changes of the myocardium
in children.

Arteries supplying the brain, the most intensively developed until 3 to 4 years of age, the
rate of growth superior to other vessels.

Functional features of the cardiovascular system

To characterize the functions of the cardiovascular system using the following key
indicators.

The heart rate (HR). The younger the child, the higher his heart rate (compared with
adults; Table. 2-7) due to enhanced metabolism and predominance of sympathetic
influences on the heart. The age reduction in heart rate occurs with increasing the volume
of cells, heart stroke volume and influence of the parasympathetic division of the
autonomic nervous system on cardiac activity. Heart rate range (the difference between the
upper and lower boundaries of the norm) at an early age is considerably less than in older
children. With age, the range increases. In boys, heart rate is slightly lower than in girls. In
children, more labile heart rate increases when changing body position, crying, increased
body temperature and the impact of Dru-Table 2-7. The heart rate other factors.
Children Children ages characterized respiratory arrhythmia (an increase in heart rate on
inspiration and decrease on expiration). In children older than 15 years of respiratory
arrhythmia observed less frequently.

AD depends on sex, age, biological maturity, the value of shock and cardiac output,
peripheral vascular resistance and elasticity, CBV, blood viscosity and other indicators.

- The average blood pressure when measured at the radial artery are shown in Table 2-
8. The feet, these figures of 10-15 mmHg above. In healthy children blood pressure in the
arteries of left and right limbs is not significantly different.

Table 2-8. Blood pressure in children depending on age

Age Heart rate, per minute

Period
newborn 140-160
1 year 120
5 years 100
10 years 80-85
15 70-80
Age Systolic blood pressure, mmHg * Diastolic blood pressure, mmHg *

Newborn 60 Is 1 / 2 or 2 / 3
1 year 80-84 SBP
5 years 100
10 years 110
15 120

* In girls, blood pressure by 5 mmHg lower than that of boys.

-- To determine the blood pressure in children over the year, you can use the following
formulas:

And this AD, = 90 + 2n (mm Hg) blood pressure = 60 + 2n (mm Hg)

where: n - age in years.

-- Pulse pressure (difference between systolic and diastolic blood pressure) proportional to
the amount of blood ejected with each heart systole. With age, pulse pressure increases: the
newborn is an average of 42 mm Hg in children aged 5-6 years - 44 mm mmHg, in 14-15
years - 52 mmHg

Sound and bioelectrical characteristics of cardiac activity (see below).

Blood volume (CBV). BCC has the largest relative value of the newborn (147 ml / kg body
weight), then the rate decreases. During puberty BCC increases again.

Venous pressure (especially central - CVP). CVP in children normally ranges from 70 to
120 mm water column (3-8 mm Hg). With age, it gradually decreases and the
schoolchildren of 60-100 mm water column

Rate of blood flow in children is higher than in adults. With age, it gradually decreases,
due to the lengthening of the vascular bed and reduction of heart rate.

Stroke and minute volumes of blood as the child grows increasing: during the first year of
the stroke volume of blood increases by 4 times, to 7 years
-- 10 times, to 15 years - 24 times.

Total peripheral vascular resistance decreases with age.

MATERIALS AND METHODS OF CARDIOVASCULAR SYSTEM Inquiries

When questions first of all find out the complaints of the patient, the time of their
appearance and triggers. The main complaint characteristic pathology of the
cardiovascular system, as follows.

Weakness and fatigue during physical exertion.

Shortness of breath (disturbance frequency, rhythm and depth of breathing, subjective

feeling of lack of air) during physical exertion or even at rest.

Cyanosis of lips, nails, a common skin cyanosis at rest or during physical exertion.

Edema of legs, waist, face.

Feeling the heartbeat (the patient feels the blows of his heart).

Fainting.

Pain in the heart (in older children). In this case it is necessary to clarify their localization,
time and frequency of occurrence, duration, intensity, irradiation, trigger factors, the
nature of pain, reaction to medications and other effects.

You may experience intermittent claudication (pain in the muscles of the legs, occurring
during physical exertion and disappearing at rest), indicating a chronic insufficiency of
blood circulation of the lower extremities.

The patient and his parents need to specify how often the child suffered from SARS (and
bronchopulmonary infections in general) and quinsy, whether in the family sick with
rheumatism, heart diseases and other diseases of the cardiovascular system. It is also
necessary to determine whether the child does not lag behind in physical development of
their peers.

Inspection

General examination. Evaluate the clarity of consciousness, severity of condition and

position of the patient. On the severity of the patient can be judged by blood pressure,
presence of dyspnea, cyanosis, edema visible.

Situation in heart failure patients can be stimulated.

-- In severe heart failure patients usually feel better in bed with high headboard, prefers to
lie on the right side.

-- When pronounced heart failure patient takes Half-upright position or sitting with
lowered legs (ortopnoe; in this position dyspnea decreases).

-- In acute coronary insufficiency patients usually lie, prefer a low pillow, and try to move
less.

Shortness of breath can manifest an increase in NPV (tachypnea) and the participation of
auxiliary muscles. Shortness of breath with heart disease usually expiratory or mixed,
amplified in a prone position and weakened when the patient sits up. Dyspnea paroxysmal
and may be accompanied by cyanosis. Often it occurs in chronic levozhelu-dochkovoy
failure (cardiac asthma attack).

Pallor and cyanosis (cyanotic hue of the skin and mucous membranes) due to slowdown
in peripheral blood flow and increase the number of reduced hemoglobin in small blood
vessels of various divisions of the body. Cyanosis may be localized around the mouth
(perioral cyanosis), at the ends of the fingers and toes, tip of the nose and cheeks, lips, tip of
your tongue or ears (acrocyanosis) or to be more common, until the total. Tint color of skin
and mucous membranes may be pale blue, blue, cherry red, etc. Cyanosis may occur during
physical exertion or remain constant.

Pulsation of blood vessels in the neck of a healthy child in an upright position is usually
not visible at all or only slightly visible. Pathology outwards from the sternoclavicular-
mastoid muscle can see the swelling and pulsating jugular veins, it is also possible to
identify abnormal pulsation in the epigastric, epigastrium and right hypochondrium.

Pastoznost tissue or edema - signs of right ventricular heart failure. First edema appear
on the feet and shins, reinforced by the evening and the morning disappear
(decrease).Then, if the edematous syndrome increases, swelling can occur on the torso,
back, face, genitals (boys) and in body cavities (peritoneal, pleural). Cardiac edema move
under the influence of gravity and are more pronounced on the side of the body, which is
sick.

"Drum" (clubbing of the fingers, sometimes the feet) and the "hour glass" (spherical
shape of the nails) may be signs of chronic pathology of the respiratory or cardio-vascular
system.

Precapillary pulse detected in aortic insufficiency. With slight pressure at the end of the
nail so that the middle of his left a small white spot, it is noticeable that sync with the pulse
spot expands, and then narrows. When viewed from the oral cavity in such patients can see
the rhythmic alternation of pallor and a normal pink mucosa.
 Build patient sometimes can get some information. For example, the disproportion of the
upper and lower halves of the body ( "athletic" shoulder girdle with under-developed legs)
suggests the presence of coarctation of the aorta.

Examination of the heart. On examination of the heart can determine the localization of
the apical impulse. You can also identify visible cardiac impulse and the "heart hump".

The apical impulse - ripple caused by a blow on the top of the heart anterior chest wall,
visible on the front of the chest wall within the same intercostal space inwards from the
anterior axillary line (children under 2 years old - in the fourth, but in older children - in
the fifth intercostal space ). In pathological states, apical impulse can be displaced both in
vertical and horizontal direction.

Cardiac impulse - diffuse pulsation of the heart that occurs only in pathological conditions
(primarily in right ventricular hypertrophy). At various diseases can be seen pulsating in
the second and third intercostal space on the left and right of the sternum, as well as in her
arms.

Cardiac hump - the deformation of the ribs in the form of a uniform protrusion of the
heart. There is increased pressure due to the long regions of the heart on the front wall of
the chest.

Flatness intercostal gaps can occur in severe swampy pericarditis.

Examination of the blood vessels. On examination of peripheral arteries can reveal signs
of circulation (decrease in skin temperature of limbs, her pallor or cyanotic) and trophic
system tissue (the deterioration of the growth of nails and hair, thinning of the skin and
subcutaneous fatty tissue).

Violation of blood flow in large veins is rapidly developing collateral circulation, with
collateral veins can sometimes be found under the skin (eg, occlusion of superior vena cava
- in front of the chest wall, occlusion of the inferior vena cava - the lower abdomen). The
increase in the shin and edema may be signs of deep vein thrombosis leg.

Measuring blood pressure

Blood pressure - the pressure of blood on the walls of the arteries.

Systolic blood pressure - the maximum pressure in the arteries during systole of the left
ventricle due to heart stroke volume and elasticity of the aorta and major arteries.

Diastolic blood pressure - minimum pressure during diastole of the heart, depending on
the tone of the peripheral arterioles.
 Pulse blood pressure - the difference between systolic and diastolic blood pressure. To
measure blood pressure on the hands and feet using cuffs, age-appropriate and shoulder
and thigh circumference of the child. In healthy children blood pressure in the arteries of
left and right limbs is not significantly different, and the difference of blood pressure on the
hands and feet is 15-20 mmHg

Functional features of the cardiovascular system

To characterize the functions of the cardiovascular system using the following key
indicators.

The heart rate (HR). The younger the child, the higher his heart rate (compared with
adults; Table. 2-7) due to enhanced metabolism and predominance of sympathetic
influences on the heart. The age reduction in heart rate occurs with increasing the volume
of cells, heart stroke volume and influence of the parasympathetic division of the
autonomic nervous system on cardiac activity. Heart rate range (the difference between the
upper and lower boundaries of the norm) at an early age is considerably less than in older
children. With age, the range increases. In boys, heart rate is slightly lower than in girls. In
children, more labile heart rate increases when changing body position, crying, increased
body temperature and the impact of Dru-Table 2-7. The heart rate other factors.
Children Children ages characterized respiratory arrhythmia (an increase in heart rate on
inspiration and decrease on expiration). In children older than 15 years of respiratory
arrhythmia observed less frequently.

AD depends on sex, age, biological maturity, the value of shock and cardiac output,
peripheral vascular resistance and elasticity, CBV, blood viscosity and other indicators.

- The average blood pressure when measured at the radial artery are shown in Table 2-
8. The feet, these figures of 10-15 mmHg above. In healthy children blood pressure in the
arteries of left and right limbs is not significantly different.

Table 2-8. Blood pressure in children depending on age

Age Heart rate, per minute

Period
newborn 140-160
1 year 120
5 years 100
10 years 80-85
15 70-80
Age Systolic blood pressure, mmHg * Diastolic blood pressure, mmHg *

Newborn 60 Is 1 / 2 or 2 / 3
1 year 80-84 SBP
5 years 100
10 years 110
15 120

* In girls, blood pressure by 5 mmHg lower than that of boys.

-- To determine the blood pressure in children over the year, you can use the following
formulas:

And this AD, = 90 + 2n (mm Hg) blood pressure = 60 + 2n (mm Hg)

where: n - age in years.

-- Pulse pressure (difference between systolic and diastolic blood pressure) proportional to
the amount of blood ejected with each heart systole. With age, pulse pressure increases: the
newborn is an average of 42 mm Hg in children aged 5-6 years - 44 mm mmHg, in 14-15
years - 52 mmHg

Sound and bioelectrical characteristics of cardiac activity (see below).

Blood volume (CBV). BCC has the largest relative value of the newborn (147 ml / kg body
weight), then the rate decreases. During puberty BCC increases again.

Venous pressure (especially central - CVP). CVP in children normally ranges from 70 to
120 mm water column (3-8 mm Hg). With age, it gradually decreases and the
schoolchildren of 60-100 mm water column

Rate of blood flow in children is higher than in adults. With age, it gradually decreases,
due to the lengthening of the vascular bed and reduction of heart rate.

Stroke and minute volumes of blood as the child grows increasing: during the first year of
the stroke volume of blood increases by 4 times, to 7 years

-- 10 times, to 15 years - 24 times.

Total peripheral vascular resistance decreases with age.

MATERIALS AND METHODS OF CARDIOVASCULAR SYSTEM Inquiries

When questions first of all find out the complaints of the patient, the time of their
appearance and triggers. The main complaint characteristic pathology of the
cardiovascular system, as follows.
 Weakness and fatigue during physical exertion.

Shortness of breath (disturbance frequency, rhythm and depth of breathing, subjective

feeling of lack of air) during physical exertion or even at rest.

Cyanosis of lips, nails, a common skin cyanosis at rest or during physical exertion.

Edema of legs, waist, face.

Feeling the heartbeat (the patient feels the blows of his heart).

Fainting.

Pain in the heart (in older children). In this case it is necessary to clarify their localization,
time and frequency of occurrence, duration, intensity, irradiation, trigger factors, the
nature of pain, reaction to medications and other effects.

You may experience intermittent claudication (pain in the muscles of the legs, occurring
during physical exertion and disappearing at rest), indicating a chronic insufficiency of
blood circulation of the lower extremities.

The patient and his parents need to specify how often the child suffered from SARS (and
bronchopulmonary infections in general) and quinsy, whether in the family sick with
rheumatism, heart diseases and other diseases of the cardiovascular system. It is also
necessary to determine whether the child does not lag behind in physical development of
their peers.

Inspection

General examination. Evaluate the clarity of consciousness, severity of condition and

position of the patient. On the severity of the patient can be judged by blood pressure,
presence of dyspnea, cyanosis, edema visible.

Situation in heart failure patients can be stimulated.

-- In severe heart failure patients usually feel better in bed with high headboard, prefers to
lie on the right side.

-- When pronounced heart failure patient takes Half-upright position or sitting with
lowered legs (ortopnoe; in this position dyspnea decreases).

-- In acute coronary insufficiency patients usually lie, prefer a low pillow, and try to move
less.
 Shortness of breath can manifest an increase in NPV (tachypnea) and the participation of
auxiliary muscles. Shortness of breath with heart disease usually expiratory or mixed,
amplified in a prone position and weakened when the patient sits up. Dyspnea paroxysmal
and may be accompanied by cyanosis. Often it occurs in chronic levozhelu-dochkovoy
failure (cardiac asthma attack).

Pallor and cyanosis (cyanotic hue of the skin and mucous membranes) due to slowdown
in peripheral blood flow and increase the number of reduced hemoglobin in small blood
vessels of various divisions of the body. Cyanosis may be localized around the mouth
(perioral cyanosis), at the ends of the fingers and toes, tip of the nose and cheeks, lips, tip of
your tongue or ears (acrocyanosis) or to be more common, until the total. Tint color of skin
and mucous membranes may be pale blue, blue, cherry red, etc. Cyanosis may occur during
physical exertion or remain constant.

Pulsation of blood vessels in the neck of a healthy child in an upright position is usually
not visible at all or only slightly visible. Pathology outwards from the sternoclavicular-
mastoid muscle can see the swelling and pulsating jugular veins, it is also possible to
identify abnormal pulsation in the epigastric, epigastrium and right hypochondrium.

Pastoznost tissue or edema - signs of right ventricular heart failure. First edema appear
on the feet and shins, reinforced by the evening and the morning disappear
(decrease).Then, if the edematous syndrome increases, swelling can occur on the torso,
back, face, genitals (boys) and in body cavities (peritoneal, pleural). Cardiac edema move
under the influence of gravity and are more pronounced on the side of the body, which is
sick.

"Drum" (clubbing of the fingers, sometimes the feet) and the "hour glass" (spherical
shape of the nails) may be signs of chronic pathology of the respiratory or cardio-vascular
system.

Precapillary pulse detected in aortic insufficiency. With slight pressure at the end of the
nail so that the middle of his left a small white spot, it is noticeable that sync with the pulse
spot expands, and then narrows. When viewed from the oral cavity in such patients can see
the rhythmic alternation of pallor and a normal pink mucosa.

Build patient sometimes can get some information. For example, the disproportion of the
upper and lower halves of the body ( "athletic" shoulder girdle with under-developed legs)
suggests the presence of coarctation of the aorta.

Examination of the heart. On examination of the heart can determine the localization of
the apical impulse. You can also identify visible cardiac impulse and the "heart hump".

The apical impulse - ripple caused by a blow on the top of the heart anterior chest wall,
visible on the front of the chest wall within the same intercostal space inwards from the
anterior axillary line (children under 2 years old - in the fourth, but in older children - in
the fifth intercostal space ). In pathological states, apical impulse can be displaced both in
vertical and horizontal direction.

Cardiac impulse - diffuse pulsation of the heart that occurs only in pathological conditions
(primarily in right ventricular hypertrophy). At various diseases can be seen pulsating in
the second and third intercostal space on the left and right of the sternum, as well as in her
arms.

Cardiac hump - the deformation of the ribs in the form of a uniform protrusion of the
heart. There is increased pressure due to the long regions of the heart on the front wall of
the chest.

Flatness intercostal gaps can occur in severe swampy pericarditis.

Examination of the blood vessels. On examination of peripheral arteries can reveal signs
of circulation (decrease in skin temperature of limbs, her pallor or cyanotic) and trophic
system tissue (the deterioration of the growth of nails and hair, thinning of the skin and
subcutaneous fatty tissue).

Violation of blood flow in large veins is rapidly developing collateral circulation, with
collateral veins can sometimes be found under the skin (eg, occlusion of superior vena cava
- in front of the chest wall, occlusion of the inferior vena cava - the lower abdomen). The
increase in the shin and edema may be signs of deep vein thrombosis leg.

Measuring blood pressure

Blood pressure - the pressure of blood on the walls of the arteries.

Systolic blood pressure - the maximum pressure in the arteries during systole of the left
ventricle due to heart stroke volume and elasticity of the aorta and major arteries.

Diastolic blood pressure - minimum pressure during diastole of the heart, depending on
the tone of the peripheral arterioles.

Pulse blood pressure - the difference between systolic and diastolic blood pressure. To
measure blood pressure on the hands and feet using cuffs, age-appropriate and shoulder
and thigh circumference of the child. In healthy children blood pressure in the arteries of
left and right limbs is not significantly different, and the difference of blood pressure on the
hands and feet is 15-20 mmHg

Palpation
On palpation of the heart, first determine the apical impulse. If the tip of the heart is under
the edge, to study the apical impulse to turn the child on his side. The apical impulse is not
possible to determine with swampy pericarditis and severe myocarditis. Evaluate the
localization, size, height and strength of the apical impulse.

In normal situation the apical impulse in children under 2 years - the fourth inter-edges
outwards from sredneklyuchichnoy line, from 2 to 7 years - the fifth interregional Berryer
sredneklyuchichnoy outwards from the line, after 7 years - the fifth mezhrebe-Phe on
sredneklyuchichnoy line or medially from her .

If the area of the apical impulse is less than 1,5-2 cm 2, it is called limited if the area is
greater than 2 cm 2, the apical impulse believe diffused. Children apical impulse may be to
admit diffused if it is palpable in two or more intercostal space.

Height (value), determined by the amplitude of vibration of the chest. The height of apical
impulse may be moderate (normal), high and low.

Strength (resistance) - the resistance that is felt with your fingers, preventing the
push. Temperate (normal), high resistance and weakened apical impulse. The height of the
apical impulse is increased when excited child. Note that the height and strength of the
apical impulse depends on the degree of development of subcutaneous tissue and muscles
of the chest.

Cardiac impulse is felt throughout the palm of his hand shaking as part of the chest over the
area of absolute stupidity of the heart.

Systolic or diastolic anterior chest wall vibration of (cat purring), identifiable by palpation
of the heart in some patients due to the transfer of vibrations arising in the turbulent
stream of blood through the change of valve opening [or pathological reports, such as
ventricular septal defect (DMZHP), outdoor ductus arteriosus].

Epigastric pulsation is easier to identify at an altitude of deep breaths. In healthy children

often define a small "transfer" pulse from the abdominal aorta. In the epigastric region can
be defined and enhanced diffuse pulsation enlarged right ventricle, and liver.

Palpation of major vessels including the possible identification of systolic and pulse jitter in
the base of the heart, the ascending aorta above the second intercostal space to the right of
the sternum and above the aortic arch in the jugular cutting and over the trunk of the
pulmonary artery in the second intercostal space left of sternum. Normally weak pulse
determined only in the jugular notch.

Palpation of peripheral arteries. Palpation of peripheral arteries evaluate pulse. Arterial

pulse - periodic oscillations tolchkoobraznye walls of peripheral vessels that are
synchronized with the systole of the ventricles of the heart. Reducing fluctuations in the
peripheral blood vessels constitutes a violation of their blood. Explore the pulse of
radiation, sleeping (at the inner edge of the sternoclavicular-mastoid muscle at the upper
edge of the thyroid cartilage), temporal (in the temporal fossa), femur (at the mid-crural
arch ), knee (in the popliteal fossa), posterior tibial (for inner ankle) arteries, the arteries of
the rear foot (on the border of the distal and middle thirds of the rear foot). Pulse overtures
on both hands and feet, and compare. In the femoral artery pulse is usually stronger than
on the hands, but in infants on their feet in a normal pulse is weaker. In children older than
2 years of the main characteristics of the pulse to determine the radial artery. Estimated
frequency, rhythm, stress, content, size and shape of the pulse.

Counting the pulse rate hold for 1 min. You must compare the heart rate to heart rate
according to auscultation. Since the pulse rate in children during the day varies, it can be
more objectively assess the morning immediately after waking up the child (before the
transition to a vertical state and fasting). This pulse is called basal. In healthy children, the
pulse rate corresponds to heart rate. Pulse deficit - a condition in which not all the pulse
wave reaches the radial artery (eg, atrial fibrillation). The tolerance of the pulse rate from
the age norm for no more than 10-15%, with a pulse of a rare show of bradycardia, while
quickening -- of tachycardia.

The rhythm of the pulse can be right or wrong. In a normal heart rate in children may be
very labile (respiratory arrhythmia). Arrhythmia best expressed in the age of 4-12 years
and most often associated with breathing (exhale on the pulse becomes more
rare). Respiratory arrhythmia disappears when holding the breath. At an early age to one
breathing movement have 3-3,5, a senior - 4 of cardiac contraction.

Voltage is characterized by the pressure required to interrupt the pulse wave in

peripheral vessels. Normally, the voltage pulse is moderate. If you change the
characteristics of the possible voltage

Table 2-9. The boundaries of the relative cardiac dullness with percussion

Border Age groups

2-7 years 7-12
Up to 2 years
Upper II The right edge Second intercostal space III rib
Right inwards from the right
parasternal line parasternal line Beyond the right edge of the sternum is
Left not more than 1 cm by
At 1,5-2 cm outwards At 0,5-1,5 cm outwards from sredneklyuchichnoy line or 0,5-1 cm
from sredneklyuchichnoy sredneklyuchichnoy line medially from her
line

Dull percussion tones define the front surface of the portion of the heart, not covered by
light. This region is called ACD.
 In order to measure the transverse size of the heart, determine the distance from the left
and right borders of the relative dullness of the heart to the front

zhenny hard or soft lax pulse. judged by the degree of stress on blood pressure and tone of
the arterial wall.

Filling evaluated by comparing the volume of the artery against its full-passing
PRINCIPLES FOR GOOD GOVERNANCE and restoring blood flow in it (distinguish full and
empty heart rate). The degree of filling depends on the systolic ejection, the total number
of blood and its distribution.

The quantity - a characteristic determined on the basis of overall evaluation of voltage

and filling. The value of pulse amplitude is proportional to the AD. Expending large and
small pulse.

The form is characterized by fast rise and fall of pressure inside the artery. Excrete fast
and slow pulse.

Percussion

For percussion of the heart determine its size, configuration and location, as well as the
width of vascular bundle. Children older than 4 years of percussion of the heart carried out
the same way as adults. In infants with direct percussion percussing use only one finger,
while indirect percussion finger-plessimeter impose only one terminal phalanx. Percussion
should be quiet.

Region corresponding to the topographical boundaries of the heart, called the relative
cardiac dullness (Table 2-9), as part of the front surface of the heart, covered by light, with
the percussion makes dull percussion tone. Borders of the heart mark on the outer edge of
the finger-plessimeter facing the clearer sound. The right border of the relative dullness of
the heart is formed by the right atrium, the upper - the cone of the pulmonary artery and
the eye of the left atrium, the left - the left ventricle.

median line (in adults, they are 3-4 and 8-9 cm) and summarize them (adult transverse size
of about 11-13 cm).

Determine the configuration of the heart, connecting the points corresponding to the
borders of the relative dullness of the heart (to further define the limits of the relative
dullness of the third intercostal space on the right, as well as in the third and fourth
intercostal space on the left). Normally the left between the vascular bundle and the left
ventricle is determined by the obtuse angle - "the waist of the heart.
 The width of the vascular bundle defined in the second intercostal space in the
percussion of the right and left toward the chest (normal beam does not go beyond the
breast). In adults, the width is 5-6 cm

Auscultation

Auscultation of the heart should be carried out in different positions of the patient, in
the first place - when the patient lies on his back, on the left side, sitting or standing. In
addition, comparing data auscultation of the heart during normal breathing of the patient,
against the backdrop of breath-holding (to inhale or exhale), before and after physical
exertion.Points of the best listening to the sound of phenomena arising in the field of heart
valve, does not quite coincide with the projection of the valve seats on the front chest wall.
Classic auscultation points in Fig. 2-15.

Fig. 2-15. Classic seats listening to heart tones: 1 - a point of listening to the aortic valve (second
intercostal space to the right of the sternum), 2 - a point of listening to the valve of pulmonary trunk
(second intercostal space left of the sternum), 3 - point Botkin-Erba, an additional point of listening to
diastolic noise with aortic valve insufficiency (third left intercostal space at the sternum), 4 - a point of
listening to the mitral valve (the tip of the heart, usually the fifth intercostal space to 1-1,5 cm
inwards from the left sredneklyuchichnoy line), 5 - a point of listening to tricuspid valve (the lower
third of sternum ).

5-3029

Cardiac. Over the whole area of the heart in healthy children can listen to two tones. If you
need to identify auscultation of the heart tones, to evaluate their tone and integrity of
sound, correct heart rhythm, the ratio of volume I and II tones. I listen to the tone after a
long pause. It coincides with the apical impulse and the carotid pulse. II listen to the tone
after a short pause. The interval between I and II tones corresponds to systole (in adults it
is usually 2 times shorter diastole).

I (systolic) tone occurs in the phase of isometric contraction of the ventricles after
slamming atrioventricular valves. There are three components which determine its
appearance:

-- valve (swing tricuspid and mitral valves due to their closure);

-- muscle (myocardium ventricles fluctuation during their reduction);

-- vascular (primary vibration aorta and pulmonary trunk in the early phase of blood
ejection).
 II (diastolic) tone occurs early in ventricular diastole. It is caused by slamming aortic and
pulmonary artery and its fluctuation along the walls of the primary divisions of these
vessels. There are two component tones II: aortic and pulmonary.

Loudness of tones depends on several parameters:

the volume of tone I - from a sealed chamber at the time of ventricular contraction, the
rate of contraction of the ventricles (as determined by the contractile ability of the
myocardium and systolic ventricular volume), density of the atrioventricular valves and
the position of their wings before reduction;

volume II tone - the density of the closing valves of the aorta and pulmonary artery, the
rate of closure and oscillations in protodiastolic period, the density of the valves and walls
of major vessels and valves of valve before protodiastolic period.

In children the first days of life, observe the physiological weakening of the heart tones,
further cardiac sounds in children is a greater sonority and clarity than in adults.
Moderately weakened called muted tones, a sharp decrease - the deaf.

I and II tones differ in sonority. Value sonority tones with age changes.

In adults, on top of the best I could hear the tone, but on the basis of the heart, valves of
the aorta and pulmonary artery, - II tone.

Newborn during the first 2-3 days at the top and at the point-to-oping Erba II tone louder
than I, later they are aligned with the sonority, and with 3 months I tone prevails.

Based on the heart in the newborn period is better heard II tone, and then compared the
sound of tones, and with 1,5 years again prevails II tone.

From 2 to 12 years II tone in the second intercostal space left listens better than the right,
ie accent II has a physiological tone of the pulmonary artery.

For 12 years compared to the sound of tones, and then II tone better auscultated on the
right (above the aorta).

Children 6-7 years at the pulmonary artery often determine the tone accent II. It is due to
relatively higher pressure in the pulmonary artery.

Sometimes when auscultation can detect that the heart tones auscultated in the form of
two sounds, that is regarded as splitting (splitting) of the main tones. Sometimes children
can hear additional tones III and IV.
 III due to fluctuations in muscle tone of the ventricles when they are fast filling with blood
in early diastole. Pacific III tone can hear the children in the apex of the heart, he has a soft,
muffled tone.

IV tone occurs before I voice at the end of ventricular diastole and is associated with their
rapid filling due to atrial contractions. This rare phenomenon can be found in healthy
children and adolescents in a very quiet sound.

In the presence of III and / or IV tone formed a three-link rhythm - "gallop rhythm".

Rhythm of heart tones (correct heart rhythm) is determined by the uniformity of diastolic
pauses. Embryocardia - mayatnikoob-a different rhythm, in which the volume I and II of
the same colors and equal intervals between the tones. During the first 2 weeks of life
embryocardia believe are normal (cause pathological embryocardia see below in the
section "Semiotics of lesions of the cardiovascular system").

Noises heart. In addition to the tones in the auscultation of the heart and large vessels can
be heard more sounds of longer duration - noise. Noises often listen to the children (even
perfectly healthy). There are two groups of noise: intracardiac and exocardial. Vnutriser-
dechnye noises are divided into organic, due to the presence of anatomical characteristics
of valve openings or walls of the heart, and functionality that are the basis for dysfunction
of valves, acceleration of blood flow through the holes unchanged or decrease in blood
viscosity.

If you notice the noise should define the following parameters.

Phase of the cardiac cycle, during which the audible noise.

-- Systolic noises occur in the heart and major blood vessels in the phase of contraction
(systole) and listen between the I and II tones.

-- Diastolic sounds occur in diastole phase and listen during a long pause between the I and
II tones.

-- Systolic and diastolic sounds arise from violations of laminar blood flow and its
transformation into a turbulent due to various reasons.

-- Detection of a single point in both systolic and diastole-ic noise indicates a combined
heart disease (insufficiency listen at this point the valve and stenosis of the corresponding
holes).

-- Revealing at one point organic systolic murmurs, and in the other - indicates diastolic
heart disease combined (simultaneous destruction of two different valves).
-- When fibrinous pericarditis noise over the area of the heart may not be associated with
any phase of the cardiac cycle, such noise is called the pericardial friction noise.

Duration of noise (short or long) and its position relative to the phases of the cardiac
cycle (early systolic, late systolic, pansistolichesky, protodiastolic, mezodiastoliches-cue
presistolichesky, pandiastolichesky);

Loudness (intensity), noise (loud or quiet) and its variation depending on the phase of the
cardiac cycle (descending, rising, monotonic, etc.).

-- The volume of noise depends on the speed of blood flow and conditions of the sound on
the chest wall. The loudest noises listen with small defects with preserved contractile
capacity of myocardium in children with poorly expressed subcutaneous adipose tissue.

-- The intensity of the noise depends on the magnitude of stroke volume: what it is, the
stronger the noise.

The timbre of sound: rough, harsh, blowing, delicate, soft, music, scrapes, etc.

Localization of noise - the point (punctum maximum) or a zone of its maximum

audibility.

The direction of the noise (the left armpit area, carotid or subclavian artery,
interscapulum, etc.).

Variability of noise depending on changes in body position, physical activity, the phase of
respiration.

Evaluation of these parameters makes it possible to interpret the noise as a functional or

organic, and suggest the probable cause of its occurrence.

Organic noises occur in congenital or acquired heart diseases, inflammation of the

endocardium and pericardium, lesions of the myocardium. Noises associated with changes
of heart valves in their inflammatory edema or erozirovanii, listen, in the projection zone of
the affected valves.

Functional noise characteristic of childhood. Usually functional systolic sounds are, they
are short-lived, rarely occupy the entire systole, usually heard in mid-systole. It sounds
more functional noise soft, tender, can have "musical" tone, heard in limited areas and are
not carried out far from the maximum listening. They are not consistent, vary depending
on body position (better listen, in a prone position), the phase of respiration, physical
activity (changing the intensity and timbre) are not accompanied by changes in I and II
tones, the appearance of additional tones, the expansion of the heart, and signs of
circulatory failure [in Mitral valve prolapse (MVP) can be determined by the systolic
click]. The emergence of functional noise may be due to various reasons.

-- At the heart of the dynamic noise is a significant increase in blood flow velocity, as noted
in feverish conditions, ty-reo-toxicosis, neurosis, physical and mental stress, etc. The
appearance of noise in anemia due to a decrease in blood viscosity in combination with a
certain acceleration of blood flow and tachycardia.

-- The emergence of functional noise may be due to changes in tone of the papillary
muscles or the entire myocardium, and vascular tone, resulting in incomplete bite of heart
valve regurgitation, and blood (myocardial dystrophy, SVD).

-- Transient noises could be linked to the ongoing formation of the heart, and also be the
result of incomplete compliance with the pace of development of various cardiac
structures, resulting in imbalance between the chambers and the openings of the heart and
blood vessels. In addition, the possible unevenness of the growth of individual valve
leaflets and chords, which leads not only to the temporary insolvency of locking function of
valves, but also to change their resonance properties.

-- Noises arise in the presence of "small anomalies" heart and blood vessels, when no
hemodynamic disturbances, changes in heart size and contractile capacity of the
myocardium.Most of this additional chords, anomalous arrangement of the chords,
especially the structure of the papillary muscles, etc.

From exocardial noise most often reveal pericardial rubbing sound (usually heard on a
particular area is being conducted in other locations, increases with pressure
phonendoscope the chest) and plevrope rikardialny-noise (listen to the left of the relative
dullness of the heart, increases in the height of inspiration, disappears when holding the
breath).

Auscultation of blood vessels. Normally, a healthy baby at the carotid and subclavian
arteries can hear 2 tones, on the femur - sometimes I just tone, in other arteries of the tones
are not heard. Above the large arteries can hear the noises arising in them during their
expansion or contraction or perform a heart valve and aorta.

Instrumental study

To estimate the size of the heart and major vessels used echocardiography, X-rays in 3
projections, angiography, CT and MRI to assess the functional state of the cardiovascular
system is widely used test with measured physical load.

ECG is important for the diagnosis of heart disease. Children ages ECG has its own
peculiarities. Her character influence varies with the age of the child ratio of the mass of
the right and left ventricles, the position of the heart in the chest, and heart rate.
-- The main features of ECG of healthy children (compared with adults). The lesser duration
of spikes and the intervals determined by the more

rapid conduction of excitation in the conduction system and myocardium.

On the variability of the length of intervals and the width of teeth, depending on the child's
age and heart rate.

On the possible presence of respiratory sinus arrhythmia.

Expression of the lability of the rhythm of heart contractions, especially in puberty. Great
variations of height of teeth.

On the Developmental Dynamics of the ratio of the amplitude peaks R and S in the standard
and precordial leads.

On the presence of some children of incomplete blockade of right bundle Heath (syndrome
of delayed excitation of the right supraventricular scallop).

About the possible negative T wave in III and unipolar precordial leads (from V, to V 4).

About Deep Q wave in the three standard leads when you turn the top of the heart
posteriorly.

The predominance of the vertical position of the heart or its deviation to the right (more
often in infants and young children).

On Reducing the length of time with the age of ventricular activation in the right precordial
leads and increase it in the left.

-- To clarify the causes of changes in the ECG conduct tests (medical and physical load).

-- To assess the daily rhythm of the heart conducting Holter monitorirova-tion, which
enhances the detection of arrhythmia.

Phonocardiography (PCG) and polikardiografiya can objectively assess the state of tones,
noise and ekstratony.

Echocardiography (Echocardiogram) - informative non-invasive method for studying the

heart, which allows to diagnose a wide range of pathological and physiological states, as
well as to investigate the morphological formation of the heart, their motion, myocardial
contractility, the state of central hemodynamics.

Reovazografii and Doppler can judge the state of the central and peripheral vessels.
SEMIOTICS INJURIES OF CARDIOVASCULAR SYSTEM

Cyanosis - a symptom, depending on the state of the capillary network, the peripheral
circulation, the number is not oxygenated hemoglobin, the presence of abnormal forms of
hemoglobin and other factors.

Acrocyanosis (peripheral cyanosis) - signs of peripheral circulation, characteristic of right

ventricular failure (stagnation of blood in the systemic circulation), heart defects.

Generalized (central) cyanosis - a sign of arterial hypo-ksemii due to various reasons.

-- Intensive total cyanosis of the skin and visible mucous membranes with a violet shade is
usually detected in children with the UPU, primary pulmonary hypertension, veno-arterial
shunt and other serious cardiovascular diseases.

-- Cyanosis with a cherry-red hue - a sign of pulmonary artery stenosis and non-rheumatic
carditis with a small cavity of the left ventricle.

-- Light cyanosis with pallor - a symptom of Tetralogy of Fallot.

Cyanosis differentiated (more pronounced on the hands than feet) - a sign of

transposition of great vessels with the presence of stenosis, or coarctation of the aorta.

Pallor of the skin and mucous membranes are usually observed in the aortic heart defects
(stenosis or insufficiency).

Palpitation celebrated as pathology of the heart, and without it.

Often it is a sign of functional disorders of the nervous regulation or the result of reflex
influences of other organs. The feeling of palpitations often occur in children in the
prepubertal and pubertal periods, especially in girls. He watched with SVD, anemia,
endocrine diseases (thyrotoxicosis, hypercorticoidism, etc.), gastrointestinal diseases,
feverish conditions, infectious diseases, as well as emotional stress, and high standing of
the diaphragm and smoking.

Less frequently this symptom is caused by disorders of the heart, but can be very
important for diagnosis. For example, the heartbeat is the only symptom of paroxysmal
tachycardia.

The feeling of "disruption" occurs when arrythmia. When ekstrasisto-Violence develops

against the background of severe heart disease, subjective sensations of patients are
usually absent.

False angina (pain in the heart) occur in many diseases.

 Kardialgiya due to cardiac, note the anomalous coronary circulation (pain in coronary
insufficiency - compressing, compression - are located behind the breastbone, may extend
to neck, jaw and shoulders, provoked by the physical and emotional pressures), pericarditis
(increase with movement, deep breath) , a sharp increase in the size of the heart or major
vessels.

Kardialgiya in the absence of changes in the heart occur in emotionally unstable children
with neurosis (usually localized in the apex of the heart, felt as burning, stabbing or aching,
accompanied by emotional displays).

Reflex pain in the heart may occur when pathology of other organs (stomach ulcer and
duodenal ulcer, cholecystitis, diaphragmatic hernia, an incremental edge, etc.).

Pain in the left half of the chest may be due to acute respiratory diseases (tracheitis,
pleuropneumonia Peste, etc.).

Pain in the chest and prekardialnoy of note in trauma and spinal diseases, herpes zoster,
muscle diseases, shortness of breath - a symptom caused by heart failure, leading to
stagnation of blood in the lungs, reducing the elasticity of lung tissue and reduction of
respiratory surface area. Cardiac dyspnoea is expiratory or mixed, amplified in a prone
position and decreases in the sitting position (ortopnoe).

Shortness of breath - one of the first indications of the emergence of stagnation in the
lesser circulation as a result of violations of the outflow of blood from the pulmonary veins
into the left atrium that observed with mitral stenosis (and other heart defects, including
congenital, particularly Tetralogy of Fallot), carditis with a decrease in left ventricular
cavity, adhesive pericarditis, mitral valve insufficiency, etc.

Shortness of breath may be due to right ventricular failure in acute or chronic pulmonary
heart and pulmonary embolism.

Attacks of breathlessness increased in conjunction with the worsening cyanosis is called

odyshechno-tsianoticheskih attacks. Registers of children with UPU "blue-type", especially
with Tetralogy of Fallot.

Cough in diseases of the cardiovascular system develops as a result of sharply pronounced

stagnation of blood in the lesser circulation and usually associated with shortness of
breath. It may be a reflex, arising as a result of stimulation of the vagus nerve branches
extended left atrium, dilatirovannoy pulmonary artery or aortic aneurysm.

Edema in heart disease develops in profound perturbation of blood flow and evidence of
right ventricular failure.

Fainting in children most often represented by the following options.

 Vazovagalnye - neurogenic (psychogenic), benign, arising from the deterioration of
cerebral blood flow in arterial hypotension on the background of SVD in the primary
increase vagal tone.

Orthostatic (after a rapid change in body position from horizontal to vertical), occurring
as a result of violations of the regulation of blood pressure in imperfect reflex reactions.

Carotid sinus, developing as a result of pathologically increased sensitivity of the carotid

sinus (triggered by a sharp bend of the head, neck massage, wearing tugogo collar).

Cough, resulting in a fit of coughing, accompanied by a decrease in cardiac output,

increased intracranial pressure and a reflex increase in resistance of cerebral vessels.

Cardiogenic syncope in children registered on the background of reduction in cardiac

output (aortic stenosis, Tetralogy of Fallot, hypertrophic cardio-myopathy), as well as
violations of rhythm and conduction (heart block, tachycardia, against the backdrop of
lengthening the interval Q-T, sinus node dysfunction, etc.) .

Cardiac hump - a sign of significant cardiomegaly, usually arises in early

childhood. Parasternal protrusion is formed at the preferential increase in the right-wing,
left-hand - with an increase in the left heart. Observed at WFC, chronic carditis,
cardiomyopathy.

Deformations of fingers on the type of "drumsticks" with nails in the form of "time
windows" point in UPU "blue-type, subacute infective endocarditis, and chronic lung
disease.

Change the apical impulse is possible in various states.

Offset apical impulse celebrated as in cardiac (increasing from left and right ventricles,
increasing the mass of the heart, dextrocardia) or extracardiac (high-or low-standing
diaphragm due to ascites, bloating, emphysema, obesity, mediastinal shift due to the
increase in pressure in one of pleural cavity with hydro-and pneumothorax, adhesive
processes, atelectasis) pathology.

The weakening of the apical impulse usually caused by extracardiac causes (obesity,
emphysema), but may also occur with edema (gidroperikard), pericardial effusion,
pnevmogterikarde.

Strengthening the apical impulse due note of left ventricular hypertrophy in aortic
defects, mitral insufficiency, arterial hypertension.
 High resistance of apical impulse is possible with increasing reductions in heart disease
(hyperthyroidism), left ventricular hypertrophy (aortic valve insufficiency, "racing" heart),
a thin chest, highstand diaphragm, mediastinal extension.

Diffuse apical impulse identify with anterior displacement of the heart, dilation of the left
ventricle (aortic or mitral insufficiency, aortic stenosis, hypertension, acute myocardial
damage).

Cardiac impulse can be seen and palpated in lean children with severe physical stress,
thyrotoxicosis, anterior displacement of the heart, right ventricular hypertrophy.

Pathological ripple - not uncommon symptom in cardiovascular disease.

Ripple carotid arteries (carotid dance ") - a symptom of aortic insufficiency, usually
accompanied by involuntary nodding his head (a symptom Musset).

The swelling and throbbing neck veins - signs of increasing CVP, resulting in right
ventricular failure. Observe when compressed Research Institute, obliteration or
thrombosis of superior vena cava, which is accompanied by swelling of the face and neck (
"collar" Stokes). Pulsation neck veins are also seen in outflows of blood from the right
atrium and tricuspid valve.

Pathological pulsation in the epigastric area accompanied by a pronounced hypertrophy

or dilatation of the right ventricle (mitral stenosis, tricuspid regurgitation, pulmonary
heart). Ripple, located below the epigastrium to the left of the midline abdomen indicates
abdominal aortic aneurysm.

Strong pulsation in the second intercostal space to the right of the sternum is in the
ascending aortic aneurysm or aortic valve insufficiency.

Strong pulsation in the second and third intercostal space to the left of the sternum
indicates the expansion of the pulmonary artery due to pulmonary hypertension.

Strong pulsation in the jugular fossa is possible with an increase in pulse pressure in the
aorta in healthy children after severe physical exertion, as well as in aortic insufficiency,
arterial hypertension, aneurysm of the aortic arch.

Cordial jitter ( "feline purr") is due to the turbulent flow of blood through the valves are
deformed or narrowed openings.

Systolic shake:

-- the second intercostal space to the right of the sternum and the jugular clipping - with
aortic stenosis;
-- the second and third intercostal space on the left - with isolated stenosis of the
pulmonary artery of stenosis of combined defects and high DMZHP;

-- on the basis of the heart to the left of the sternum and suprasternalno - with patent
ductus arteriosus;

-- in the fourth and fifth intercostal space at the edge of the sternum - when DMZHP, mitral
valve insufficiency.

Diastolic jitter in the apex of the heart observed in mitral stenosis.

Changes in heart rate may be as a sign of a pathological condition, and are normal.

Rapid pulse noted in infants and young children during physical and mental stress, with
anemia, thyrotoxicosis, pain, feverish conditions (with an increase in body temperature by
1 C, pulse rate of 8-10 per minute). When cardiac pathology rapid pulse characteristic of
heart failure, paroksizmal-term tachycardia, etc.

Rare heart rate may be an option rules during sleep in trained children, and for negative
emotions, as well as a symptom of heart disease (with blockades of the conducting system
of the heart, sinus, aortic stenosis), intracranial hypertension, hypothyroidism, infectious
diseases, malnutrition, etc.

Arrhythmic heart rate in children is usually caused by changes in vagal tone associated
with the act of breathing (respiratory arrhythmia - more frequent at the height of
inspiration and slower on expiration). Pathologic arrhythmia noted in arrhythmia, atrial
fibrillation, atrioventriku-lar blockade.

The weakening of the pulse indicates a narrowing artery, which forms the pulse
wave. Significant weakening of the pulse on both legs identify with coarctation of the
aorta. The weakening or absence of pulse in one arm or leg or on the hands during normal
characteristics of the pulse on the legs (you can choose different combinations) observed
when nonspecific aortoarteriite.

The alternating pulse - uneven power pulse strikes - identify the disease, accompanied by
violation of the contractile capacity of the myocardium. In severe stages of heart failure, he
is considered a sign of unfavorable prognosis.

Quick and high pulse rate observed in the aortic valve insufficiency.

Slow and low pulse rate typical for stenosis of the aorta.

Pulse deficit (difference between heart rate and pulse) appears when certain
irregularities of heart rhythm (atrial fibrillation, frequent ekstrasis-tolii, etc.).
Arterial giperteneiya

The main reasons for increase in systolic blood pressure: an increase in cardiac output and
blood flow in the arterial system during ventricular systole and a decrease in elasticity
(increase in density, stiffness) wall of the aorta. Leading reason for a higher diastolic blood
pressure - increased tone (spasm) of arterioles, increases the total peripheral
resistance.Hypertension can be primary and secondary (symptomatic). The most common
causes of secondary hypertension:

heart and blood vessels (coarctation of the aorta, renal artery stenosis, aortic valve
insufficiency, arteriovenous shunts, renal vein thrombosis);

endocrine diseases (Itsenko-Cushing's syndrome, thyrotoxicosis, pheochromocytoma,

aldosteronoma, etc.);

kidney disease (hypoplasia, polycystic, glomerulonephritis, pyelonephritis, etc.);

CNS lesions (tumors of the brain, the effects of skull trauma, encephalitis, etc.).

Arterial gipoteneiya

Hypotension can also be the primary and secondary. The latter occurs when the following
diseases.

Endocrine disease (adrenal insufficiency, hypothyroidism, hypopituitarism).

Kidney.

Some of the UPU.

Symptomatic hypotension may be severe (shock, heart failure) and chronic, but also occur
as a side effect of drugs.

Changes in heart size and width of vascular bundle

Increased heart borders on all sides is possible with pericardial effusion, combined and
combined defects of the heart.

Increased relative dullness of the heart to the right reveal an increase in the right atrium or
right ventricle (tricuspid regurgitation, mitral stenosis, pulmonary heart).

Offset boundary of the relative dullness of the heart to the left point with di-latatsii or left
ventricular hypertrophy (aortic insufficiency, mitral insufficiency, aortic stenosis,
hypertension, acute myocardial damage, etc.), mediastinal shift to the left, high-standing
diaphragm (supine heart ").

Offset boundary relative dullness of the heart goes up with a significant increase in the left
atrium (mitral stenosis, mitral insufficiency).

Reducing the size of the relative dullness of the heart mark at omission of the diaphragm
and emphysema (in this case the size of cardiac dullness is impossible to judge the true size
of the heart).

Changing the configuration of the heart:

mitral (dilatation of the left atrium and smoothing "waist of the heart") - with stenosis or
insufficiency of the mitral valve;

aortic (left ventricular dilatation and emphasized "the waist of the heart") - with failure
or decompensated stenosis of the aortic valve;

spherical and trapezoidal - in swampy pericarditis. Expansion of the vascular bundle

observed in tumors of the mediastinum, an increase in the thymus, aortic aneurysm or
extension of the pulmonary artery.

Changing the colors of the heart

The weakening of the two tones of the heart while maintaining the predominance of tone I
usually associated with vnekardialnymi causes (obesity, emphysema, pericardial effusion,
the presence of fluid or air in the left pleural cavity), and possibly in diffuse lesions of the
myocardium.

Reducing the tone I occurs when tightly closing valves, but the atrial-ventricular valves
(mitral insufficiency or tricuspid valve), a significant slowdown in the reduction of the left
ventricle with a decrease in contractile capacity of the myocardium (acute myocardial
damage, diffuse lesion of infarction, heart failure), slowing the reduction of hypertrophied
ventricle ( for example, aortic stenosis), slower atrioventricular conduction blockade left
bundle Heath.

Reducing tone II watch with tightness of closing aortic and pulmonary artery, reducing the
rate of closure (heart failure, lower blood pressure) or mobility (valvular aortic stenosis)
sashes semilunar valves.

Increased tone I may have children with thin chest wall, with the physical and emotional
stress (due to tachycardia). Also, it occurs if the following pathological conditions:

shortened interval P-Q (the ventricles are reduced shortly after the atria for more wide-
open valves);
 states, accompanied by an increased cardiac output (SVD with hyperactivity syndrome,
fever, anemia, "sporty heart, etc.);

mitral stenosis (due to fluctuations compacted mitral valve at the time of closing);

increase blood flow through atrioventricular valves (patent ductus arteriosus, DMZHP).

Flapping I listen to the tone at the top with mitral stenosis, expressed sympathicotonia,
carditis with reduced left ventricular cavity, and at the base of xiphoid process - stenosis of
the right atrioven-trikulyarnogo holes.

Cannon tone Strazhesko (sharp increase in the tone I heart) - a sign of complete
atrioventricular blockade and other violations of the heart rhythm when the atrial and
ventricular systole match.

Accent II tone of the aorta most often noted in arterial hypertension (due to the increased
rate of slamming the aortic valve leaflets), but it can also be caused by condensation of the
aortic valve leaflets and aortic wall (atherosclerosis, aortitis, etc.).

Accent II tone of the pulmonary artery is a sign of pulmonary hypertension, occurring in

mitral stenosis, pulmonary heart, levozhelu-dochkovoy heart failure, etc.

Splitting of tone I mark as a result of Asynchronous closure and vibration of mitral and
tricuspid valves.

Minimum splitting observed in healthy children. It differs variability, more pronounced

during deep breaths (an increase in blood flow to the right heart).

Noticeable splitting of tone I often listen to the blockade with right bundle Heath's
syndrome and Wolff-Parkinson-White type A.

Even more pronounced splitting of tone I can arise due to the appearance of tone exile in
aortic stenosis, aortic valve folding.

Splitting II can hear the tone in healthy children in the second intercostal space on the left
with a deep breath at the height of inspiration, when the increase in blood flow to the right
heart valve closure of the pulmonary artery is delayed (physiological splitting of tone
II). Pathological splitting occurs when states, accompanied by an increase in the time the
expulsion of blood from the right ventricle [atrial septal defect (atrial septal defect),
Tetralogy of Fallot, pulmonary artery stenosis, blockage, right bundle Heath and others].

III tone appears at significant reduction of left ventricular myocardium (myocarditis, heart
failure, etc.) and increase in atrial (mitral or tricuspid insufficiency), with vagotonia due to
the increase in diastolic tone of the ventricles, the violation of relaxation (diastolic
stiffness) of left ventricular myocardium with its pronounced hypertrophy .
IV tone is formed due to increased end-diastolic pressure in the left ventricle with a
decrease in contractile capacity of the myocardium (myocarditis, heart failure) or severe
myocardial hypertrophy of the left ventricle.

"Gallop rhythm" - a three-link heart rhythm, listen to the background tachycardia and
gallop sound is like a running horse. Extra tone with the rhythm of galloping can be
positioned relative to the main follows.

Extra tone (IV) I listen to the tone - presistolichesky gallop rhythm.

Extra tone (III) listen to the beginning of diastole after II tone - pro-todiastolichesky
gallop rhythm.

"The rhythm of quail" - a sign of narrowing of the left atrioventricular opening - a

combination of enhanced (claps) I tone and split tone II, listens to the apex of the heart and
at Botkin and the resulting emergence of additional colors (click) the opening of the mitral
valve. In "the rhythm of quail" usually listen to characteristic of mitral stenosis, diastolic
noise.

Embryocardia - oscillating rhythm when the duration of systole and diastole virtually
identical, and the volume and timbre of the tones I and II, the heart does not differ from
each other - there is acute heart failure, paroxysmal tachycardia, high fever, etc.

Heart sounds

Organic systolic sounds are divided into two types.

Noises expulsion in such cases arise when, during systole blood encounters an obstacle in
passing from one department to another of the heart or major blood vessels - systolic
sound exile in stenosis of the aorta or pulmonary trunk and stenosis of the output tract of
the ventricles. The longer the noise of exile, the more pronounced stenosis.

Noises regurgitation occur when the blood during systole comes back into the
atrium. They listen with mitral insufficiency, and tricuspid valves, as well as DMZHP.

Diastblicheskie noise is also divided into two types.

Early diastolic sounds occur when aortic insufficiency or pulmonary embolism due to
backflow of blood from vessels in the ventricles of incomplete closure valve leaflets.

"Detainees" diastolic noise listen to stenosis of the left or right atrioventricular opening,
because during diastole there is a restriction on the path of blood flow from the atria to the
ventricles. Continuous systole-diastole noise most often noted in patients with patent
ductus arteriosus.
Coronarism

Coronary insufficiency - mismatch of blood flow in coronary arteries in myocardial oxygen

demand, leading to diffuse or local myocardial ischemia. There are acute (sudden breach of
patency of coronary artery due to its spasm, thrombosis or embolism) and chronic
(continuous decrease in blood flow in venous arteries), coronary insufficiency. Separately
identifiable relative lack of coronary blood flow due to myocardial hypertrophy with
unchanged coronary arteries. The causes of coronary insufficiency in children - congenital
anomalies, disease and injury of coronary vessels, the relative lack of coronary blood flow,
hypoplasia of the ventricular myocardium.

Heart failure

The syndrome of heart failure - a condition where the heart is unable to translate the
venous flow of adequate cardiac output. Heart failure develops when some of the toxic,
septic conditions, as well as accompanying congenital and acquired heart defects,
myocarditis, fibroelastoz, arrhythmias, etc.

Left ventricular failure clinically manifested dyspnea, fatigue, sweating, feeling of

palpitation, tachycardia. Extreme manifestation of left ventricular failure - pulmonary
edema.Chronic left ventricular failure is characterized by the expansion of the relative
dullness of the heart to the left, dim or voiceless heart tones, the appearance of additional
tones III and IV.

Right ventricular failure manifested an increase in the liver and spleen, the appearance of
edematous syndrome, fluid accumulation in serous cavities.

Excrete 3 degrees of heart failure (by Beloserov YM, Mu-Raska E., Gaponenko VA, 1994).

I degree: tachycardia (heart rate 20-30% more than the norm) and dyspnea (NPV of 30-
50% more than the norm) at rest; disappears against the background of oxygen cyanosis of
mucous membranes, voiceless heart tones, expanding the boundaries of the heart,
increasing CVP to 80 -- 100 mm water column

The degree *, tachycardia (heart rate of 30-50% more than the norm) and dyspnea (NPV
of 50-70% more than the norm), cyanosis of mucous membranes, acrocyanosis, ne-
riorbitalnye edema, voiceless tones the heart, expand the frontiers of cardiac dullness, liver
enlargement (2-3 cm appears from under the edge costal arch), increased CVP and decrease
cardiac output by 20-30%.

PB degree: the same changes, the appearance of stagnation in the small circle of blood
circulation, oliguria, peripheral edema.
 III degree (decompensation stage): tachycardia (heart rate of 50-60% more than the
norm), and dyspnea (NPV by 70-100% more than the norm), voiceless colors, expanding
the boundaries of the heart, signs of incipient pulmonary edema, hepato-megalia,
peripheral edema, ascites. In the terminal stage - beard-card, lowering blood pressure,
bradypnea, muscular hypotonia, arefleksiya, CVP increased to 180-200 mm water column,
reduction of cardiac output by 50-70%.