Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.
Lecture 1: 30 January 2022 Abdullah Abdelbaky Cardiovascular Examination SURGICAL SOCIETY JUNIOR ANATOMY SERIES | CPA LECTURE SERIESContents 1. Cardiovascular Examination 2. Surface Anatomy 3. Murmurs 4. ECGs 5. Practice Questions S U R G S O C J A S | C P A L E C T U R E S E R I E S Structure of the Examination Wash hands Position and Exposure Introduction Inspection Permission Palpation Exposure Percussion Reposition Auscultation Q: Are you comfortable? Q: Are you in any pain? S U R G S O C J A S | C P A L E C T U R E S E R I E S Palpation Pulses Chest Palpation Radial Pulse Apex Beat Ulnar Pulse Heaves Brachial Pulse Thrills Common Carotid Pulse S U R G S O C J A S | C P A L E C T U R E S E R I E S Radial Pulse At the wrist between the distal end of the radius and lateral to the tendon of flexor carpi radialis muscle Need to be able to assess rhythm and rate Rhythm: regularity of the beat Rate: number of beats in 1 minute Normally palpate the right arm only Character and Volume? S U R G S O C J A S | C P A L E C T U R E S E R I E S Common Carotid Pulse Palpated in the neck between the medial to the sternocleidomastoid muscle and lateral to the thyroid cartilage Make sure the patients head is straight if the neck to twisted to the left you will not be able to palpate the right common carotid pulse (Can comment on the character and volume) S U R G S O C J A S | C P A L E C T U R E S E R I E S Other Palpable Pulses Ulnar At the wrist over the distal end of the forearm lateral to the tendon of flexor capri ulnaris muscle Brachial In the cubital fossa Medial side of the tendon of biceps brachii and keep the elbow fully extended S U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E S Apex Beat Pulsation caused by the apex of the left ventricle of the heart against the anterior chest wall during contraction Not always palpable Position: 5 intercostal space, mid-clavicular line Start laterally and work inwards S U R G S O C J A S | C P A L E C T U R E S E R I E S Heaves Abnormal character of a beat Place hand vertically adjacent to the sternum to the left and to the right Positive sign: heel of your hand will lift with each heartbeat Main cause: hypertrophy of the left or right ventricle S U R G S O C J A S | C P A L E C T U R E S E R I E S Thrills Palpable murmur across a valve Place hand horizontally across chest at each of the heart valve locations (same as the ones for auscultation) S U R G S O C J A S | C P A L E C T U R E S E R I E S Auscultation Auscultation of all 4 valves Usually hear S1 + S2 heart sounds only Murmurs are any added heart sounds Accentuating murmurs Sound radiating S U R G S O C J A S | C P A L E C T U R E S E R I E S 5th S U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E S Valve Location Bell vs Diaphragm Aortic right 2nd intercostal space Diaphragm next to the sternum left 2nd intercostal space Pulmonary next to the sternum Diaphragm Tricuspid left 5th intercostal space Diaphragm near the sternum left 5th intercostal space at Mitral the mid-clavicular line (= Bell apex beat area) S U R G S O C J A S | C P A L E C T U R E S E R I E S Surface Anatomy and Key Anatomical Landmarks Sternal Angle and 4 Borders of the Intercostal spaces Heart Aortic Arch S U R G S O C J A S | C P A L E C T U R E S E R I E S Sternal Angle and Intercostal spaces Sternal angle is the manubriosternal joint and is at the level where the 2 costal cartilage joins the sternum nd Use to find the first palpable intercostal space, the 2 intercostal space Then locate the rest of the relevant intercostal spaces S U R G S O C J A S | C P A L E C T U R E S E R I E S Aortic Arch Aortnd arch starts and ends at the level of the sternal angle at the 2 ICS Arch of aorta S U R G S O C J A S | C P A L E C T U R E S E R I E S 4 Borders of the Heart Upper Border: 3 CC – 1cm from sternal border to the 2 ICSd Upper th rd Border Right Border: 6 CC 1 cm from sternal border to the 3 ICS 1 cm from sternal border th th Right Left Lower Border: 5 ICS to apex beat at MC line to 6 CC 1 cm Border Border from sternal border nd th Lower Left Border: 2 ICS to the 5 ICS to apex beat at MC line Border S U R G S O C J A S | C P A L E C T U R E S E R I E S Murmurs Aetiology Aortic Murmurs Mitral Murmurs S U R G S O C J A S | C P A L E C T U R E S E R I E SAetiology of • Occur due to abnormal blood flow across the valve Murmurs • Due to: • Structural • Surrounding structures • Congenital • Infection S U R G S O C J A S | C P A L E C T U R E S E R I E SAortic Murmurs Aortic Stenosis Aortic Regurgitation Ejection Systolic Murmur Early diastolic Radiates to carotid arteries No radiating sounds Loudest on Expiration Loudest on Expiration Accentuating Maneuver: get the Accentuating Maneuver: get the patient to lean forward and get patient to lean forward and get them to breath out them to breath out S U R G S O C J A S | C P A L E C T U R E S E R I E SMitral Murmurs Mitral Stenosis Mitral Regurgitation Low rumbling mid-diastolic with Pan-systolic murmur opening snap murmur Radiates to the left axilla Radiates to left axilla Loudest on Expiration Loudest on Expiration Accentuating Maneuver: get the Accentuating Maneuver: get the patient to lean on the left and get patient to lean on their left and them to breath out get them to breath out S U R G S O C J A S | C P A L E C T U R E S E R I E S Interpreting a 12 lead ECG Calculating Heart Rate Rhythm Cardiac Axis PR Intervals ST Segment S U R G S O C J A S | C P A L E C T U R E S E R I E S Calculating Heart Rate Regular cardiac rhythm: 300 Number of Large Squares between R waves Irregular cardiac rhythm: Number of R waves X 6 S U R G S O C J A S | C P A L E C T U R E S E R I E S Rhythm Main point is to compare if its regular or an irregular rhythm If irregular then can start thinking about different tachycardias and bradycardias or fibrillation depending on where the rhythm has started S U R G S O C J A S | C P A L E C T U R E S E R I E S Cardiac Axis Sum depolarisation direction and magnitude generated during a complete cardiac cycle Normal Axis: -30 to +90 o o Left Axis Deviation: <-30 Right Axis Deviation: >+90 o Compare Lead I and aVF is the fastest way to estimate axis deviation S U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E S PR Intervals Interval between P and R wave Normal PR interval: 0.12-0.2s Larger PR intervals = bradycardia (heart block) S U R G S O C J A S | C P A L E C T U R E S E R I E S First Degree Heart Block Prolonged PR interval but regular P waves followed by QRS complexes Caused by abnormally slow conduction through the AVN Usually presents no symptoms and is left untreated S U R G S O C J A S | C P A L E C T U R E S E R I E S Second Degree: Mobitz I Gradually prolonging PR interval until a P wave is not followed by a QRS complex Regularly Irregular Due to conduction issues across the AVN Normally presents with no symptoms or mild dizziness or faint S U R G S O C J A S | C P A L E C T U R E S E R I E S Second Degree: Mobitz II P waves are regular but not always followed by a QRS complex Normal PR interval Regularly irregular of a ratio between number of P waves and QRS complexes Can cause chest pain, SOB, postural hypotension S U R G S O C J A S | C P A L E C T U R E S E R I E S Third Degree Heart Block No relationship between P waves and QRS complexes and occur at their own rates Can cause: faints, SOB, extreme tiredness, confusion, chest pain S U R G S O C J A S | C P A L E C T U R E S E R I E S ST Segment Looking for ST elevation which can signify a STEMI ST depression normally signals an NSTEMI If both are present then suspect a STEMI as the ST depression is due to ischemia of the myocytes From the leads affected can distinguish where the infarction is occurring in the heart and possibly which blood vessels are affected S U R G S O C J A S | C P A L E C T U R E S E R I E SPathophysiology of • Occurs due to ischaemia of the an MI cardiac tissue due to occlusion of the supplying blood vessels • Leads to reduces function of the cardiac tissue • NSTEMI: partial occlusion • STEMI: complete occlusion S U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E S Practice Questions S U R G S O C J A S | C P A L E C T U R E S E R I E S What is this? A: 12 Lead ECG S U R G S O C J A S | C P A L E C T U R E S E R I E S What is the main pathology exhibited here? S U R G S O C J A S | C P A L E C T U R E S E R I E S What area of the heart is affected? A: ST elevation in leads I, aVL, V1-V4 Lateral or Anterolateral Area Reciprocal ST depression in leads III &aVF (LAD Occlusion) STEMI S U R G S O C J A S | C P A L E C T U R E S E R I E S You examine a patient and find they have a midsystolic crescendo-decrescendo murmur that is a grade 3/6 and radiates to the neck what is your differential diagnosis? A: Aortic Stenosis S U R G S O C J A S | C P A L E C T U R E S E R I E SYou examine a patient and find a pansystolic high pitched murmur that is loudest on expiration that radiates to the axilla, what is your differential diagnosis A: Mitral Regurgitation S U R G S O C J A S | C P A L E C T U R E S E R I E S Describe two features of this ECG? A: • ST depression in lead I, II and V5-V6 • ST elevation in V1- 2 and aVR • Rate of 86 bpm S U R G S O C J A S | C P A L E C T U R E S E R I E S Abdullah Abdelbaky aa5319@ic.ac.uk JAS Leads CPA Lead: Mohamad Abou-Eid (ma2219@ic.ac.uk) Phase 1a Lead: Sree Kanakala (sk1821@ic.ac.uk) Phase 1b Lead: Ananya Jain (aj620@ic.ac.uk) Feedback
