The Heart and Blood Vessels

Anatomy: The heart is positioned behind the sternum and is encased inside a sac called the pericardium, which allows for friction free movement of the heart. Within the heart there are four chambers - two atria and two ventricles. The heart receives blood from the body via the superior and inferior vena cava. The heart has four valves - the tricuspid, mitral, pulmonary, and aortic. The coronary arteries supply blood to the heart muscle or myocardium The electrical conduction system controls the pace of the heart The main pace maker of the heart is the SA node. The impulse is carried to the AV node, the Bundle of His, and finally to the Purkinje Fibers causing the heart to contract. In between heats the heart is in a relaxed phase called diastole. Contraction is called systole. The blood pressure reflects these two phases: the systolic pressure is the pressure in the arteries while the heart is contracting, and the diastolic pressure while the heart rests. While listening to the heart two sounds are made as the valves close with contraction The first sound or S l is due to the AV valves closing and the second or S 2 is due to the closing of the pulmonary and aortic valves. Heart murmurs are unexpected sounds due to:

1. Incompetence of the valve with regurgitation or back flow of blood into the heart or
2. Stenosis or narrowing of the opening thorough which the blood must flow.

1. Blood Pressure - Check blood pressure in both arms.
2. Inspection - Neck veins for distension or pulsations
   • Check the Precordium for pulsation (the area over the heart)
3. Palpation - Feel for the apical impulse at the apex
   • Palpate the left sternal boarder and the suprasternal notch (where the base of the heart is located).
   • Check Pulses and compare upper and lower extremities
4. Auscultation: the heart is listened to in 5 areas while sitting and lying down
   1. Aortic valve area: second right intercostal space right sternal boarder.
   2. Pulmonic valve area: second left intercostal space left sternal boarder.
   3. Second pulmonic area: third left intercostal space left sternal boarder
   4. Tricuspid valve area: fourth left intercostal space left sternal boarder
   5. Mitral valve area at the apex of the heart, fifth intercostal space, mid clavicular line.
   
   Note: Check rate (speed) and rhythm (regular or not); listen for SI and S2 ("lub-dubb") and any abnormal sounds
5. Check for any edema, or varicose veins.

1. Coronary Artery Disease - CAD: A disorder of the blood vessels that supply the heart muscle (myocardium) with oxygenated blood. It is characterized by arteriosclerosis - (a thickening of the walls of the arterioles with loss of elasticity and contractility) and by arterioscleroris - (an accumlation of lipids -cholesterol deposited in the arterioles). Sclerosis means hardening, and the arteries become hardened and blocked.
   Risk Factors: age, male gender, hypertension, cigarette smoking, obesity, physical inactivity, diabetes mellitus, and excessive intake of cholesterol and saturated fats. CAD leads to angina pectoris, myocardial infarction and death

   S: Chest - (angina) caused by an insufficient supply of blood to the heart due to narrowed coronary arteries. Provoked by physical exercise, relieved by rest The patient has great anxiety due to a fear of death. Diaphoresis (sweating), and dyspnea.
   O: Elevated blood pressure, arrhythmia’s may be present with changes on EKG (ST segment depression) and tachypnea (rapid breathing).
   A: Angina
   P The diagnosis of angina is strongly supported if sublingual nitroglycerin gives relief acts in 1 to 2 minutes. Dosage: one placed under the tongue, may be repeated at 3 to 5 minute intervals. If pain is not relieved after 3 to 4 tablets or the pain lasts more then 20 minutes consider myocardial infarction.
   Refer to MD.

2. Myocardial Infarction (MI): An infarct is an area of the heart that undergoes necrosis (death) following blockage of the blood supply caused by an occlusion of one or more of the coronary arteries.

   S: Severe crushing chest pain radiating into the left shoulder, sweating, nausea, vomiting, shortness of breath, with pain lasting more than 30 minutes. Dizziness, and pallar. Not relieved by nitroglycerin
   O: Anxiety, EKG with ST segment elevation Tachycardia or Bradycardia. Blood pressure elevated, Cardiac enzymes elevated CPK first to rise.
   A: Myocardial Infarction
   P: Medical Emergency MD I PA ASAP!
   Begin oxygen, and IV, continuous cardiac EKG monitoring Pain relief: Morphine sulfate 4-8 mg or
   Meperidine 50-75 mg
   Lidocaine infusion 1-2 mg - used to prevent arrhythmias.

3. Cardiac Arrest: heart functions stop, fatal without treatment Due to lethal arrhythmia’s

   S: Unconscious
   O: Apnea (no breathing), cyanosis, no pulse, dilated pupils, no heart beat or blood pressure.
   A: Cardiac Arrest
   P: CPR, ACLS, Defibrillation.

4. Hypertension: High blood pressure has no symptoms until it reaches an advanced stage However if untreated leads to stroke, heart attack or kidney damage. In an adult hypertension is defined as a systolic pressure over 140 mm Hg or a diastolic pressure that is higher than 9OmmHg In most cases the cause is unknown and is referred to as primary or essential hypertension. Risk factors include a positive family history, black, male, smoker, abuse of alcohol, over weight, diet (salt) and stress

   S: Usually no symptoms, may develop dizziness, headache, chest pain, dyspnea, or blurred vision
   O: Elevated blood pressure as measured twice a day for 3-5 days.
   A: Hypertension
   P: Treatment is for life. Diuretics, Beta blockers, ACE inhibitors, etc. Stress reduction, loss of weight, stop smoking, no salt. Refer to medical officer.

5. Varicose Veins: Enlarged, twisted, knotted, superficial veins. Most common in lower legs and due to incompetent venous valves. Aggravated by pregnancy, obesity and prolonged standing.

   S: Dull aching pain and cramping.
   O: Dilated veins beneath the skin in the thigh and leg. Swelling may occur.
   A: Varicose Veins
   P: Rest, elevation, elastic support stockings and surgical treatment to remove incompetent veins.

6. Thrombophlebitis: Inflammation of a vein due to partial or complete occlusion by a thrombus blood clot) usually in a leg. The formation of a blood clot or thrombus is a life saving process when it occurs during hemorrhage. It is a life - threatening event when it occurs at the wrong time because it can occlude and stop the blood supply to an organ. The thrombus, if detached, becomes an embolus and occludes a vessel at a distance from the original site, for example, a clot in the leg may break off and cause a pulmonary embolus.
   1. Superficial venous thrombophlebitis: Occurs spontaneously in a person with varicose veins, in women during and following pregnancy, or taking oral contraceptives, and following trauma.

      S: Dull pain in the area of the vein usually the calf or thigh. May be swollen, warm and red.
      O: Induration, swelling, tenderness over a vein May be red and feel like a knot.
      A: Superficial Thrombophlebitis
      P: Local heat, bed rest, keep leg elevated.
      Non-steroidal anti-inflammatory drugs like ASA, Motrin, etc Refer to medical Officer

   2. Deep venous thrombophlebitis: The urgent nature of this condition stems from the often fatal complication of pulmonary embolus. Commonly involves the deep veins of the calves. Risk increases with oral contraceptives, following surgery, or with varicose veins.

      S: Rapid onset of pain and swelling of the limb.
      O: Diffuse muscular tenderness on manual compression. Forcible dorsiflexion of the foot causes pain in the calf. Calf and thigh circumferences of the involved extremity at least 2 cm more than the normal leg. Slight fever or Tachycardia.
      A: Deep vein thrombophlebiits.
      P: Refer to medical officer for hospital admission for anticoagulation using Heparin.

Hospital Corpsman Sickcall Screeners Handbook

Naval Hospital, Great Lakes

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