Signos vitales: Pulso y Ritmo cardiaco.

Video 1.1: Anatomia basica del corazón

La localización del corazón esta en la cavidad toraxica. El corazón es un organo muscular huevo en forma
de cono. El Esofago y la traquea estan posteriores al corazón. Encerrado por el pericardio el cual lo ancla
y protege

Localización general.

Posicionado en el mediastino

en la cavidad pericardial

entre las cavidades pleurales

Estructura interna del corazón:

4 camaras o compartimentos:

l壱 Dos camaras superiores o auriculas (atria)

l弐 Dos camaras inferiores o ventriculos

Para evitar que se mezcle la sangre entre las cámaras: tabique interauricular y tabique interventricular

Las paredes ventriculares son más gruesasa que las paredes auriculares porque son las responsables de
de bombear sangre en la circulación sistemica y pulmonar.

Auricula Derecha.

Recibe la sangre desoxigenada de tres vasos sanguineos:

La vena cava superior: la cual transporta la sangre proveniente de las extremidades superiores, del
cuello y de la cabeza

La vena cava inferior: la sangre proviene de las extremidades inferiores y la cavidad abdominal.

Seno coronario: sangre de la circulacion coronaria, es decir de la circulacion del corazón.

De la auricula derecha la sangre va a la el ventricula derecho

Ventriculo Derecho: Bombea sangre desoxigenada en el tronco pulmonar.

Auricula izquierda: Recibe la sangre oxigenada via las venas pulmonares m

Ventriculo izquierdo: Bombea sangre oxigenada en la aorta

Las paredes ventriculares izquierdas son más gruesas que las ventriculares derechas porque necesitan
contraerse con más fuerza para enviar sangre a través de la circulación sistémica

La circulación sistémica suministra sangre oxigenada a los tejidos y órganos del cuerpo.

La sangre nuevamente desoxigenada regresa a la auricula derecha a traves de la vena cava superior, la
vena cava inferior y el seno coronario

Video 1.2a: El latido de tu corazón

El corazón a nivel microscopico:el corazón está organizado en dos unidades funcionales

separadas.

Llamamos a cada una de ésas unidades funcionales sincitio. El corazón está organizado

en un sincitio auricular y en un sincitio ventricular.

La auricula se contraé, luego los venticulos y entonces el corazón se relaja.
Dos tipos de celusas en las paredes del corazón:
Celulas contractoras
Celuas que generan una señal electrica

Forma el sistema de conducción cardiaca:

Ocurre en cada latido del corazón.

El sistema cardiaco de conducción, comienza en el nódulo sinoauricular (SA node), El nódulo SA está
localizado en la aurícula derecha, cerca de donde la vena cava superior entra en la aurícula derecha. El
nódulo SA es de hecho la parte del sistema de conducción que puede generar una señal eléctrica más
rápidamente. Entonces el nódulo SA es parte de el sistema de conducción que, si queréis pensarlo de
esta forma, es la que dispara primero. Esparce su señal rapidamente sobre todo el sincitio auricular y
hacia el nodulo auriculoventricular (AV node).
La señal pasa através del haz auriculoventricular (AV bundle).
La señal llega a el nodulo intraventricular
Pasa a traves de dos ramas de haces ( derecha e izquierda)
En el apex, las fibras ramificadas abundantemente, forman las fibras de Punkinje.

l壱Electrocardiograms (ECGs) assess the cardiac conduction system

l弐Determine if electrical activity of the heart is working properly

Video 1.2b: ECG Demo

l壱ECGs are devices we use to detect the electrical activity in the heart

l弐Electrodes are placed on the body

§2 upper limb leads

§2 lower limb leads

§6 precordial leads

§Allows you to look at the heart from 12 different angles-> can pinpoint location of abnormality, if
present

l壱The current arising from the SA node is a positive current, called depolarization

l弐The positive current passes through the atrial walls

l参A negative current restores the electrical potential of the atrium back to normal after the passing of
the positive current, this is called repolarization

l壱Normal Sinus Rhythm

l壱P wave: first wave

l壱QRS complex: second group of waves

l弐Consists of the Q, R, S waves

l壱T Wave: third wave

l壱Isoelectric lines –occur when there is no change occurring in the electrical state of the heart (i.e., no
depolarization or repolarization is occurring)

§Between P wave and QRS complex

§Between QRS complex and T wave

Video 1.3a: Heart Valves, Part 1

l壱Heart valves ensure that blood flows in one direction through the heart

l弐Composed of dense, fibrous connective tissue

l参covered in endocardium-

l壱Heart has 4 valves- organized as two pairs

l弐Atrioventricular valves (AV valves)

l参Location:

§tricuspid valve
§mitral valve:

§Close when ventricles contract and the pressure in the ventricles exceeds pressure in the atria

·chordae tendinae:

·papillary muscles contract along with ventricles, creating tension in the chordae tendinae, preventing
the free edges of the valves from swinging upward into the atria

§Open after ventricular relaxation, when atrial pressure exceeds ventricular pressure

l壱Semilunar valves (SL valves)

Video 1.3b, Heart Valves, Part 2

l壱Blood passes from right ventricle to the pulmonary trunk and from the left ventricle into the aorta

l弐Semilunar valves:

l参pulmonic valve

§aortic valve

§When closed, the cusps fall into the center of the pulmonary trunk and aorta to prevent backflow of
blood from the vessel into the ventricle

§When the ventricles contract, pressure in them increases- when ventricular pressure exceeds pressure
in the aorta and pulmonary trunk, the semilunar valves open

§When the ventricles relax, pressure drops- when the ventricular pressure falls below the pressure in
the aorta and pulmonary trunk, the semilunar valves close

Movement of valves during the cardiac cycle

l壱When the heart is relaxed

l弐the semilunar valves are closed and the AV valves are open

l参 blood is coming back to the right atrium through the superior vena cava, inferior vena cava and
coronary sinus

l四 On the left side, blood is returning to the heart from the pulmonary veins from the lungs

l壱Atria contract

l弐Pressure in atria increases

l壱Atria relax, ventricles contract

l弐Pressure in ventricles exceeds pressure in atria

l壱Pressure continues to climb as ventricles continue to contract -> ventricular pressure exceeds
pressure in aorta and pulmonary trunk

l壱Ventricles stop contracting, start to relax

l壱Cycle repeats

l弐When valves close, they cause vibrations to occur in the blood that’s passing through the heart

l参Vibrations are carried to the body’s surface and can be heard with a stethoscope

l四sound one:

l壱sound two:

Video 1.3c, Assessing Heart Rate Demo

l壱Auscultation:

l壱The heart is positioned deep to the sternum, slightly to the left of the midline in the chest cavity

l弐the apex:

l参Location:

§Orientation:

§point of maximal impulse- the most accurate place to check heart rate

l壱Feeling the heart rate, or palpating, assesses the number of beats per minute

l弐Auscultation allows assessment of heart rate as well as heart sounds

l参Heart sounds include sound one and sound two, usually called S1 an S2

l四S1

§S2

l壱Physicians often auscultate in multiple locations to assess heart sounds related to the specific valves

l弐aortic valve:

l壱pulmonic valve:

l壱tricuspid valve:

l壱mitral valve:

l壱If a valve does not close all of the way, it will make a swishing sound

l弐If a valve does not open all of the way, it will make a clicking sound

Video 1.4a, The Cardiac Cycle, Part 1

Electrical Changes During the Cardiac Cycle

l壱Conduction system:
l壱Starts at the SA node

l弐Excitation of the atria creates the P-wave on an ECG

l壱Signal sent to the AV node

l弐Delayed for 1/10th of a second—

l壱Passed to AV bundle

l弐The only electrical connection between the atrial syncytium and ventricular syncytium

l壱Excitation of the ventricles creates the QRS complex on an ECG

l壱Heart relaxes, ventricles repolarize

l弐Creates the T wave on the ECG

l壱These electrical signals create changes in the contracting cells, triggering muscle contraction
Video 1.4b: The Cardiac Cycle, Part 2

Pressure Changes During the Cardiac Cycle

l壱Pressure changes in the heart cause the valves to open and close, to prevent backflow of blood

l弐The P wave on an ECG is followed closely by an increase in atrial pressure

l参atrial contraction, atrial systole

§After atrial systole, the atria contract and pressure remains low

§The QRS complex on an ECG is followed almost immediately by an increase in ventricular pressure

§The period of ventricular contraction is called ventricular systole

§When ventricular pressure exceeds aortic pressure, the semilunar valves open

·Once this pressure peaks, the ventricles stop contracting

·Pressure in ventricles falls below the pressure in the aorta and pulmonary trunk

·The ventricles continue to relax and ventricular pressure continues to fall

·When this pressure falls below atrial pressure, the AV valves open

·The period when the ventricles are relaxed is called ventricular diastole –during this phase, ventricles
fill with blood

Ventricular Volume During the Cardiac Cycle

l壱Ventricular volume is fairly high during relaxation, or diastole

l壱During atrial systole- a little more blood is pushed into the ventricles, so the volume increases slightly

l壱Ventricles contract, pressure increases and volume decreases

l弐Blood is being ejected to the aorta and pulmonary trunk

l参AV valves open and ventricular volume begins to increase again

Heart Sounds During the Cardiac Cycle

l壱Heart sound one indicates the start of ventricular systole

l壱Heart sound two indicates start of ventricular diastole

Video 1.4c: Assessing Pulse Demo

l壱Heart rate:

l壱Pulse:

l壱We assess pulse in elastic arteries, which can distend and retract

l弐Pulse and heart rate are typically the same in a person with healthy cardiovascular function, but
could be different if someone has poor peripheral circulation or arterial disease

Locations to assess pulse:

l壱carotid artery

l壱brachial artery (at the antecubital fossa)

l壱radial artery

l壱femoral artery

l壱dorsalis pedis

l壱posterior tibial
Video 1.5: Cardiac Output

l壱Need to keep blood circulating through the body to supply the cells with oxygen and nutrients and to
carry away metabolic waste products

l弐Cardiac Output (CO) = the volume of blood ejected per minute

l壱Influenced by heart rate (HR) and stroke volume (SV)

l弐CO = HR x SV

l壱Stroke volume: the volume of blood ejected during a single heartbeat

l壱End diastolic volume (EDV):

l壱End systolic volume (ESV):

l壱Stroke volume = EDV - ESV

l壱Cardiac output can be increased or decreased to meet the needs of the body

l壱The autonomic nervous system plays a role in regulating cardiac output

l壱Two branches: parasympathetic and sympathetic

l弐sympathetic division:

·in the heart, the sympathetic nervous system innervates SA node, AV node and the contractile cells of
the myocardium

·when activated, causes the SA node to depolarize more quickly and can shorten the delay at the AV
node

l壱tachycardia = HR > 100 bpm

l弐sympathetic activation also causes contractile cells of myocardium to contract more forcefully ->
leads to increased stroke volume

l参parasympathetic division:

·in the heart, the parasympathetic nervous system innervates the SA node & the AV node

·parasympathetic nervous system slows the SA node’s rate of self-excitation

·parasympathetic signals are carried to the SA node by the vagus nerve

·bradycardia = HR < 60 bpm

11. Pregunta 1
The tricuspid valve is located:
between the right atrium and right ventricle.
between the left atrium and aorta.
between the left atrium and left ventricle.
2Pregunta
The first heart sound (S1) is caused by closure of the AV valves and the second heart sound (S2) is caused
by closure of the SL valves.
True
False

3Pregunta
The two valves located on the right side of the heart are the:

aortic valve and pulmonary valve.

mitral valve and pulmonary valve.
tricuspid valve and pulmonary valve.
aortic valve and mitral valve.

4Pregunta
Oxygenated blood flows from the pulmonary circulation into the right atrium via the pulmonary veins.

True
False

5Pregunta
Choose the answer that correctly depicts the order of impulse conduction in the cardiac conduction
system.
SA node > AV bundle > AV node > Purkinje fibers > left and right bundle branches
AV node > AV bundle > SA node > Purkinje fibers > left and right bundle branches
SA node > AV node > AV bundle > left and right bundle branches > Purkinje fibers
SA node > AV bundle > AV node > left and right bundle branches > Purkinje fibers

69. Pregunta 9
The AV node is considered the heart's pacemaker.
True
False

710. Pregunta 10
On an electrocardiogram the QRS complex results from ____________ and the P wave results from
______________.
ventricular depolarization . . . atrial depolarization
ventricular depolarization . . . ventricular repolarization
ventricular depolarization . . . atrial repolarization
atrial depolarization . . . ventricular depolarization

811. Pregunta 11
Which of the following factors can increase cardiac output?
Increasing heart rate, increasing the contractility of the heart (i.e., increasing the forcefulness of
contraction), increasing end diastolic volume
decreasing heart rate, decreasing end diastolic volume, decreasing contractility of the heart
increasing stroke volume, decreasing heart rate, decreasing contractility of the heart

911. Pregunta 11
María y su hija recién nacida, Isabelle, fueron dadas de alta hace aproximadamente 5 semanas. María ha
notado que Isabelle no está comiendo bien. Isabelle nunca pareció prenderse bien durante la lactancia.
Hace dos semanas María cambió a la alimentación con biberón con fórmula. María todavía siente que
Isabelle se está alimentando mal, incluso después de cambiar a la alimentación con biberón. Isabelle no
se alimenta por mucho tiempo y solo toma alrededor de 1 onza a la vez. María se da cuenta de que
Isabelle parece respirar con dificultad todo el tiempo, pero que su respiración empeora aún más
después de alimentarse. María decide ver a una enfermera practicante (NP) para discutir sus
preocupaciones sobre la dificultad para alimentar y respirar de Isabelle.

Después de escuchar las preocupaciones de María, el NP pesa a Isabelle y realiza un examen físico.
Cuando el NP ausculta el pecho de Isabelle, oye un murmullo. Al PN le preocupa tanto el soplo, como
porque Isabelle no ha ganado mucho peso desde su nacimiento. El NP decide ordenar un ECG y un
ecocardiograma para evaluar el corazón de Isabelle. El ECG mostrará la frecuencia cardíaca y el ritmo de
Isabelle. El ecocardiograma (ultrasonido del corazón) proporcionará una imagen de la estructura del
corazón de Isabelle y mostrará cómo fluye la sangre a través del corazón de Isabelle. Para algunas de las
preguntas del estudio de caso, debe imaginar que la sangre en el corazón está codificada por colores de
acuerdo con su estado de oxigenación (la sangre oxigenada es roja, la sangre desoxigenada es azul). El
ecocardiograma revela que el soplo de Isabelle es causado por algo llamado defecto del tabique
ventricular (VSD). Un VSD es un orificio en el tabique interventricular, la pared muscular que separa el
ventrículo izquierdo del ventrículo derecho. El ECG muestra ritmo sinusal sin anomalías de conducción.
Piensa en la posición del corazón en la cavidad torácica. La VSD de Isabelle se encuentra en el tabique
interventricular entre las válvulas mitral y tricúspide. ¿En qué ubicación anatómica escucharía mejor el
NP el murmullo de Isabelle?

Between the right lower sternal border and the left lower sternal border

Between the right upper sternal border and the left upper sternal border
At the second intercostal space at the left upper sternal border
At the fifth intercostal space at the left midclavicular line

10 Pregunta 13
Choose the answer that correctly depicts the order of blood flow through a normal heart and major
blood vessels:
Right atrium > right ventricle > pulmonary trunk > pulmonary veins > left atrium > left ventricle > aorta
Pulmonary trunk > pulmonary veins > right atrium > right ventricle > left atrium > left ventricle > aorta
Right atrium > right ventricle > pulmonary veins > pulmonary trunk > left atrium > left ventricle > aorta
Right ventricle > right atrium > pulmonary trunk > pulmonary veins > left ventricle > left atrium > aorta

1114. Pregunta 14
In what, if any, manner would you expect a VSD to alter the flow of blood through Isabelle's heart?
I would expect that some blood would flow from the left ventricle to the right ventricle during systole
due to higher pressure in the left ventricle during systole.
I would not expect a VSD to change the direction of blood flow through the heart.
I would expect that some blood would passively flow from the right ventricle to the left ventricle during
diastole due to lower pressure in the left ventricle during diastole.

1215. Pregunta 15
In the heart of a person without a VSD, blood in the right ventricle would be _________, and blood in
the left ventricle would be _________.
oxygenated....deoxygenated
deoxygenated....deoxygenated
oxygenated....oxygenated
deoxygenated....oxygenated
1316. Pregunta 16
Remember to imagine that blood in the heart is color-coded according to its oxygenation status
(oxygenated blood is red, and deoxygenated blood is blue). What color of blood would you expect to see
in Isabelle's left ventricle?
Red
Blue
Both red and blue

1416. Pregunta 17
Remember to imagine that blood in the heart is color-coded according to its oxygenation status
(oxygenated blood is red, deoxygenated blood is blue). What color of blood would you expect to see in
Isabelle's right ventricle?

Red
Blue
Both red and blue

15 Pregunta 18
Cardiac output is the volume of blood pumped by each ventricle per minute. The cardiac output is the
product of:
Stroke volume and end systolic volume
End diastolic volume and heart rate
End diastolic volume and end systolic volume
Stroke volume and heart rate

1619. Pregunta 19
How would you expect the VSD to affect Isabelle's cardiac output?
Cardiac output would not change.
Cardiac output would decrease because stroke volume would decrease.
Cardiac output would increase because stroke volume would increase.
Cardiac output would decrease because heart rate would decrease.
1719. Pregunta 19
Remember that a VSD is located in the interventricular septum. Based on the location of a VSD, what
part of the cardiac conduction system might be affected?

Sinoatrial node
Atrioventricular bundle (bundle of His)
Bundle branches
Both the atrioventricular bundle and the bundle branches

1819. Pregunta
Case Study #2: Pulmonary Valve StenosisPlease use the following case study to answer the remaining
quiz questions. Enjoy the case!

You are taking care of Carl, a one month old with pulmonary valve stenosis. Pulmonary valve stenosis is
a narrowing of the pulmonary valve. You notice Carl is cyanotic (bluish in color), lethargic, and irritable.
When you auscultate Carl's heart with a stethoscope, do you expect to hear a murmur?
Yes, I expect there to be a murmur when either the AV or SL valves do not function normally.

No, I expect there to be a murmur only when the AV valve does not function properly.
No, I expect there to be a murmur only when the SL valve does not function properly.
No, a murmur is never heard when a SL valve is not functioning properly.

1919. Pregunta 19
The wall of a heart chamber thickens, or hypertrophies, when the chamber has to work extra hard to
eject blood. Given Carl's pulmonary valve stenosis, which part of his heart may become hypertrophied?

right atrium
right ventricle
left atrium
left ventricle

2019. Pregunta 19
Why do you think Carl has cyanosis, or a bluish skin color?

Because it is difficult for Carl's heart to pump blood into the pulmonary circulation, deoxygenated blood
will be pumped from the right ventricle into the aorta.
Because it is difficult for Carl's heart to pump blood into the pulmonary circulation, his blood will contain
a higher than normal percentage of deoxygenated blood. Deoxygenated blood has a dark red or purplish
color, which causes Carl's skin to have a bluish tint.
Because it is difficult for Carl's heart to pump blood into the pulmonary circulation, blood will flow from
the superior vena cava into the left ventricle and will be pumped directly back into the systemic
circulation.

21
Pregunta 6
Blood returns to the heart from the systemic circulation through which blood vessels?
aorta, coronary sinus, pulmonary veins
inferior vena cava, superior vena cava, coronary sinus
pulmonary veins, inferior vena cava, superior vena cava
inferior vena cava, superior vena cava, aorta

22. Pregunta 5
The mitral valve is closed during:
ventricular diastole.
ventricular systole.
both ventricular systole and diastole.
Esto no debería estar seleccionado 
neither ventricular systole or diastole.

23. Pregunta 5
Tachycardia and bradycardia are respectively defined as heart rate greater than _____ beats per minute
(bpm) and heart rate less than _____ bpm.

80 . . . 60
100 . . . 60
Correcto 
Tachycardia and bradycardia are respectively defined as heart rate greater than 100 beats per minute
(bpm) and heart rate less than 60 bpm.
120 . . .50
100 . . . 50