questions 1

Splitting

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Topic updated on 05/28/17 7:46am

Snapshot
  • A patient presents to the ED with a chief concern that has been confirmed as a case of acute cholecystitis.  Upon doing a general physical exam the intern notices that S2 has a splitting pattern that remains constant regardless of inspiration or exhalation.  The patient states that they had a, "heart thing," since birth that the doctors said did not need to be treated.
Overview

Introduction
  • Normal splitting 
    • physiology
      • inspiration creates a negative intrathoracic pressure
        • this pulls more blood from the systemic venous circulation into the right heart
        • this also holds more blood in the lungs as well leading to less blood going to the left heart
      • this causes A2 to close earlier (less blood) and P2 to close later (more blood flow) increasing the splitting
  • Wide splitting
    • physiology
      • a decreased ability of the RV to empty blood into the pulmonary circulation resulting in exaggerated delay in pulmonic valve closure
    • associated conditions
      • states of delayed RV emptying
  • Fixed splitting 
    • physiology
      • shunting of blood from left to right that results in increased right heart volume resulting in consistent delay in pulmonic valve closure 
      • can lead to pulmonary hypertension if large
    • associated conditions
      • ASD
  • Paradoxical splitting
    • physiology
      • a decreased ability of the LV to empty blood into the systemic circulation resulting in a delayed closure of the aortic valve
        • the left heart fills more during expiration so splitting occurs during expiration and P2/A2 move closer during inspiration
    • associated conditions
      • states of delayed LV emptying (e.g., aortic stenosis or left bundle branch block) 


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