急性心包炎課件（ 24頁(yè)）

1、ACUTE PERICARDITISAcute pericarditis is a syndrome due to inflammation of the pericardium characterized by chest pain ,a pericardial friction rub ,and a serial electrocardio-graphic abnormalities The incidence :ranges from 2-6%(several autopsy series). menwoman1.the most common causes: idiopathic ,v

2、iral pericarditis,uremia,bacterial infection ,acute myocardial infarction, pericardiotomy, tuberculosis,neoplasm, and trauma 2.pathological changes: presence of polymorphnuclear leukocytes, increased pericardial vascularity and deposition of fibrin.Chest pain is the chief complaint,its quality and l

3、ocation are variable.Common locations:retrosternal and left precardial regions. Radiates to the trapezius ridge and neck.Pain aggravated by lying supine,coughing,deep inspiration and swallowing,pain eased by sitting up,leaned forward. Ischemic pain Pericardial pain Location retosternal , left should

4、er,arm precardium:left trepezius ridge Quality pressure, burning, buildup sharp, dull, pleuritic Thoracic motion no effect increased by breathing Duration angina: 1 or 2 to 15 min hours or days unstable: 1/2hr to hoursEffort angina:usually no relation unstable:usually not Posture no effect; may sit,

5、belch,use leaning forward for relief valsalva knee-chest position aggravated by recumbency for relief Dyspnea is aggravated by fever,large pericardial effusionAdditional symptoms:cough, sputum production,weight loss.In elderly patients the chest pain and dyspnea are subtle.4.Physical examinationThe

6、friction rub:a scratching,grating,high-pitched sound ,the sound is believed to arise from friction between the roughened pericardial and epicardial surfaces.Ewart signThe pericardial friction rub is classically described as having three components that are related to cardiac motion during atrial sys

7、tole(presystole),ventricular systole and rapid ventricular filling in early diastole.Location: lower left sternal border.Important feature: often evanescent and change in quality Detection of rub: stethoscope applied firmly to the chest at the lower left sternal border during inspiration and full ex

8、piration with the patient sitting up and lean forward. 12.Cardiac tamponade:elevation of intracardiac pressure progressive limitation of ventricular diastolic filling reduction of stroke volume and cardiac output.Clinic manifestation:a decline in systemic arterial pressureelevation of systemic venou

9、s pressurea small, quiet heart. Jugular venous distention, tachypnea, tachycardia , pulsus paradoxus, hypatomegaly. pulsus paradoxus:an inspiratory decrease in the amplitude of palpated pulse in the femoral or carotid arteries.Laboratory studies:ECG: electrical alternansUCG5.Electrocardiagram: four

10、stagesStage :comprise ST segment elevation is concave upward and present in all leads except avR and V1. T waves are upright.Stage : ST segments return to baseline, T wave flattening.Stage : T waves in normalStage IV: reversion of T wave changes to normal Others: isolated,PR-segment depression,sinus

11、 tachycardia, atrial arrhythemias.Echocardiogram: is the most sensitive and accurate tool in the detection and quantification of pericardial fluid.Electrocardiagram6.Blood test : leukcytosis and elevation of the sedimentation. 7. The chest roentgenogam: for a large pericardial effusion,the X-ray sho

12、w both enlargement and changes in configuration of the cardiac sihouette provide clues to the underlying cause of the pericarditis. 8.Pericardicentesis and biopsy.The chest roentgenogam9.Management:detect an underling disease that requires specific therapypain relief:nonsteroidal anti-inflammatory a

13、gents:aspirin,indomethicia or corticosteroids.antibiotics: purulent pericarditis10.Natural history: viral, idiopathic, post-myocardial infarction percarditis or post-pericardiotomy syndrome are usually self-limited.11.Recurrent pericarditis:20-28% 診斷要點(diǎn)不同類(lèi)型心包炎的臨床特點(diǎn) 急性非特異性 結(jié)核性 腫瘤性 化膿性病因 病毒 結(jié)核桿菌 轉(zhuǎn)移癌 葡萄

14、球菌 G+病癥 急起 心前區(qū) 發(fā)燒及結(jié)核 漸進(jìn)性呼吸 高熱毒血癥 劇痛，發(fā)燒 中毒病癥 困難體癥 心包摩擦音 中大量積液 大量積液 中大量積液 少量積液積液性質(zhì) 漿液纖維蛋白 漿液纖維蛋白 血性 化膿性治療 皮質(zhì)激素 抗癆 治療原發(fā)病 抗生素及引流術(shù)預(yù)后 好，易反復(fù) 易縮窄 差 較好Constrictive pericarditis CP is present when a fibrotic,thickened,and adherent pericardium restricts diastolic filling of the heart.Calcium deposition may con

15、tribute to thickening and stiffing of the pericardium. Tuberculosis is the leading cause3.clinical factures Constrictive restrictrve pericarditis cardiomyopathyS3 gallop absent may be presentPericardial knock may be present absent Palpable systolic absent may be preset apical impulse Pericardial calcification may be present absent Equal RV and LVdiastolic pressure usually present LVRVRate of LV