急性心包炎课件（ppt 24页）

ACUTE PERICARDITIS Acute pericarditis is a syndrome due to inflammation of the pericardium characterized by chest pain ,a pericardial friction rub ,and a serial electrocardio- graphic abnormalities lThe incidence :ranges from 2-6%(several autopsy series). menwoman 1.the most common causes: idiopathic ,viral 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. 3.History .Chest pain is the chief complaint,its quality and location 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 shoulder,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 hours Effort angina:usually no relation unstable:usually not Posture no effect; may sit,belch,use leaning forward for relief valsalva knee-chest position aggravated by recumbency for relief Dyspnea is aggravated by fever,large pericardial effusion Additional symptoms:cough, sputum production,weight loss. In elderly patients the chest pain and dyspnea are subtle. 4.Physical examination The friction rub:a scratching,grating,high-pitched sound ,the sound is believed to arise from friction between the roughened pericardial and epicardial surfaces. Ewart sign The pericardial friction rub is classically described as having three components that are related to cardiac motion during atrial systole(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 expiration 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 pressure elevation of systemic venous pressure a 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 alternans UCG 5.Electrocardiagram: four stages Stage :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 normal Stage IV: reversion of T wave changes to normal Others: isolated,PR-segment depression,sinus tachycardia, atrial arrhythemias. Echocardiogram: is the most sensitive and accurate tool in the detection and quantification of pericardial fluid. .Electrocardiagram 6.Blood test : leukcytosis and elevation of the sedimentation. 7. The chest roentgenogam: for a large pericardial effusion,the X-ray show 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 roentgenogam 9.Management: detect an underling disease that requires specific therapy pain relief:nonsteroidal anti-inflammatory agents:aspirin,indomethicia or corticosteroids. antibiotics: purulent pericarditis 10.Natural history: viral, idiopathic, post-myocardial infarction percarditis or post-pericardiotomy syndrome are usually self-limited. 11.Recurrent pericarditis:20-28% 诊断要点不同类型心包炎的临床特点 急性非特异性 结核性 肿瘤性 化脓性 病因 病毒 结核杆菌 转移癌 葡萄球菌 G+ 症状 急起 心前区 发烧及结核 渐进性呼吸 高热毒血症 剧痛，发烧 中毒症状 困难 体症 心包摩擦音 中大量积液 大量积液 中大量积液 少量积液 积液性质 浆液纤维蛋白 浆液纤维蛋白 血性 化脓性 治疗 皮质激素 抗痨 治疗原发病 抗生素及引流术 预后 好，易反复 易缩窄 差 较好 Constrictive pericarditis CP is present when a fibrotic,thickened,and adherent pericardium restricts diastolic filling of the heart.Calcium deposition may contribute to thickening and stiffing of the pericardium. 1.Pathophysiology 2.Etiology Tuberculosis is the leading cause 3.clinical factures Constrictive restrictrve pericarditis cardiomyopathy S3 gallop absent may be present Pericardial knock may be present absent Palpable systolic absent may be preset apical impulse Pericardial calcification may be present absent Equal RV and LV diastolic pressure usually present LVRV Rate of LV