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ODESSA NATIONAL MEDICAL UNIVERSITY
DEPARTMENT OF SURGERY № 1
METHODOLOGICAL INSTRUCTIVE ELABORATION
of the practical lesson from the discipline "Surgical diseases with child's
surgery and oncology" for teachers.
Module number 4. "Symptoms and Syndromes in surgery
Conceptual module number 8. "Clinical manifestations of surgical diseases.
Theme number 21. Syndrome chest pain, respiratory and heart failure in the
diagnosis and differential diagnosis of diseases of the chest cavity "
It is discussed and ratified on to the
methodical conference of the Department
"29" auguct 2014 р.
Protocol № 1.
Head of the Department
Professor __________Grubnik V.V..
ODESSA 2014
Post practice: "chest pain syndrome, respiratory and heart failure in the diagnosis
and differential diagnosis of diseases of the chest cavity - 6hod.
1. Urgency of the theme.
Pain in the chest (torakalhiya) is associated with the defeat of the internal organs,
bone and cartilaginous structures of the chest, myofascial syndrome, diseases of
the spine and nervous system peryferichnoyi or psychogenic illness. Torakalhiya
may be a manifestation of angina, myocardial infarction, mitral valve prolapse
Aortic aneurysms that rozsharovuye pulmonary embolism, pleurisy, pneumonia,
malignant neoplasm of the lung diseases of the gastrointestinal tract (gastric or
duodenal ulcer, pancreatitis or pancreatic cancer, cholecystitis) , diaphragmatic
abscess. In daily medical practice timely differentiation chest pain is important,
because adequate diagnosis and promotes rational therapy. Torakalhiya may also
be a manifestation of serious conditions such as acute respiratory and acute heart
failure.
Acute respiratory failure - most frequent and regular priority pathological state of
emergency medicine. Acute respiratory failure in its genesis can be primary,
caused by pathological process of airway and lung parenchyma, or secondary,
associated with a lesion of other organs and systems. Severe acute respiratory
failure parenchymatous type, which often occurs in dangerous conditions, poses a
serious problem and often causes a lethal outcome or disability. Symptom-complex
of acute respiratory failure is the main clinical feature of syndrome of acute lung
injury and acute respiratory dystress - syndrome. Cardiovascular disease is the
leading cause of death worldwide. If in 1900 the share of GCC had less than 10%
of deaths, then according to the WHO in 2000, CVD is the main cause of death. In
1996, the world of CVD deaths and 15 million people by Experts predict by 2020
the figure could reach 25 million.
2. The purpose of training:
2.1. Study objective:
1 level:
- To acquaint students an idea about the latest achievements of medicine in the
diagnosis and differential diagnosis of chest pain syndrome;
Tier 2:
- The student should know, having learned the pathogenesis of diseases that are
accompanied by pain in the chest syndrome, acute heart and respiratory failure.
3 level:
- Give students the opportunity to develop the skills and techniques techniques of
inspections, additional diagnostic methods of research with the syndrome of pain
in the chest, master algorithm in patients with acute heart and respiratory failure;
Stage 4:
- Give students the opportunity to analyze the results of laboratory, X-ray, ECG
examination of patients with acute heart and respiratory failure;
- Differentiate diseases that are accompanied by chest pain syndrome;
- Teach students to explore the ability of patients with chest pain syndrome.
2.2. Educational Goal:
- To introduce students to the contribution of local scientists in studying the
problem of chest pain syndrome, diagnosis and treatment of acute respiratory and
heart failure.
- Form a deontological principles and examination of patients with chest pain
including psychosomatic aspects of the pathogenesis of this disease;
- Developing a sense of legal responsibility for the timeliness and accuracy of
billing diagnosis.
3. Interdisciplinary integration
:№
Disciplines
Know
Be able
1.Poperedni subjects:
1.Anatomiya
2. Physiology
3.Propedevtyka
Home
diseases
Anatomy of thoracic
cavity
Physiology of lung and heart
Test Methods
respiratory and cardiovascular
systems
Define
function
respiratory and circulatory parameters
Be able to identify boundaries
heart to
percussion and
Lung auscultation
and heart
2.Nastupni
1. Cardiology
2. Pulmonology
Clinical signs and changes in
Electrocardiogram in acute myocardial
infarction
Clinical signs of disease
lung and displays them on
radiograph OHP
Read ECG
Detect changes in
radiograph
the chest
cavity
3.Vnutrishnopredmetna
integration
1.Torakalna surgery
2.Kardiohirurhiya
State of emergency diseases
of the chest cavity
Symptoms of acute coronary
syndrome
Provide emergency
help
Identify
algorithm
modern
diagnosis and
treatment
4.Zmist theme
1. Causes of chest pain syndrome.
- Nekardynalni causes pain attacks
1. Diseases of the chest wall and spine:
• kostohondryt (syndrome aunt) fybrozyt, myositis, osteochondrosis of the thoracic
spine, fractured ribs, breast-clavicular arthritis joints that shingles.
2. Diseases of the gastrointestinal tract:
• Esophagus: esophagitis, spasm, reflux;
• gallbladder: colic, cholecystitis, cholelithiasis, cholangitis;
• ulcer;
• pancreatitis.
3. Mental disorders:
• neurocirculatory dystonia
• hyperventilation syndrome;
• panic attacks, depression, somatoform disorders.
4. Pain in the chest associated with extracardiac cause may be due to the PA?
? Olohiyeyu of thorax
- Pathology of large blood vessels (pulmonary embolism, thoracic aortic aneurysm
that rozsharovuye)
- Diseases bronholehenevohoho apparatus and pleura (pneumonia, pleurisy, lung
abscess, bronchial and lung tumors)
Pulmonary embolism.
Development promoted by the PE in patients of chronic thrombophlebitis, phlebitis
pelvic veins, congestive heart failure (especially atrial fibrillation), infective
endocarditis, prolonged bed rest after suffering a surgical intervention.
Pain in the chest when PE occurs in 50-90% of cases, there is a sharp, by its
intensity and localization (for breast or parasternalno) may resemble the painful
option of myocardial infarction. Very frequent symptom of pulmonary embolism
are breathlessness, which also occurs suddenly. Characteristic sharp weakness,
with massive PE possible loss of consciousness. In some patients experiencing
hemoptysis. At clinical examination: pallor, cyanosis, tahipne, weak or filamentary
pulse, falling blood pressure, tone and accent II noise systole in pulmonary arteries.
Possible easing breathing, moist rales and pleural friction noise.
Diahnostka PE is rather complicated and requires a comprehensive approach. In
addition to history taking and clinical examination is needed evaluation data of
ECG, X-ray of the chest, anhiopulmonohrafiya.
Allocate 5 possible options ECG in pulmonary embolism:
1. Signs of acute right ventricle overload (SL-QIII, negative prong Tiii, deep
Sv5_6 and negative prongs Tv1-4) --White syndrome MakDzhina (typical for
massive pulmonary embolism).
2. Positional changes (deep Sv5_6).
3. Depression or ST segment elevation in the left breast assignments.
4. Blockade of the anterior branch of the right or left bundle Hysa, P-pulmonale.
5. The absence of changes in ECG.
When radiography of the chest may detect pulmonary vascular pattern and
increased transparency of lung tissue on the side of defeat, declining by 24-36 h
after embolism (symptom Vestermarka) extension to the inflow tract of the right
heart, dilatation of right cavities of the heart, increasing the diameter of the trunk
and main pulmonary artery appearance effusion in the pleural cavity and
dyskovydnyh atelectases.
In anhyopulmonohrammah defined central or land filling defects, "amputation" of
vessels, areas depleted blood supply, expanding the diameter of the pulmonary
artery, lung asymmetry contrasting root and slowing blood flow to the side of
defeat. In order to clarify the diagnosis and possible CT scan of the chest.
Thoracic aortic aneurysm that rozsharovuye, often occurs against a background of
continued leaking AG, pronounced atherosclerosis of the aorta, syphilitic aortic
failure, Marfan syndrome, and severe chest injuries. Distinguish proximal and
distal aneurysm segregation. Strain in intima of aorta proximal segregation occurs
most often at 2.5 cm from the aortic ring. Distribution of the proximal direction
leads to hemoperykardu, job aortic valve, severe aortic insufficiency, occlusion of
coronary arteries (more often - right). At the distal tear Sex segregation often
occurs immediately after the departure of the left subclavian artery. Distribution of
segregation in the proximal direction uncharacteristic, and aortic insufficiency
hemoperykardu usually does not happen.
The pain is usually intense, refractory to nitrate and is not associated with physical
activity. The characteristic localization in the sternum, no irradiation to the neck,
lower jaw, in both half of the chest. Pain syndrome is very similar with that in
myocardial infarction and severe angina attack. The pain may last from hours to
several days. Objectively determined by extending the vascular bundle, cardiac
dullness, expressed hluhist heart tones, possible cyanosis, swelling of the jugular
veins. Weather often unfavorable.
Diagnosis is difficult, a correct diagnosis is only 50% of cases. Specific
electrocardiographic signs of the disease there. In the case of hypertension and
aortic blemish on an electrocardiogram can be signs of left ventricular
hypertrophy. In developing a possible sharp decline hemoperykardu-voltage wave
R. When X-ray study of the chest - the shadow aortic enlargement. With CT you
can find a place detached intimacy, and false main channels, the liquid in the
cavity of the pericardium. Chrezstravohidna EchoCG has high diagnostic value,
sensitivity and specificity of the method is above 90%. In the blood hipohromna
possible anemia.
Diseases of the respiratory system.
Pain syndrome with pulmonary disease:
1. The emergence or strengthening of pain during deep breathing or coughing.
2. Acute intermittent pain, usually limited, with no tendency to irradiation.
3. The presence of other pulmonary symptoms (cough, sputum Branch, or
shortness of breath Dyspnoe various).
4. Acute or chronic lung disease in history, pleural friction noise, dry or moist
rales, perkutornoho data suggest emphysema, cavity formation or thickening of
lung tissue.
It should be noted that the pain syndrome in diseases of the lungs although
common, but usually not the leading clinical syndrome. More specific cough,
sputum selection, dyspnea, hemoptysis, cyanosis, fever, signs of intoxication.
Spontaneous pneumothorax is a collection of air in the pleural cavity in nontraumatic chest injury or medical action. Can develop diseases that occur with the
destruction of lung tissue (tuberculosis, abscess, bronchiectasis, tumor, bullous
emphysema, ehinokokova cyst). Sometimes a possible pneumothorax in healthy
subjects.
Clinically the disease is characterized by sudden sharp pain in the chest. Typically,
there are shortness of breath, frequent shallow breathing, agitation, sweating.
Shortness of breath inspiratorna. When an objective test - tympanyt side defeated,
no noticeable excursion of the lower border of the lungs, lower blood pressure,
tachycardia.
When X-ray - presence of air in the pleural cavity.
Pleurisy flowing with pain of various localization. When defeat pariyentalnoyi
pleural pain, usually localized in the lower and lateral parts of the chest.
Determined by its strengthening during deep inspiration and coughing. Pain in the
shoulder blade and is conditioned defeat, the upper parts of pleura prystinochnoyi
lungs. When apical pleurisy possible pain in the hand due to irritation of brachial
plexus. Abdominal pain, nausea and sometimes pain when swallowing are
observed at the dry diaphragmatic pleurisy.
When the diagnosis of pleurisy oriented on typical pain syndrome, fever, signs of
intoxication, friction noise pleura perkutornoho and auscultatory signs of pleural
effusion. When X-ray can reveal pleural effusion, to verify the etiology of which is
required pleural. It is possible to pleural biopsy.
In membranous pneumonia pain often barbed, increases with deep breath and
cough, and therefore inhibit its patients seek. Possible irradiation in abdominal
pain. Pain with membranous pneumonia found in 96% cases, the focal - in 88%. In
chronic inflammatory lung diseases, pneumoconiosis, tuberculosis are prolonged
pain. When lung abscess intense pain, it is determined when you click on
strengthening rib or intercostal location of an abscess near the cortical layer of the
lungs. In addition, pain increases before breakthrough abscess in the bronchus.
Decisive in the diagnosis of pneumonia is detection or krepituyuchyh
milkopuzyrchastyh moist rales at auscultation, prytuplennya perkutornoho sound.
When X-ray revealed signs of inflammation in the lungs.
Pain often accompanies tumor lung failure - from 50 to 88% of cases. The pain is
very different: dull, aching, that a crushing, burning, boring. Possible irradiation in
the shoulder, neck, abdomen, head, increased cough, deep breathing. Often
localized on the affected side, but possible side irradiation in healthy herpes. Pain,
usually permanent.
Pain in tumors may be associated with involvement pariyentalnoyi pleura,
diaphragm, chest, trachea and major bronchi, the shift of the mediastinum,
mediastinal pleura tension, which largely determines the nature of the pain. The
most severe pain caused by tumor pressure on the nerve trunk and germination of
their tumor.
The availability of a bulk formation of the lung can be thought of in the presence
of pain, cough, dyspnea, hemoptysis. Diagnosis is confirmed by radiological
investigation, computed tomography, bronchoscopy and lung biopsy.
Diseases of the abdominal cavity.
Pain syndrome characteristic of many diseases of the abdominal cavity.
In esophagitis, marked by constant smoking breast, pain along the esophagus that
increases with swallowing associated with the intake of cold or hot, solid food.
Diagnosis based on typical pain syndrome, signs of dysphagia. X-ray study reveals
dysmotility, inequality outlines the esophagus, the presence of barium depot with
erosions, fibroezofahoskopiya - hyperemia and mucosal erosion.
In achalasia cardia-(kardiospazm, idiopathic ampulla) localized pain behind the
breastbone, clearly associated with dysphagia and regurgitation of food. Pain
episode may provokuvatysya meals. In addition to clinical implications in the
diagnosis of important X-ray study in which the observed delay barium
suspension, a significant expansion of the esophagus and the fusiform narrowing in
its distal part.
-Pain with hiatal hernia often is localized in the lower sternum. Characteristic of its
appearance or increase after a meal, in a horizontal position, decreases pain while
rapid changes in body position. Disease is diagnosed based on radiological and
endoscopic studies.
-Pain in stomach ulcer and duodenal ulcer, chronic cholecystitis may sometimes
irradiyuvaty in the left half of the chest that creates a certain diagnostic difficulties,
especially if diagnosed underlying disease have not yet installed.
Fibrohastroduodenoskopiya and ultrasound of the abdomen to detect the real
reason of pain in the chest.
Chest pain associated with neurological diseases.
Pain syndrome in the chest caused by various neurological diseases. Primarily, this
disease of the spine, anterior chest wall and shoulder girdle muscles
(osteochondrosis and other musculo-fascial syndrome), in addition, differ in
structure cardialgia psycho-vegetative syndrome.
Harakteristika various pain syndromes in diseases of the spine and muscles:
Syndrome fascial or musculo-costal-vertebral pain (not visceral):
1. Fairly constant pain localization.
2. Unconditioned pain connection with a voltage corresponding muscle groups and
body position.
3. Low intensity of pain, lack of common symptoms associated with chronic or
clear current dependence early in acute trauma.
4. Clear palpation data, allowing identification of disease: local pain (limited)
palpation of relevant muscle groups, muscle hypertonus, the presence of trigger
zones.
5. Reduction or disappearance of pain with various local acts (mustard plasters,
plaster pepper, or electro-acupuncture, massage or эlektrofizyoprotsedury,
novocaine infiltration of trigger areas or hydrocortisone).
Radicular pain syndrome (including intercostal neuralgia):
1. Acute onset of disease or a clear exacerbation of chronic flow.
2. Most localization of pain in the area corresponding nerve root.
3. The distinct relationship with the movements of the spine (at radykulyarnoy
pain) or body (in neuralgia).
4. Neurological symptoms of breast or cervical radiculitis.
5. Cutting local tenderness in the places of intercostal nerves.
-Osteochondrosis.
This degenerative-dystrophic intervertebral disc failure, in which process,
beginning often in pulpoznomu nucleus progressively cover all elements of the
disc, follow the entire segment (adjacent vertebral bodies, intervertebral joints,
ligamentous apparatus). Degenerative spinal changes lead to failure of secondary
nerve roots, causing pain in the chest. The mechanism of pain associated with
compressed spine displaced intervertebral disc symptoms of a neck-thoracic
radiculitis, inflammatory changes of nerve roots, sympathetic chain boundary
irritation, accompanied with pain vegetative disorders.
The nature of the pain syndrome in osteochondrosis of the cervical spine may be
different and depends on the localization of lesions measure compression roots.
Radicular pain may be cutting, sharp, shooting. It is worse when natuzhenni,
coughing, bending and turning heads. When defeat root S6 concerned pain in the
hand that extends from the outer surface nadplechchya shoulder and forearm to the
fingers I-II, hypersensitivity in these areas, hypotrophy and reduced reflexes of
biceps shoulder. At the C7 root compression pain spreads to the outer surface of
the back and shoulder and forearm to finger III. Distribution of pain along the inner
surface of the shoulder and forearm to the fingers of IV-V characteristic for the
defeat of root C8. When osteochondrosis thoracic spine pain, usually localized in
the first region of the spine and then developing symptoms of thoracic radiculitis.
Pain syndrome associated with the movement, triggered by turning the torso.
Diagnosis is based on neurological radicular symptomdlogy, conducting functional
tests and instrumental methods of examination (radiography, CT).
-Muscle-fascial syndrome occurs in 7-35% of cases. His appearance provoked soft
tissue injury with hemorrhage and serous-fibrous ekstravazatamy, pathological
ympulsatsiyeyu of visceral lesions, vertebrohennыmy factors. As a result of
multiple etiologic factors of developing musculo-tonic response in the form
hypertonus affected muscles. The pain caused by muscle spasms and a violation of
microcirculation in the muscles. The characteristic appearance or greater pain
reduction in muscle groups, movement of hands and torso. The intensity of pain
syndrome may range from discomfort to severe pain.
-Anterior chest wall syndrome observed in patients after myocardial infarction and
myocardial defeat at heart. Maybe it is related to abnormal flow of impulses from
the heart of vegetative chain segments, leading to dystrophic changes in the
respective institutions. In some cases the syndrome can be caused by traumatic
myositis. On palpation revealed tenderness poured anterior chest wall, triggering a
period of 2-5-second breast-rib joints. When plecholopatkovomu parasynovitis
pain associated with movements in the shoulder joint, are determined changes of
the wrist. Blades for costal syndrome characterized by pain in the blades and then
spread to nadplichchya and neck, side and front surface of the chest. When
mizhlopatkovomu pain syndrome mizhlopatkoviy pain localized in the region, it
facilitates the emergence of static and dynamic overload. Syndrome is
characterized by small chest muscle pain in the III-V ribs hrudynoklyuchychnoyi
in line with possible irradiation in the shoulder.
In-aunt syndrome marked a sharp pain at the point of connection to the sternum
hryashamy II-IV ribs. Genesis syndrome possibly associated with aseptic
inflammation costal cartilages. Ksyfoyidiya revealed a sharp pain in the lower
sternum, which increases the pressure on mechovydnyy bone. When
manubryosternalnomu syndrome revealed a sharp pain on top of the sternum or
lateralnishe. Skalenus syndrome caused by compressed neurovascular bundle of
the upper limb between the front and middle scalenus, and I normal or extra edge.
This pain in the front of the chest combined with pain in the neck, shoulder joints.
At the same time can be observed autonomic disturbances in the form of fever and
pallor of skin.
Diagnosis of muscle-fascial syndrome based on the detection of morbidity and
seals on palpation of muscles, identifying trigger points, pain due to stress certain
muscle groups.
Cardialgia-psychogenic pain is an option in the heart that often occurs is that the
very phenomenon of pain being so, leading the clinical picture at any stage of the
disease, is different both in structure and inefficiency of the autonomic disorders,
pathogenesis-related pain in the heart. Pain is usually localized in the zone apex of
the heart, prekardyalnoyi area and left nipple area. Possible "migration" of pain.
Determine the nature of pain variability. Maybe nagging pain, piercing, crushing,
squeezing, burning or throbbing, he often sinuous, not kupiruyetsya nitroglycerin,
at the same time may be reduced after Validola sedatyvnыh and drugs. The pain is
usually long, but possible, and intermittent pain, which requires exclusion of
angina.
Cardiac causes
1.Typova angina
Retrosternal pain or discomfort characteristic quality and duration. There is an
exercise or stress psychoemotional. It is held at rest or with nitroglycerin.
2.Atypova angina
A number of GCC, which are characterized syndromnoy angina and require
differentiation from angina pectoris as a clinical form of IHD. The most significant
of which resulted listed below:
• mitral valve prolapse;
• aortic heart defects (aortic stenosis mouth, Aortic insufficiency);
• mitral stenosis;
• myocarditis (focal and diffuse);
• Hypertrofichnyy subaortalnyy stenosis;
• aneurysm (hematoma) vyshid?% B
Doho aorta that rozsharovuye;
• aortyt;
• rheumatic heart disease with coronaritis;
• infective endocarditis (with a bacterial-thrombotic embolism);
• pericarditis (acute and chronic);
• systemic connective tissue diseases (systemic lupus erythematosus, nodular
periarteriyit, scleroderma and others.)
• primary and secondary pulmonary hypertension;
• panarteriyit aorta (Takayasu's disease);
• thromboangiitis obliterans
(Buerger's disease);
• tahykardytychni paroxysmal cardiac rhythm: ventricular tachycardia,
SUPRAVENTRICULAR tachycardia, atrial tahyarytmiya.
Among the listed diseases of the cardiovascular system of great practical
importance in the differential diagnosis, in our opinion, are the following.
1. Acquired heart defects: aortic, mitral, aortic, mitral stenosis. Aortic insufficiency
appearance anhinnoho pain caused by low pressure diastole, decrease coronary
blood flow in hypertrophied left ventricular myocardium (LV). When aortic
stenosis pain syndrome in the heart resulting from reduction of systolic and minute
blood in high need in hypertrophied ventricular remodeling that leads to a
reduction of coronary blood flow. When mitral vice anhinni pain caused by stasis
of blood in the coronary sinus as a result of increased pressure in the right atrium,
reduced stroke volume and inadequate growth in its exercise.
2. Acute pericarditis fybrynoznyy. Characterized by intense constant pain in the
chest of various atypical localizations, exacerbated by deep breathing. The data
also allow to exclude ECG Coronarogenic genesis of pain syndrome in the heart
(Concordant ST segment elevation followed by a negative T wave, the absence of
pathological teeth Q, rapid positive dynamics).
3. Chronic pericarditis. Is the length of the pain syndrome that increases with the
change of position, misleading cardiomegaly finding sometimes lime deposits, bad
teeth T, which is kept stable, and Dr.
4. Myocarditis. Connection with diseases characterized by viral infection,
cardialgia wears a long, persistent nature, the pain is average. no paroxysmal flow,
ECG changes have a definite evolution of ST-T, is typical of IS. Chronic forms of
myocarditis occur quite often with cardiomegaly, heart failure, heart rhythm
disturbances.
5. Mitral valve prolapse. More common in women, pain in the left half of the chest
occurs spontaneously at rest, defined by different measure of mitral regurgitation,
heart rate, interruptions, multiple anomalies of skeletal structure.
6. Hypertrophic cardiomyopathy (variant subaortalnoho stenosis). Too often has a
hereditary character, different kind of auscultatory and EchoCG-painting,
ventricular rhythm disorders, has continued the existing ECG signs of LVH.
2. Clinical manifestations of acute respiratory and heart failure.
A. Definitions. On respiratory insufficiency say if the patient had hypoxemia
(arterial pO2 <50 mm Hg. Cent.) Inhalation mixture containing 50% oxygen,
hypercapnia, accompanied or not accompanied by hypoxia (arterial rSO2> 50
mmHg. Cent.) . In domestic practice adopted a different definition of respiratory
failure and dividing it by degree. Criterion is presented respiratory failure (pO2
below 50 mmHg. Cent.) - Third degree, which requires transferring the patient on
artificial ventilation.
Etiology. The reasons leading to the development of acute respiratory failure, a lot.
The most common cause of respiratory failure are listed below.
1. Obstructive breach
well. Obstruction of upper airway abnormalities may occur during development
(Hoan atresia, Pierre Robin syndrome, adhesions larynx, nadsv'yazochnyy stenosis,
vascular rings), aspiration of stomach contents or foreign body, infections
(epihlotit), allergic laringospazm, accretion (tumors, cysts hypertrophy of tonsils).
b. Lower respiratory tract obstruction can occur if anomalies (bronhomalyatsyya,
emphysema), aspiration (if traheoezofahealnoyi fistula, uncoordinated muscle
contraction of pharynx), infection (whooping cough, bronchiolitis, pneumonia),
inflammation, bronchospasm (asthma, bronchopulmonary dysplasia) as well as
outside bodies.
2. Restrictive violation
well. With the defeat of lung parenchyma. Hypoplasia of lung, RDS,
pneumothorax, hemorrhage, pulmonary edema and exudative pleurisy.
b. With the defeat of the chest wall. Diaphragmatic hernia, absence of ribs,
hypoplasia and aplasia sternum, chest (rickets), bloating, kifoskolioz, traumatic
limit the mobility of the chest, severe myasthenia psevdoparalitychna, muscular
dystrophy and obesity.
3. Diseases leading to inadequate gas exchange between alveoli and capillaries
well. Diseases of diffusion disorders. Pulmonary edema, interstitial fibrosis,
kolahenozy, pneumonia (Pneumocystis carinii), sarcoidosis, interstitial pneumonia
deskvamatyvna. PPC Clinic adults can develop in shock, or sepsis in children
undergoing drowning.
b. Diseases due to oppression respiratory center. Traumatic brain injury, infection
CNS drugs overdose sedatyvnыh, severe asphyxia and tetanus.
4. Other circumstances that contribute to the development of acute respiratory
failure
well. Increase in hydrostatic pressure.
b. Congestive heart failure.
with. Excess fluid is introduced.
d. Intussusception.
e. Chronic lung and bronchial disease
C. Clinic Clinically acute respiratory failure found in the first place, violation rate,
breathing rate and depth:
1. Apnea (full stop breathing). There stops the heart, Surgery, acute exogenous,
including medication poisoning, cranial trauma
2. Stenotic breathing - inspiratorna expressed (by inhalation), shortness of breath
with all the auxiliary respiratory muscles. Occurs when the upper airway
obstruction (foreign body, edema edema, trauma, compression of the larynx)
3.
Cheyne-Stokes respiration, Biota (liquid, irregular periodic breathing). It appears
usually in ahonalnoy stage of brain stem lesions.
4. Bradipnoye. Observed in poisoning (especially barbiturates, narcotic
analgesics).
5. Tachypnea. Determined by acidosis, fever, circulatory failure, mental
overexcited.
At any marked manifestations ADU pronounced cyanosis of mucous membranes.
1. Pulmonary symptoms
well. Tachypnea, violation of the depth and rhythm of respiratory movements
involving intercostal spaces, the expansion wing nose, cyanosis, increased
sweating.
b. Sound phenomena may be weakened or absent; possible: breathlessness and
wheezing.
2. Neurological symptoms. As a result of increased sensitivity of brain to
hypoxemia developing headache, anxiety, irritability, convulsions and sometimes
coma.
3. Symptoms of the cardiovascular system. Bradycardia and hypotension. Severe
and prolonged respiratory failure can lead to heart failure and pulmonary edema.
3. Acute heart failure.
Acute sertsena failure (CCP), a consequence of violation of myocardial contractile
capacity and reduce systolic and minute volumes of the heart, it appears extremely
difficult clinical syndromes: cardiogenic shock, pulmonary edema, acute
pulmonary heart.
Major causes and pathogenesis
The fall of contractility of the myocardium occurs as a result of his or overload, or
due to decreased functioning myocardial mass, reducing the ability of Contractile
myocytes or lower ductility wall cells. These states developed in the following
cases:
· In diastolic dysfunction and myocardial infarction systole (the most common
cause), inflammatory or dystrophic diseases of the myocardium and tahy and
bradyarytmyyah;
· The sudden occurrence of myocardial overload due to rapid significant increase
in resistance to the outflow tract (in the aorta - hypertensive crisis in patients with
compromised myocardium in the pulmonary artery - branches of the pulmonary
artery thrombosis, prolonged attack of asthma and acute pulmonary emphysema
and others.) Or by load capacity (weight of circulating blood for example, the
massive infusion of fluids - type option hyperkinetic circulation);
· In acute disorders of intracardiac hemodynamics due to rupture or intraventricular
septum of the aortic and mitral insufficiency or trykuspydalnoyi (cloisonné heart
attack, heart attack or break papillary muscle, perforation cusps of valves in
bacterial endocarditis, rupture of chords, trauma);
· With increasing load (physical or psychoemotional load, increasing flow in a
horizontal position, etc.). Decompensated myocardium in patients with chronic
congestive heart failure.
Classification
Depending on the type of flow, of which struck the heart ventricle and the
pathogenesis of some features distinguish the following clinical forms of CCP.
1. Hemodynamics with congestive type:
• right ventricular (venous stasis in a large circle of blood circulation);
• left ventricular (cardiac asthma, pulmonary edema)
2. With hypokynetychnym type circulation (small ejection syndrome - cardiogenic
shock):
• arrhythmic shock;
• reflex shock;
• real shock.
Possible complications
Any of the options OCH is a life-threatening condition. Acute congestive right
ventricular failure, which is not accompanied by a syndrome of small emission
itself is not so dangerous as the disease leading to right ventricular failure.
The clinical picture
· Acute congestive right ventricular failure turns venous stagnation in a big circle
of blood circulation with increased systemic venous pressure, swelling of veins
(more than all that noticeable on the neck), liver enlargement, tachycardia.
Appearance of edema in the lower body (with a long horizontal position - on the
back or side). Clinically, right ventricular failure from chronic intense pain it is
different in the liver, which are amplified by palpation. Specific features overload
and dilation of the right heart (extending the right of heart, systole over noise and
shoot mechovydnym protodiastolichnyy gallop, II Tone emphasis on pulmonary
artery and the corresponding ECG changes). Reduction of left ventricular filling
pressure due to right ventricular failure can lead to a drop in minute volume of the
left ventricle and the development of arterial hypotension, until the picture
cardiogenic shock.
When pericardial tamponade and constrictive pericarditis picture of stagnation in
the large circle is not associated with failure of myocardial contractile function,
and treatment aimed at restoring diastolic filling of the heart.
Biventrikulyarna failure - option when congestive right ventricular failure
combined with left ventricular not considered in this section, because treatment of
this condition differs little from the treatment of severe acute left ventricular
failure.
· Acute congestive left ventricular failure clinically manifested paroxysmal
dyspnea, choking and painful ortopnoэ that appear more often at night sometimes breathing Cheyne - Stokes, cough (dry at first and then with vidilennyam mucus
that does not bring relief), later - frothy sputum, quite often colored in pink, pale,
akrotsyanozom, hyperhidrosis, and is accompanied by excitement, fear of death. In
acute stagnate moist rales may be initially determined vysluhovuvatysya or scrap
milkopuzyrchatyh rales over the lower lungs, swelling of the mucous membrane of
small bronchi can occur with moderate picture bronhoobstruktsyy prolongation of
expiration, wheezing and signs of dry lung emphysema. Differential-diagnostic
feature that allows you to differentiate this condition from asthma, may serve as a
dissociation between the severity of the patient and (in the absence of pronounced
character of expiratory dyspnea, as well as "silent zones") nothingness auscultatory
pattern.
Calls calibers moist rales over all lungs, which can vysluhovuvatysya away (breath
that klekoche), typical of extended pattern of alveolar edema. Possible acute
enlargement of the heart to the left, the appearance of noise on top of systolic heart
protodyastolichnoho gallop and II focus on the tone of pulmonary artery pressure
and other signs of right heart until the picture of right ventricular failure. Blood
pressure may be normal, increased or decreased, tachycardia characteristic.
The picture of acute stagnation in the small circle of blood circulation that
develops within the stenosis of the left atrioventricular heart opening, in essence, a
failure of left atrium, but traditionally deals with left ventricular failure.
· Cardiogenic shock - a clinical syndrome characterized by arterial hypotension
and signs of a sharp deterioration of microcirculation and tissue perfusion,
including blood supply to the brain and kidneys (retardation or agitation, fall in
diuresis, cold skin, then covered with sticky, pale, marble picture skin), sinus
tachycardia is compensatory in nature.
The fall of cardiac output in clinical cardiogenic shock can occur in several
pathological conditions not related to failure of myocardial contractile function acute obturation atrioventricular heart or atrial myxoma hole kulevydnym platelet /
platelet ball prosthesis, pericardial tamponade in, with massive pulmonary
embolism . These states are quite often combined with a clinical picture of acute
right ventricular failure. Pericardial tamponade and atrioventricular heart
obturation hole requiring immediate surgical guide; drug therapy in these cases can
only worsen the situation. Furthermore, the picture of shock in myocardial
infarction often mimics aortic aneurysm that rozsharovuye, in this case a
differential diagnosis because this condition requires a fundamentally different
therapeutic approach.
There are three main clinical forms of cardiogenic shock:
· Arrhythmic shock develops as a result of falling circulation minute volume due to
tachycardia or bradycardia tahiarytmiyi bradyarytmiyi; after stopping cardiac
quickly restored adequate hemodynamics;
· Reflex shock (painful collapse) develops as a reaction to the pain and the
resulting reflex tone increase vahusa sinus bradycardia and is characterized by the
rapid response to therapy, primarily analgesic, is observed at relatively small sizes
of heart attack (often - back wall), the signs Congestive heart failure and
deterioration of tissue perfusion no, pulse pressure usually exceeds the critical
level;
· Valid developing cardiogenic shock defeat in the amount that exceeds 40-50% of
myocardial mass (often in the anterior-lateral and recurrent heart attacks in people
older than 60 years, with hypertension and diabetes) is characterized by full blown
picture of shock resistant to therapy, which quite often combined with congestive
left ventricular failure, depending on selected criteria for diagnosis mortality rate
ranges from 80-100%.
In some cases, especially in myocardial infarction in patients treated with diuretics,
shock, developing a character hypovolemic and adequate hemodynamics restored
relatively simply by filling in circulating volume.
Diagnostic criteria
One of the most constant signs of acute heart failure serves as a sinus tachycardia
(in the absence of sinus, complete AV-blokadы or reflex sinus bradycardia),
characterized by extending the left or right heart and the emergence of third tone at
the top or above mechovydnym shoot.
· In acute right ventricular failure stagnant diagnostic value are:
o swelling of neck veins and liver;
o Kussmaul's sign (swelling of the jugular vein on inspiration);
o intense pain in right hypochondrium;
o ECG signs of acute overload of right ventricle (type SI-QIII, growth in R-wave
assignments V1, 2 and formation of deep S wave in abduction V4-6, depression
STI, II, and VL and lifting STIII, and VF, as well as assignments V1, 2; possible
blockade of the right bundle Hysa, the negative teeth T in assignments III, aVF,
V1-4) and signs of overload of right atrium (high sharpened teeth PII, III).
· Acute congestive left ventricular failure turns on the basis of the following
symptoms:
o dyspnea intensity varying degrees, even to suffocation;
o paroxysmal cough, dry or frothy sputum, separation of foam from the mouth and
nose;
o ortopnoэ position;
o availability of moist rales that vysluhovuyutsya over an area of posterior-inferior
divisions across the surface of the chest, wheezing local milkopuzyrchasti typical
for cardiac asthma, pulmonary edema in the expanded vysluhovuyutsya
krupnopuzyrchasti wheezing over the whole surface of the lung and at a distance
(breathing klekoche).
· Cardiogenic shock on stage underhospital diagnosed on the basis of:
o fall of systolic less than 90-80 mm Hg. Art. (Or 30 mmHg. Cent. Below the
"working" level in people with hypertension);
o Reduction of pulse pressure - less than 25-20 mm Hg. Art.;
o signs of microcirculation and tissue perfusion - the decline in diuresis less than
20 ml / h, cold skin, covered with sticky sweat, pallor, skin marble picture, in some
cases - peripheral veins that spalysya.
5. Plan and organizational structure of the lesson
5.1. Tasks for self-rising level of knowledge
Question
1. Tell anatomic structure of the lungs and heart ..
2. Describe fizyolohiyu lungs and cardiovascular system.
3. Share methods of lung and heart.
4. Naming the parameters of lung function is normal.
5. Options normal electrocardiogram
:№
Main tasks
Instructions (call)
1.Nazvaty main reasons for the emergence of pain syndrome in the chest-cardiac
- No cardiac
2.
Nekardialni syndrome causes pain in the chest - diseases of the chest wall and
pozvonochnyka
- Diseases of the gastrointestinal tract
- Mental Disorders
- Pathology of the chest
3.Bil chest related to extracardiac cause may be due to pathology in the thorax,
large vessel (pulmonary embolism, thoracic aortic aneurysm that rozsharovuye);
Disease-bronchopulmonary apparatus and pleura (pneumonia, pleurisy, lung
abscess, a tumor of the bronchi and lungs)
4.Kardialni causes chest pain, typical angina
-Atypical angina
5. Acute respiratory failure-etiology
-Pathogenesis
-Clinical signs
6. Acute heart failure-etiology
- Pathogenesis
- Classification
- Clinic
7. Cardiogenic shock
-Classification
-Clinical
6.Materialy for self-control on the quality of training.
A. Questions for the self
1. Name a major cause of pain syndrome in the chest 2.Nazvit nekardialni
syndrome causes pain in the chest
3. Name the diseases that cause chest pain associated with extracardiac cause, due
to pathology of the chest.
4.Nazvit clinical signs of pulmonary embolism, acute thoracic aortic bundles.
5. Naming the clinical features of lung diseases with the presence of chest pain.
6.Nazvaty clinical manifestations of acute pulmonary failure.
7. Naming the clinical manifestations of acute heart failure.
B. Objectives for the self
Problem number 1.
Patient A., 65rokiv. Urgent entered the hospital in the region seriously. Coma,
120ud/hv pulse, respiratory rate 28, blood pressure 110/70mm Hg. Art. Face
purple-blue. On chest X-ray eclipse zone in the lower lung, a form of triangles. On
ECG there are signs of myocardial infarction were found. Neurological deficits
were found. What are you most likely diagnosis in a patient with the above:
A. pulmonary embolism.
B. Acute stroke.
V. myocardial infarction.
S. pneumonia.
D pneumothorax.
The correct answer - A.
Problem number 2.
Patient K., 27rokiv. Joined complaining of sharp pain in the left half of the soil
cavity, difficult breathing, heartbeat. 96ud/hv Pulse, blood pressure 110/70 mm Hg
century, respiratory rate 24 min. Right auscultatory breath auscultated throughout
the left - sharply weakened. Renhenolohichno - kolabovana left lung, shifted
shadow mezhestinnya pravobich. What is the diagnosis in a patient with
nyzhchepererahovanyh:
A. nearside pneumothorax.
B. nearside pleurisy.
V. Pravobichna pneumonia.
G. right lung cancer.
D. emphysema.
The correct answer - A.
7.Perelik learning practical tasks to be completed during practice
1.Pravylne reading chest X-ray.
2.Virne interpretation of ECG recognition of acute myocardial infarction.
3.Vmity form a treatment algorithm pneumothorax.
8. Tests.
1.Nazvit cardiac causes pain in the chest cavity:
A. myocardial infarction
B. pulmonary embolism
V. thoracic aortic aneurysm rupture
G. pleurisy
D. pneumothorax
The correct answer - A.
2. What are the symptoms of acute respiratory failure:
A. Violation of frequency, rhythm and depth of breathing
B. Increase pressure and pulse rate
V. fever, cough
G. Krovoharkotinnya
D. Increase pressure and pulse rate, fever, cough krovoharkotinnya
The correct answer - A.
9.Literatura:
-For students
1. Hospital Surgery: Management / Kovalchuk LY and others - Ternopil ': t group,
1999.-590p.
2.Serdechno-sosudystaya surgery: Management / BurakovskyyV.Y., Bokeryya LA
- M.: Medicine, 1989 .- 752.
-For teachers
1. Belokon NA Vrozhdennie defects serdtsa.-M.: 1990.-352p.
2. Amos N., Y. Bendet Terapevtycheskye aspect kardyohyrurhyy-K.: Health,
1990.-296s.
The methodological
instructive elaboration is made
by associated professor _________________________ Polyak SD