Download 14 Cardiomegaliya

Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
"Approved"
Vice Rector for Academic Affairs
Professor ___________ Teshaev O.R
"____" ___________ 2012
Department: Pediatrics GPs
Subject: Pediatrics
TECHNOLOGY TRAINING
on practical training on the topic:
SYNDROME cardiomegaly
Tashkent
Compiled by:
Iskanova GH - Assistant Professor, MD
Education technology approved:
At the faculty meeting protocol number from "___" ____________ 2012
Topic:
the syndrome of cardiomegaly
1. Location classes
- Department, Clinic-I, 14-cardiorheumatology housing department.
2. Duration of study subjects
Number of hours - 6.0
3. Purpose of the lesson
To consolidate and deepen the students' knowledge of infectious endocarditis, non-rheumatic carditis, congenital heart
defects develop the skill of early diagnosis, differential diagnosis and tactics GPs on remediation and clinical examination.
4. Pedagogical objectives:
- To teach students the criteria for diagnosis cardiomegaly in children.
- Discuss the correct choice of drug correction of basic vital functions of organs and systems.
- Demonstrate the principles of differential diagnosis.
- Consider the criteria of possible complications cardiomegaly.
- Organization of specialized advice to the sick child with cardiomegaly.
- To teach students draw up a plan recreational activities.
- To introduce the cardiomegaly prevention in children.
5. Learning outcomes
A student must:
- Know the AFI cardiovascular
- Tell the etiology, pathogenesis and clinical non-rheumatic carditis, infective endocarditis.
-A classification of carditis.
- To know the criteria for the diagnosis of the disease.
- To identify the major cardiac and extracardiac complications carditis.
-Have an understanding of the principles of treatment and prevention cardit
- Know the indications for consultation cardiologist.
The student should be able to:
- The right to collect medical history and complaints of the patient, to interpret them.
- Inspect the child with carditis
- Conduct palpation, percussion, auscultation of the heart in children.
- Interpret the results of clinical and biochemical studies on the disease.
- To calculate the dose of antibiotics, prednisolone, NSAIDs, depending on the age of the child.
6. Methods and techniques of teaching
Brainstorming, graphic organizer - a conceptual table
7. Learning Tools
Manuals, training materials, ECG patients, slides, video, audio, medical history
8. Forms of learning
Individual work, group work, team
9. Conditions of Learning
Audience, the Chamber
10. Monitoring and evaluation
Oral control: control issues, the implementation of learning tasks in groups, performing skills, CDS
11. Motivation
12. Intra and interdisciplinary communication
Teaching of the subject is based on the knowledge of students the basics of anatomy, physiology, pathophysiology, pathology,
microbiology, biochemistry, internal medicine, propaedeutics childhood diseases, clinical pharmacology. Acquired during the
course knowledge will be used during the passage of the GP - pediatrics and other clinical disciplines.
13. Contents classes
13.1. The theoretical part
Topic: Cardiomegaly syndrome in children.
Cardiomegaly is any abnormal increase in heart size. The reasons for this increase are: the extension of one or more chambers
of the heart, myocardial hypertrophy or infiltration, pericardial effusion, or ventricular aneurysm. Cardiomegaly can be
detected on physical examination is, more often - on chest radiography. Cardiomegaly is the result of a chronic process, in this
regard, for detection of the disease has led to an increase in heart size, and to assess the consequences of the physiological
cardiomegaly require full examination of the patient.
The main clinical symptoms of cardiomegaly:
- Palpitations, irregular, false angina, shortness of breath
- Arrhythmias and conduction
- Physical data: expanding the boundaries of the heart, deafness tones, gallop rhythm, noise functional or organic origin.
- The specific symptoms of the disease, which: has led to cardiomegaly.
The list of diseases occurring with cardiomegaly:
1. Diseases associated with expansion chambers of the heart (cardiomyopathy, non-rheumatic carditis, rheumatism).
2. Diseases associated with disorders of the heart valves (rheumatic fever, infective endocarditis).
3. Diseases of the pericardium.
4. Diseases associated with myocardial hypertrophy ("athlete's heart", primary and secondary hypertension, congenital heart
disease).
5. Diseases associated with infiltrative lesions of the heart (endocrinopathies, diffuse connective tissue disease, amyloidosis of
the heart).
Congenital and acquired heart disease (see Topic: Noise of the heart.)
Non-rheumatic carditis in children.
Nonrheumatic carditis - damage the heart muscle, caused by the development of non-specific inflammatory changes.
According to the autopsy, the prevalence of carditis in children is higher than in adults, severe forms occur in young children.
Carditis frequency increases significantly during epidemics of viral infections.
Etiology and pathogenesis.
Carditis may be complicated by any infectious disease, regardless of the causative agent. However, in most cases MN arise in
children with acute viral infection. The greatest value in their appearance is given coxsackievirus, especially groups A and B,
and ECHO. Other etiologic factors include influenza and parainfluenza viruses, measles, mumps, cytomegalovirus, etc. MN can
be caused by bacteria, rickettsia, fungi, and other infectious agents. Funds are also MH infectious origin, in particular, allergic
and toxic myocarditis.
Bacterial carditis in infants often arise in connection with an umbilical, skin, otogenic sepsis, and the older - on the background
of osteomyelitis. In this case, heart disease may be due to metastatic disease or have an infectious-allergic mechanism. Fungal
carditis occur in patients with chronic diseases receiving long-term antibiotic therapy.
In recent years, attracting the attention of hereditary factors in non-rheumatic carditis. Carditis malosimptomno in such cases,
with the development of heart failure only in the final. At the heart probably lies genetically determined defect of antiviral
immunity.
Pathogenesis of acute and chronic carditis, probably
different. In acute carditis matter exposure
infectious factors (the trigger), the allocation
inflammatory mediators, the occurrence of immediate hypersensitivity reactions (severe immune inflammation under the
influence of immune complexes) with an increase in vascular permeability and cellular infiltration, often with damage to blood
vessels. Autoallergy with acute course can only be a component, but not the leading mechanism. Due to the different
structure of immune complexes, their size, location and deposition of reparative reactions infarction possible benign or
malignant outcome of acute carditis.
During the chronic pathogen is not critical and the basis of the disease are autoimmune disorders. In this case, the interaction
of autoantibodies (antibodies anticardical) and / or sensitized lymphocytes autoallergen amid altered immune tolerance. In
response to autoantigens secondary (only property damage, heart tissue damage or a combination of this with the viral
antigen) antibodies formed antikardialnye usually aggressive. The reason for such a state is decreased formation of Tsuppressors, which leads to the activation of helper effects of hyperstimulation and B-lymphocytes. Especially chronic carditis
(self-sustaining process, systemic, malignant and recurrent, refractory to therapy) can think of autoimmune mechanism as the
basis of their formation.
Based on many years of observation Belokon NA et al. proposed a working classification of non-rheumatic carditis in children.
In practice, not always possible to determine whether the disease in the child, especially young children, congenital or
acquired. Often, its etiology remains unknown. The question of diffuse or focal nature of carditis is controversial. Back in 1836
an outstanding student corvisart J. Bouillaud established "law of simultaneous presence" for the heart, by which this body can
not be amazed one shell. Community and ample blood supply, the rhythm of the single, hematogenous route of infection,
impaired immune homeostasis as the basis of the pathogenesis of carditis exclude isolated lesion, as well as patchy, myo-,
endo-or pericardium. It could be a different diffusion processes that the clinic is equivalent severity (mild, moderate, severe).
Classification of non-rheumatic carditis
Period of the disease
Congenital (antenatal) - Early and Late
Acquired
Causative factor
Viral, bacterial, viral, bacterial, parasitic, fungal, iersienoz, allergic, idiopathic
Form (for the preferential localization of the process)
Carditis
The defeat of the cardiac conduction system
Course
Sharp - up to 3 months
Subacute - up to 18 months
Chronic - more than 18 months (relapsing, primary chronic):
The severity of carditis
Moderate to Heavy Light
The form and extent of the SI
Left ventricular I, GA, IB, III degree Right ventricular I, PA, PB, III degree of Totality
Outcomes and complications
Infarction, myocardial hypertrophy, arrhythmias and conduction, pulmonary hypertension, valvular lesion, constrictive
mioperikardit, thromboembolic syndrome
Nonrheumatic carditis are congenital and acquired.
In the classification of any disease necessarily reflect its course. When non-rheumatic carditis can distinguish acute during the
rapid onset and development of the PRS with respect to (2-3 months) Rapid effects of therapy.
Subacute carditis may in some cases begin as acute, but recovery is delayed up to 18 months, in others it is possible to note a
softer start and a gradual development (primary subacute).
Chronic carditis long (more than 18 months), some patients can distinguish acute or subacute onset, the other is not (primarily
chronic).
Congenital carditis may also have sub-acute and chronic. Carditis severity determined by a complex clinical and instrumental
data: the size of the heart, the severity of heart failure, ischemic symptoms and metabolic changes in the ECG, the nature of
arrhythmias, the state of the pulmonary circulation. Evaluation for CH carditis is different. Comprehensive survey of patients
allowed to allocate extent of left and right heart failure.
CONGENITAL carditis
The diagnosis of congenital carditis is considered valid if symptoms of heart disease detected in utero or in the hospital, likely if they occur in the first months of life without prior intercurrent illness and / or anamnestic data about the illness of the
mother during pregnancy.
Anatomical substrate for congenital carditis divided into early and late.
Mandatory early morphological sign of carditis is fibroelastoz elastofibroz or endo-and myocardium. Late congenital carditis do
not have this feature.
Large amount of elastic tissue in retrospect indicates damage to the heart in the early fetal period (4-7th month of intrauterine
development), when fetal tissue respond to alteration of cell proliferation with the development of elastosis and fibrosis. With
the defeat of the heart after the 7th month ("late fetopathy"), there is a common inflammatory response and does not
develop fibroelastoz.
Macroscopically with early congenital carditis detected cardiomegaly with mild dilatation and hypertrophy of the left ventricle,
it is much thickened endocardium. Almost two thirds of patients with a valvular lesion (hemodynamic or postinflammatory).
The first signs of a heart suffering in both cases of early congenital carditis occur within the first 6 months of life (at least 2-3year)
Criteria for diagnosis of early congenital carditis
■ Histories: genetic predisposition to cardiovascular diseases, diseases of the mother during pregnancy, weight loss at birth
The first symptoms appear in the first six months of life, children with postmiocardical elastofibroz - for 6-18 months of life.
■ Clinical:
Extracardiac: unmotivated poor weight gain, stunted physical development, delayed development of static functions,
paleness, weakness, sweating, aphonia, unexplainable anxiety attacks.
Kardialnye: moderate cyanosis of the mucous membranes, the tips of the fingers, left-sided heart hump; apical impulse is
weakened or is not defined, muted tones or deafness, tachycardia, resistant to treatment, cardiovascular disease, usually
total, but with a predominance leftventriclues
■ Paraclinical:
Laboratory: erythrocyte sedimentation rate, white blood cells, protein fractions of blood serum titer ACTs and ACT are normal
or slightly altered
Radiographic: atelectasis of the left lower lobe of the lung. Spherical or oval shape of the heart, increasing the cardiac cavities
with marked dilatation of the left ventricle
On the ECG in congenital fibroelastoze fixed high voltage complexes QRS, rigid frequent rhythm (often without arrhythmias
and conduction disturbances), left ventricular hypertrophy with signs of ischemia it subendocardial departments (down below
the contour of ST-negative T wave)
Pathologic examination of late congenital carditis involving simultaneously detects two or three layers of the heart, vascular
system, sometimes the coronary vessels, a cardio and myocardial hypertrophy. However, the duration of the disease is not as
significant as evidenced by the absence of active inflammation and elastic tissue in the endo-and myocardium.
Criteria for the diagnosis of late congenital carditis
Extracardiac: average weight at birth is less common intrauterine malnutrition, fatigue, breast feeding, stunted physical
development in 3-5 months. life, the delay in development of static functions, frequent respiratory diseases; sweating changes
in the nervous system as a sudden attack of anxiety, shortness of breath, tachycardia, sometimes with loss of consciousness,
seizures, noisy breathing.
Cardiac: shortness of breath, existing from birth, tachycardia or bradycardia, pallor, cyanosis of mucous and fingertips,
symptoms CLO; reinforced, raised, shifted down apex beat, heart sounds loud enough, can be a systolic murmur, arrhythmias.
ECG rhythm and conduction disturbances, ST-segment below the contour.
Radiographically. normal or trapezoidal shape of the heart. The increase in cardiac shadow by dilatation of the cavities,
especially the left.
Laboratory: a change in the peripheral blood are not, negative revmotesty
PURCHASED carditis
The clinical features and course of acquired carditis divided into acute, subacute and chronic.
Among the acute carditis can distinguish cases with diffuse myocardial damage and mainly affecting the conduction system of
the heart in the form of atrioventricular block and persistent tachycardia.
Acute carditis occur at any age, but severe forms are characteristic of children during the first 3 years of life. They occur on the
background or soon after undergoing viral infection. Significant place in the event of carditis is prior sensitization of the
organism, the child and / or allergic mood.
As the symptoms of SARS subsided extracardial signs of heart are leading.
Criteria for diagnosis of acquired carditis
■ Histories: diseases of the mother during pregnancy, industrial hazards, prolonged use of certain medications, alcohol abuse.
The first symptoms appear against SARS or in 1 - 2 weeks after her previous sensitization of the body of the child, the presence
of anomalies in the constitution, failure to observe the vaccination. Extracardiac: decreased appetite, lag or poor weight gain,
weakness, sweating, fatigue, irritability, fits of excitement, sometimes loss of consciousness, seizures, hemiparesis, anxiety and
cries at night, nausea and vomiting, pallor, with gray color of the skin; compulsive cough, worse with a change of position.
Kardialnye: heart failure, left ventricular first and then total, cyanosis nasolabial triangle, acrocyanosis, arrhythmias,
conduction apex beat weakly resistant or not defined at all, the border of the relative cardiac dullness shifted, or muffled tone
deafness I, II Tone emphasis on the pulmonary artery , systolic murmur of a functional nature, or relative deficiency of the
mitral valve.
Laboratory: laboratory results provide little information
ECG electrical axis deviation to the right. Reducing voltage teeth complex QRS. Various arrhythmias, conduction. Change in
segment ST (offset lower contour) and T wave
Radiographically: pulmonary venous congestion, increased heart shadow, dilatation of the left ventricle.
The first cardiac symptoms are signs of left ventricular failure: shortness of breath, wheezing in the lungs, and tachycardia.
Following this reduced urine output, there pastoznost tissues, the liver increases. Heart hump is absent, indicating that the
severity of the disease. The boundaries of the heart in acute diffuse carditis in most cases expanded moderately, sometimes
dramatically.
Auscultation notes muted or voiceless one tone at the top, with cardiomegaly - gallop. Noise is absent or it function and is
associated with dysfunction of the papillary muscles.
In patients with lesions of the conduction system of the heart is more often normal sonority tones and full antioventricular
blockade on top auscultated intermittent popping "cannon" one tone. Tachyarrhythmia is due to premature beats, atrial
flutter, chronic ectopic tachycardia. Beats by which often diagnosed myocarditis occurs in 5.2% of cases and often disappears
after treatment. To engage in the process of conducting system of heart attacks indicates persistence of paroxysmal
tachycardia.
Heart failure is observed in all patients with acute diffuse carditis and is mainly left ventricle, with the defeat of the conducting
system of the heart of its display is minimal.
Symptoms and the degree of heart failure
non-rheumatic carditis in children
The degree of deficiency
Left ventricular Right ventricular
I Signs of heart failure at rest and no
appear after loading in the form of tachycardia
shortness of breath
II A heart rate and the number of breaths per minute, respectively, increased by 15-30 and 30-50% relative to the normal liver
performs at 2-3 cm from the costal
II B in heart rate and the number of breaths per minute, respectively, increased by 30-50 and 50-70% relative
standards, the ability to acrocyanosis, compulsive cough, wet finely wheezing in the lungs
The liver performs at 3-5cm from the edge of the arc, swelling of the neck veins
III heart rate and the number of breaths
Minute increasing by 50-60 and 70-100% relative to the norm; Clinic predoteka and lung edema
Hepatomegaly, edema (swelling of the face, legs, hydrothorax, hydropericardium, ascites)
The diagnostic criteria for acute carditis as reduced QRS voltage on ECG is only important first 2-3 weeks of the disease. If the
ECG was first made after the deadline, the voltage may be normal or even high. In addition, the typical deviation EOS right or
left, the overload of the left ventricle.
One of the diagnostic criteria for acute carditis is the regression of clinical and instrumental data for 6-18 months. Recovery
will be half of the children, the rest takes carditis subacute and chronic.
Subacute carditis may be torpid development with a gradual increase in heart failure in 4-6 months after the SARS (primary
subacute carditis) and delineated the acute phase, transforming the treatment in a lengthy process.
For subacute carditis all typical manifestations of acute, but planned heart hump, more often loud tones, systolic murmur of
mitral valve insufficiency, persistent emphasis II tone of the pulmonary artery, the torpid heart failure despite treatment.
Changes in the ECG are as rigidity rhythm, electrical axis deviation to the left atrioventricular disruption and intraventricular
conduction, overload of the left ventricle and both atria, are often positive T wave last two features distinguish subacute to
acute carditis.
Chronic carditis occupy the main place in non-rheumatic carditis in older children. Chronic carditis may be a primary chronic
(with clinically asymptomatic initial phase) and develop from acute or subacute.
There are two variants of chronic carditis:
- With increased left ventricular hypertrophy and its small infarction (static, or dilatation variant) expressed cardiosclerosis in.
based on the predominant violation of myocardial contractile function of the left ventricle;
- With normal or slightly reduced left ventricular cavity due to severe cardiac hypertrophy (hypertrophic version)
- With dramatically reduced left ventricular hypertrophy with or without the (restrictive version): it is based on primary
diastolic (relaxation) of left ventricular function.
Common clinical manifestations of chronic carditis should be considered relatively long asymptomatic dominated noncardiac
symptoms: stunted physical development, recurrent pneumonia, hepatomegaly, seizures, loss of consciousness, vomiting, and
other full-blown acute PRS often after SARS first identifies a Long-suffering heart.
The most common symptoms in chronic dilated version carditis are lagging in body weight, tachypnea, weak apex beat, heart
hump, dramatically expanded the boundaries of the heart, systolic murmur of mitral valve insufficiency, persistent
arrhythmias, liver enlargement, more moderate. As a rule, in dilated version of chronic carditis detected discrepancy between
cardiomegaly and satisfactory state of health, due to the development of compensatory mechanisms with prolonged illness.
Heart failure is not a long time, then it is mainly left ventricular, and, finally, becomes total.
Prolonged malosimptomno restrictive option for chronic carditis causes of late diagnosis, typical lag not only in body weight,
but also growth, crimson cyanosis, apnea-type dyspnea, raised apical impulse. In two thirds of children at the top is defined by
clapping or enhanced I tone combined with a sharp accent II tone of the pulmonary artery, sometimes muted tones. No noise
or determined mezadiastolichesky on top or systolic in the fourth - fifth intercostal space on the left (relative tricuspid valve).
The first symptom is shortness of breath, later joined and become the leading signs of right heart decompensation, up to
severe ascites, the liver can serve at 7-8 cm from the edge of the arc.
ECG also differ in different types of chronic carditis. Thus, for a variant of chronic carditis dilatation typical high or low voltage
curve, rhythm and conduction disturbances in two thirds of patients, the symptoms of moderate overload and left ventricular
hypertrophy.
In restrictive version suffers chronic carditis atrioventricular and intraventricular conduction, there are branches of bundle
branch block in various combinations, bradycardia, an overload of both ventricles and significant overload atrial
subendocardial signs of hypoxia with a positive, negative or biphasic T wave relative safety of repolarization due to
compensatory hypertrophy .
Laboratory diagnosis of
In acute non-rheumatic carditis laboratory data contain little information. Blood tests - increased erythrocyte sedimentation
rate, leukocytosis, increased α2 and γ-globulin, C-reactive protein - shows the current viral infection. The most reliable
confirmation of the diagnosis is the isolation of the virus from the blood, nasopharyngeal mucus, faeces.
Differential diagnosis of non-rheumatic carditis conducted with other diseases associated with cardiomegaly, heart rhythm
disturbances, complications in the form of heart failure:
-Congenital heart disease,
, Rheumatism,
-Vascular dystonia,
- Functional cardiomyopathy, pericarditis,
- Thymomegalia, tumors of the heart
Treatment of non-rheumatic carditis has two phases: a stationary and outpatient or sanatorium.In acute and subacute carditis
is recommended to limit the motor activity of the child in 2-4 weeks, food must be complete with plenty of vitamins, proteins,
restriction of salt, the increased amount of potassium salts. Drinking schedule determined by the amount of urine, the child is
given 200-300 ml of fluid less diuresis.
Carditis etiological treatment is not fully developed. The main purpose is to antiviral drugs (acyclovir, Zovirax, arbidol,
rimantadine, interferon viferon).
Antibiotic therapy (penicillin, ampioks, Claforan, ceftriaxone. Clarithromycin, roxithromycin, etc.) be sick for 2-3 weeks, more
for the prevention of complications in young children.
Glucocorticoids are shown in diffuse process with HF, subacute onset of chronic process as the harbinger, cardio, mainly
affecting the conduction system of the heart. Prednisolone is used inside a rate of 1-1.5 mg / kg during the month, followed by
a gradual decrease of 1/3 - ¼ tablet every 3-4 days in children during the first 3 years of life and a ¼ pill - the older. With little
effect maintenance dose of prednisone - 0.5 mg / kg / day, given a few weeks. If, in spite of treatment, the process becomes
subacute or chronic, it is recommended to prescribe aminohinolinovogo series (delagil, Plaquenil) in combination with
indomethacin or Voltaren 3 mg / kg. Salicylates rate of 0.05-0.06 mg / kg administered at 1-1.5 months.
Simultaneously, treatment CLO. To improve myocardial contractility used cardiac glycosides, digoxin is preferred. Its loading
dose should not exceed 0.03-0.05 mg / kg intramuscularly or inside. Intravenous administration of glycosides shown acute
process with edema of the lung. Loading dose is introduced uniformly for 3 days every 8 hours under the supervision of the
ECG. In the absence of the effect of saturation can be administered medication for 3 times for 1-2 days. This slow introduction
of digoxin helps avoid intolerance (intoxication), which occurs in patients with carditis in the forced administration of the drug
and its large doses. After administration of the loading dose a maintenance dose, her choice is different.
If the patient is satisfactory saturation transfer digoxin with obvious effects (normalization of heart rate, shortness of breath
decrease and reduction of the liver), the maintenance dose is 1/5 of the loading dose. The tendency to bradycardia dose
should be reduced to 1/6 - 1/8, and at a constant tachycardia - increased to ¼. Maintenance dose of digoxin is given for 2
doses in 10-12 hours in, with little effect of its type in / m, and further give the inside. Introduction glycosides should be
careful when anuria and oligourii. In such cases, treatment is initiated with diuretics and after the restoration of diuresis added
cardiac glycosides. Select effective dose of digoxin give long. Indication to remove the drug is the normalization of clinical and
instrumental data.
Important place in the treatment of patients with acute carditis and heart failure is given diuretics. Depending on the stage of
heart failure can recommend the following plan of diuretics with carditis:
Left ventricular failure stage I-IIA veroshpiron, stage left ventricular PA + right ventricular IIA-B - inside and furosemide
veroshpiron, total PB-III-furosemide or Lasix parenterally in combination with veroshpiron, the ineffectiveness or add
brinaldiks Uregei. Furosemide dose - 2-4 mg / kg, veroshpirona - 1-4 mg / kg, and brinaldiksa uregita 1-2 mg / kg. In order to
increase diuresis in refractory heart failure can assign aminophylline (no more than 3 ml 2.4% solution). Inpatient diuretics
appointed day for 1-1.5 months, if left ventricular, and the more total CH kept within the PA-B stage, they continue to give and
at home with a possible transition subsequently to receive 2-3 times per week
Measures aimed at improving the metabolism in the myocardium include transfusion polarizing mixture (10% glucose 10-15
mg / kg, 1 IU of insulin injected at 3 g sugar, Panangin 1 ml / year of life, 2.5 ml of 0.25 % solution of novocaine) riboksin to ½ 1 tablet 2 times a day for 1 month, followed by ½ - 1 tablet 2 times a day is 1 month, potassium orotate, Panangin, vitamin B12
with folic acid, calcium pantothenate.
Anabolic steroids should enter no earlier than 1.5-2 months from the onset of illness in order to avoid relapse.
When atrioventricular block shows anti-inflammatory treatment and the means to eliminate myocardial dystrophy. Those at
risk for the syndrome Stokes-Adams-Morgagni patients should be referred to the rhythm of 30-50 beats / min or less. Such
patients in the hospital to conduct a sample izadrinom, alupent, which aims to clarify the possibility of increasing the heart
rate. If, after the (3-agonist (izadrina to ½ - 1 tablet under the tongue to complete resorption) comes increased heart rate of
10-15 beats / min, then the parents should have the money with them and use them at the slightest change in the child's
condition (dizziness , weakness, syncope).
In chronic carditis should not prescribe bed rest for a long time (an exacerbation of the process - no more than 2-3 weeks). For
purposes of prednisone must be treated individually, as a chronic immune inflammation often resistant to hormone therapy.
In refractory heart failure positive effect is a combination of cardiac glycosides with low doses of prednisone (0.5 mg / kg) and
furosemide.
Courses delagila and Plaquenil with Voltaren or indomethacin can be repeated 2-3 times a year. Due to the fact that chronic
carditis occur in older children, digoxin, prescribed rate of 0.02-0.04 mg / kg (the higher the weight, the lower the dose). This is
usually ¼ - 1/3 tablets at 9-12 stages (3-4 days). Maintenance dose - ¼ -1 / 2 tablets, 2 times a day (1 tablet 0.25 mg),
depending on the severity of cardiac changes
The damaging effect of kinins released in the antigen-antibody reaction, cause chronic carditis add anginin (prodektin,
paprmidin) contrycal at 0.25-0.75 g / day for 1.5-2 months. Showing drugs that enhance the metabolic processes in the
myocardium, particularly anabolic hormones.
Clinical examination and rehabilitation of children with carditis
■ The frequency of inspection specialist: after hospital discharge 1 per month - 3 months, 1 time per quarter - 6-9 months,
then one every 6 months. pediatrician cardiorheumatology, ENT doctor, a dentist, in the treatment of drug-aminohinolinovogo
optometrist 1 every 3-6 months, and the rest on the testimony of experts
■ On examination, pay attention to:
■ frequency of intercurrent disease
■ fatigue, temperature,
■ signs of NC. heart size, volume, tones, noise, their dynamics, and the adequacy of response to physical stress.
■ More research:
- CBC - 1 time in 3 months, then 2 times a year
- A blood test for C-reactive protein, protein fraction, sialic acid - 2 times a year
- Urinalysis 2 times a year
- FEKG - 1 time in Serpent, then 1 every 6 months
- X-ray of the heart in 3 projections veloergometry
- Functional tests
■ Major road rehabilitation:
Remediation of foci of chronic infection. Treatment of intercurrent diseases. In the presence of chronic infection - seasonal
bitsilinoprofilaktika 1-3 years. Seasonal prophylaxis for 4 weeks, 2 times a year, non-steroidal drugs in half the dose in
combination with kardiotroficheskimi means. In protracted and chronic carditis - 4 amirnohinlinovye preparations 1 -2 years.
■ Duration of observation:
Not less than 3 years, with the aggravation, protracted course of the process is not less than 5 years. the chronic course to
pass the age of 15 under the supervision of a doctor's office teen
The use of "satellite expectations"
The teacher can prepare a set of questions with short answers (eg, true / false), which reveal important aspects of the topic.
Students are asked to individually or in pairs to answer these questions as accurately as possible before you start the main
part of the session. Actually it means a preliminary diagnosis on the topic of the forthcoming sessions. Technically, it is easier
to implement through the use of oral test questions with answers "Yes" and "No" or "True" and "False". In this case, an
approximate estimation of the entire group in% can be done by raising the students hands on this answer "Yes" or "right." This
method allows the teacher to get feedback on the awareness of the audience on the topic. At the end of the class students
return to these issues, to ensure that you changed their point of view and the approach to the solution.
The analytical part of
13.2.
13.2.1. Case studies:
1.Rebenok 11 months. On the tenth day since the SARS condition worsened dyspnoea, became lethargic and pale. Weak pulse,
tachycardia. Muted tones, short systolic murmur. Roentgen: heart spherical. I.Postavte diagnosis:
A pneumonia
B. nonrheumatic carditis *
V.bronhiolit
G. pleurisy
D. bronchitis
II. For diagnosis requires:
A history of prenatal development
B. reduction of inheritance
G. chest X-ray
D. all of the above *
III Treatment:
A. Antibiotics
B. antihistamines
V.cardial glycosides
G. polarizing mixture
D. all of the above *
2. Child 12 years of age. Revealed displacement of the apical impulse to the left, suspected cardiomegaly:
I. What research will help determine the degree cardiomegaly:
A. EHOKS, chest *
B. ECG
B. PCG
P. What are the cause of cardiomegaly, not related to the primary lesion of the heart:
A. rheumatism
B. nonrheumatic carditis
B. infective endocarditis
G. congenital heart disease
D. "athlete's heart" *
3.Rebenku 6 months. The diagnosis nonrheumatic carditis.
I. What form of the disease is more likely:
A. congenital carditis *
B. gained carditis
B. rheumatism
G. allergic carditis
II The most likely symptom of early congenital carditis:
A. fibroelastoz *
B. Left ventricular hypertrophy
B. hypertrophy of the right yellow> Daughter
G. dilatation of the heart cavities
D. ventricular septal defect.
13.2.2 graphic organizer: Conceptual table
medication dose duration Times prpiimaet side effect
Mildronat 0.5 mg 20 days if there is no one
Carnitine chloride 0.1 g. (14 drops of 20% solution) 1 month 3 times Pain in the substrate. area
13.3. The practical part
1. Technique determine blood pressure.
№
Events No response Complete response
1 A blood pressure cuff and stethoscope 0 10
2 The subject should be in a comfortable position sitting or lying 0 10
Cuff on the shoulder of a child at 2 cm above the elbow so that between it and the shoulder held his index finger.
Stethoscope applied to the elbow at the brachial artery without pressure. 0 10
4 Use a rubber bulb to inflate the cuff air until no pulse, then gradually deflates the cuff from 0 10
14. Control forms of knowledge, skills and abilities
- Oral
- Decision of situational problems
- Demonstration of practical skills
- CDS
15. The evaluation criteria of the current control
School
№ performance
The level of student
Score
(%) and scores
Sums up the results and makes decisions regarding the principles of health care for healthy
and sick children, health groups, the assessment and monitoring of the physical and mental
development of children. Creative thinking, self parses date dispensary observation of infants
1
96-100
It's
cool
«5»
and other ages. Applies in practice the knowledge and skills of health care for the sick and the
healthy children of health groups.
Shows high activity, creativity in interactive games. Correctly solve situational tasks with full
justification. Understand the crux of the matter. Know, talks confidently
Has accurate understanding of medical examinations of children, the formation of groups at
risk. Prepares modern informative Visual AIDS or essays of high quality using the latest
literature from 7-10 sources and the Internet
Creative thinking, knows principles of screening of healthy and sick children, health groups,
the assessment and monitoring of the physical and mental development
children. Independently reviewed the additional material. Applies in practice the obtained
knowledge and skills according to the principles of health care for healthy and sick children,
health groups, the assessment and monitoring of the physical and mental development.
2
91-95
Shows high activity, creativity in interactive games. Correctly solve situational tasks with full
justification. Understand the crux of the matter. Know, talks confidently
Has accurate understanding of screening patients and healthy
children, the formation of groups at risk, evaluation
monitoring of physical and mental development.
Independently evaluates tenets of examinations of patients and healthy
children, the formation of groups at risk, evaluation
3
monitoring of physical and mental development. Applies in practice the obtained knowledge
and skills on principles of screening patients and healthy children, the formation of groups at
risk, evaluation of the monitoring of the physical and mental development. Shows high
activity, creativity in interactive games
86-90
Correctly solve situational tasks with full justification. Understand the crux of the matter.
Knows, says confidently. Has accurate representation
4
Applies in practice. Shows high activity in the interactive games. Correctly solves the case,
but the answer is not adequate justification. Understand the crux of the matter. Know, talks
confidently
81-85
Has accurate representation
Shows high activity in the interactive games. Correctly solves the situational tasks, support
response is not complete
5
76-80
Understand the crux of the matter. Knows, says confidently. Has accurate understanding of
healthy and sick children screening
6
71-75
Ok
66-70
7
«4»
Correctly solves the case, but no response has been fully justified. Understand the crux of the
matter. Knows, says confidently. Has accurate understanding of examinations of healthy and
sick children.
Understand the crux of the matter. Correctly solves the case, but could not justify a response.
Knows, says confidently. Has accurate representation on selected topics
Satisfactorily
«3»
8
61-65
Made a mistake when solving situational tasks. Knows tells not confident. Has accurate
representation on selected topics
9
55-60
Knows tells not confident. Has partial views of the examination of patients and healthy
children
54 & below
10 Unsatisfactory
«2»
Does not have an exact image of the investigated subject. Do not know
16. Flow chart classes
№
1
2
3
4
5
6
7
stage of training
Lead-inteacher (Ad practice
sessiontopics, goals, learning
outcomes, the characteristics of
thestudies, indicators and evaluation
criteria)
Discussion of the
topicpracticallyanyoneclasses,baseline
assessmentof students' knowledgewith
the useof newteaching
technologiestransformations
Summing upthe discussion
Supervisiononpatients, performing
skills
Hear and discussstudents' individual
work
Determination of the degreeof
achievementbased on
thelessonsmasteredthe theoretical
knowledgeand the results ofthe
developmentof practical skills
The conclusion ofthe teacherin
thislesson.
Assessing the studentson a 100point
systemand itsannouncement.
Dachajob tothe next class
forms of employment
5
The survey, an explanation,
interactive
methods,
preparation and decisionof
situational problems
30
5
100
Work
incounselingclinic,hospital
(Department of Pulmonary
andrenal failure.
Abstracts,
presentations,
clinical audit.
Oral survey, case studies,
discussion discussion
Information.Questionsforselftraining
17. Test questions
List the diseases occurring syndrome cardiomegaly.
Diagnostic algorithm of cardiomegaly.
Congenital heart defects.
Acquired heart disease.
Nonrheumatic carditis.
Treatment of non-rheumatic carditis.
Infective endocarditis, treatment.
Modern methods of treatment and prevention of rheumatic fever.
Extracardiac causes cardiomegaly.
duration,
in minutes
30
45
5
Emergency treatment of acute heart failure.
18. Recommended Reading
1Disease.Red.N.P.Shabalov Baby, M., 2000.
2.Neotlozhnye state in pediatrii.Red. AA Baranov, 1998. 4.Materialy lectures. 5. internet
Summary:
1. Cardiac arrhythmias in children and adolescents. Clinical features, diagnosis, treatment. Ed. Mutafyan OA 2005.
2. Clinical lectures on pediatrics. Ed. Alexandrov GA et al 2004.
Cardiovascular blood disease in children and adolescents. LM Belyaev. 1999
Internet
More:
1. Clinical features, diagnosis, treatment. Ed.1999