Download 3. carditis

MINISTRY OF HEALTH OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF "INFECTIOUS DISEASES AND PEDIATRICS"
CASE - TECHNOLOGY
For Education on "The course of non-rheumatic cordites in young children.
Etiopathogenesis, clinical manifestations, diagnosis, differential diagnosis, treatment
and prevention. Tactics GP”
Case
Solve the problem, what is the tactic of a general practitioner with cordites in
children
TASHKENT – 2012
MINISTRY OF HEALTH OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF "INFECTIOUS DISEASES AND PEDIATRICS"
I "CONFIRM"
The pro-rector on study
Professor Teshaev O.R.
___________________
_______________ 2012
CASE - TECHNOLOGY
For Education on "The course of non-rheumatic
carditis in young children. Etiopathogenesis, clinical
manifestations, diagnosis, differential diagnosis,
treatment and prevention. Tactics GP'
Compiled by: docent Mirrahimova M.H.
The pedagogical summary
Subject: "Pediatrics"
Topic: "The course of nerevmatichekogo cordites in young children. Etiopathogenesis, clinical
manifestations, diagnosis, differential diagnosis, treatment and prevention. GP tactics. "
The purpose of this case:
• To teach students the criteria for diagnosis of cordites in children;
• To discuss the right choice of antibacterial drugs and drug correction of violations, the main vital
functions of organs and systems;
• Demonstrate the principles of the differential diagnosis;
• Review the criteria for possible complications of cordites in children;
• Giving students draw up plan recreational activities;
Expected learning outcomes - the results of the work with a case students learn how to:
• Assessment and analysis of the situation and the general condition of children with cordites.
• Choosing the right algorithm for the diagnosis of action.
• Independently provide emergency assistance if needed
• Refer to hospital for treatment
• Be able to make qualified post inpatient rehabilitation.
For the successful resolution of the case study student should know
 Anatomical and physiological features of the cardiovascular apparatus in different age periods;
 Know the etiology and pathogenesis;
 Criteria for diagnosing cordites in children;
 Classification nerevmatichekogo cordites in children;
 The main clinical manifestations, diagnosis and treatment principles nerevmatichekogo cordites in
children.
 Clinical options for the various forms of cordites, the principles of differential diagnosis;
 Major complications carditis;
 Principles of treatment and prevention;
 Indications for consulting cardiologist.
This case reflects the real situation in primary care
Information sources CASE
Medical History
MAIN REFERENCES
1. Childhood illnesses. Daminov TA Khalmatova BT, Boboeva WR, Tashkent, 2010
2. Pediatrics. N.N.Shabalov. St. Petersburg, 2008
3. Propaedeutics childhood diseases. AA Baranov. M., Medicine, 2007
4. Pediatrics. Isayev. St. Petersburg, 1997
ADDITIONAL
1. Anatomy and physiology of children and adolescents. Sain MR, St. Petersburg, 2008.
2. www.medafarm.ru
3. www.tma.uz
4. www.medlincs.ru
Characteristics of case study according to typological features
This case is classified as a desk, scene. He volume, structured. This case-issue
For didactic purposes Case Training, stimulating thinking in the real world in a hovercraft.
Case can be used in the disciplines: Pediatrics, tuberculosis, Emergencies
I CASE
"The course of nerevmatichekogo cordites in children. Etiology, pathogenesis, clinical
manifestations, diagnosis, treatment and prevention. Tactics GPs'
Introduction
Nonrheumatic cordites - damage the heart muscle, caused by the development of non-specific
inflammatory changes. According to the autopsy, the prevalence of cordites in children is higher than in
adults, severe forms occur in young children. Cordites frequency increases significantly during epidemics
of viral infections.
The solution proposed case study will enable students to achieve the following learning outcomes:
 Assessment and analysis of the situation and the general condition of children with carditis.
 Choosing the right algorithm for the diagnosis of action.
 Independently provide emergency assistance when needed.
 Refer to hospital for treatment.
 Be able to make qualified post inpatient rehabilitation.
Situation №1. Boy, 3 years, joined the SVP gravity.
From history we know those 5 days ago, he suffered a respiratory viral infection. Received inadequate
treatment. Soon she began to notice that the boy's temperature was increased periodically to sub febrile
figures catarrhal symptoms were not. Go to a doctor, it was a blood test, which revealed no changes. Was
diagnosed with the flu, aesthetic syndrome. Oxacillin received within 7 days without effect, connection
with which the patient was hospitalized.
When you receive a serious condition, the boy whiny, irritable, tires easily. Complaints of shortness of
breath and weakness. In the lungs, vesicular breathing, wheezing stagnant. Visual area of the heart is not
changed. The border of the heart: the right - on the right edge of the sternum, the top - at the edge III, left
- 1 cm medially from the mid - clavicle line. Heart sounds - moderately suppressed, tachycardia,
structurally unstable auscultator systolic murmur at the apex, the weakening of one tone, gallop rhythm.
Abdomen soft, available deep palpation, the liver and spleen were not enlarged.
Complete blood count: Hb - 90 g / l, Air - 3.5 h1012 / l Lake - 10.5 x 10 ^ 9, p / n - 2%, c 46%, E-2%, L48%, m -2%, ESR-20 mm / hour. C - Recto protein + +.
General urine analysis: Shares - 1018, protein - as, leukocytes -2-3 in p / s, red blood cells - are absent.
Responses
1. What is your diagnosis and justify it?
2. In your, look, with some pathologies to make a differential diagnosis?
3. Specify tactics GP.
Task: On the basis of the patient's condition should be a preliminary diagnosis, make the necessary
diagnosis, and make an informed decision for the future conduct of a patient with cordites.
II. Guidelines for students
2.1 The problem:
Choice of tactics and determination of the need for hospitalization in patients with cordites in a
hovercraft.
2.2. Subproblems
1. Analysis of appearance
2. Preliminary analysis of the history and events that are the etiologic factor in the occurrence of
cordites
3. Analysis of the survey
4. Selecting the appropriate diagnostic methods
5. Correlate the results and make a differential diagnosis
6. Come to a certain address in SVP
2.3. Algorithm solutions
1. Analysis of appearance includes the following research:
- Inspection of the skin and visible mucous
- The face (eyes, tongue)
2. Analysis of history
- Past medical
- Family and social history
- The duration and nature of the disease
3. Analysis of the survey
- Ps, BH.
- Percussion and auscultation of the lungs
- Percussion and auscultation of the heart
- Palpation of the abdomen
4. Selecting the appropriate diagnostic methods
- KLA, OAM
- B / c of blood
- Chest X-Ray
ECG
5. Correlate the results and make a differential diagnosis with:
- CHD myocardiodystrophy.
6. Come to a certain address in SVP
- Treatment if necessary
- Emergency hospitalization
- Emergency care
Instructions for independent work in the analysis and solution of practical situations.
Leaf analysis of the situation
Stages
Recommendations and advice
1. Familiarization with First check with case
case
Reading, Do not try to analyze the situation
2. Acquaintance with a Once again, read the information, select the paragraphs that seemed
given situation
important to you.
Try to describe the situation. Determine that it is important and what is
secondary.
3.
Identification, The problem:
formulation
and
Choice of tactics and determination of the need for hospitalization of
justification of the key children with cordites in a hovercraft.
issues
and
subproblems
4. Diagnosis of the When analyzing the situation, answer the following questions:
situation.
What range of common and dangerous diseases are accompanied by a
systolic heart murmur?
What nosologies to make a differential diagnosis and determine the most
likely causes of carditis.
Which diagnostic methods must be applied, make a plan and justify the level
survey SVP and CRH.
What additional advice specialists needed for a final diagnosis?
Determine the degree of need for follow-up (medical and non-medical
treatment.)
5.
Selection
and List all the possible ways to solve the problem in this situation.
justification of ways
and means to solve the
problem.
6. Development and Put the diagnosis, decide the issue in a hovercraft.
resolution
of
problem situation
the
Instructions for group work to analyze and solve practical situation.
Stages
Reconciliation of the situation and the
problem.
Analysis and evaluation of the
proposed methods and means of
solving problems, the choice of priority
the idea to solve the problem.
Develop mutually acceptable solution
to the problem and detailed design
implementation.
prepare a presentation
Recommendations and advice
Discuss and agree on different views of members on
the situation, the problem of the subproblems.
Discuss and evaluate the proposed options and ways to
address the problem. Select the priority, in your
opinion, the idea of solving the problem.
Develop a mutually acceptable solution to the problem
and the detailed design implementation.
Justify your diagnosis;
Justify your tactics.
Arrange the results in the form of an oral presentation
on behalf of the group. Discuss and decide the
question of who will represent the results of the group
work: the leader of the whole group or with the
division between the participants (co-reports),
depending on the tasks to be solved by them in the
course of analyzing and solving problems.
Prepare illustrative materials in the form of posters,
slides or multimedia.
In the preparation of reports, especially, mark the
approximate outline of what you say, does not go into
detail!
Sheet analysis and problem solving
The name of the stage with a briefcase
The content of work stage
Acquaintance with a given situation in Review given the particular situation and
a case
determination essential to solving the problem of
information.
Analysis of the situation
When analyzing the situation, answer the following
questions:
Preliminary analysis of the history and events that are
the etiologic factor in the occurrence of non-rheumatic
carditis in children.
Analysis of the physical examination.
Selecting the appropriate diagnostic methods.
Correlate the results and make a differential diagnosis.
Come to a certain address in SVP
Substantiation
Justification of the problem and its key components.
Choice of alternatives addressing
Formulation of alternatives solutions situational
problem.
Development and justification of Detailed development and justification of a particular
solution
decision.
III. OPTION ACTION CASEY
Teachers - KEYSOLOGOM
CASE IV - TECHNOLOGY TRAINING WORKSHOP
4.1 Model of learning technologies
Topic
Duration – 2 hours
Form of lesson
Nonrheumatic caditis
Number of students: 10 people
Workshop on widening and deepening of
knowledge, development of skills, management of
carditis
Plan workshop
ntroduction to the training session
actualization of knowledge
Work with a case of mini - groups
presentation of the results
Discussion, evaluation and selection of the best
option strategies
Conclusion. Evaluation of the groups and students,
the degree of achievement of lesson
The purpose of the training session: expanded knowledge of the tactics of children with carditis.
Developing the ability to access, analyze the situation, the choice of tactics, diagnosis, emergency care
and post-hospital rehabilitation of children with carditis at primary care level.
Tasks the teacher:
Learning outcomes:
• Consolidate and deepen the knowledge to • Access and analyze the situation and the
assess and analyze the situation and the
general condition of children with cordites
general condition of patients with carditis.
• Select action algorithm for diagnosis.
• Develop the ability to select the correct • Develop skills of independent decision-making
algorithm of actions for diagnosis.
in the management of children with carditis in
• Develop skills to provide emergency
SVP
assistance
• Produce a sequence of actions for emergency
• To develop the skills of independent
assistance if required
decision-making in the management of
children with carditis in a hovercraft.
Training methods
Case studies, discussion, practical method
Learning tools
Case, guidance
Form of training
Individual, front, group work
Conditions of learning
Audience with the technical equipment, work in
groups
Monitoring and evaluation
Observation, blitz poll presentation, evaluation
Flow chart of lesson based on the case.
Stage and the
Activities
content of the work
Tutor’s
Stages
Explains the purpose of case - the stage and its
effect on the development of professional
knowledge. Distributes materials case and
introduces the algorithm for analysis of the
situation (see Guidelines for students).
Gives the task independently analyze and record
the results in the "List of analysis of the
Students’
listen
Independently examine the
contents of an individual case
and fill the sheet of the situation.
situation"
1.1. Thread class is called, the plan, its goals,
objectives and expected learning outcomes.
1.2. Introduces the mode of operation for
employment and evaluation criteria (see the
instructions for students)
II stage main part
2.1. Justifies the statement of the problem and
60 min
the choice of the situation - relevance.
Conducting a poll in order to enhance students'
knowledge on the topic (application number 1):
Why there carditis?
List the causes of carditis?
What complications are possible with late
diagnosis of the disease?
2.2. Divides students into groups. Reminiscent of
the content and objectives of the case. Introduces
(like) the rules of the group and the rules of the
debate.
2.3. Gives the task, specify the correct
perception of the job (application number 2):
What nosologies to make a differential diagnosis
and determine the most likely causes of carditis
in children.
Diagnostic methods used in SVP
Clinical management and treatment of patients
with carditis.
2.4. Coordinates, advises, directs the learning
activities.
Evaluates the results of individual work: Sheets
of the situation.
2.5. Of the presentation on the results of the
work done to address the case study, discussion.
Organizer of the discussion: ask questions,
remarks, recalled the theoretical material
2.6. Organizer - GP algorithm of actions in this
situation (application number 3)
2.7. Tells own solution CASE
(Application number 4)
III Summary of 3.1. Summarizes the results of training activities,
studies, analysis and announces a joint evaluation of individual work.
evaluation
Analyzes and evaluates the group, notes the
20 min
positive and negative points.
3.2. Stresses the importance of case - the stage
and its impact on the future specialist
I stage. Introduction
to
the
training
session
(10-15 min)
Listen records appropriate
Answer questions, discuss, ask
clarifying questions.
Are divided into groups
Discuss, conduct a joint analysis
of
individual
problems,
determine the most important
aspects of the situation, the main
problems and their solutions,
process, results of the decision
Present options to address issues
10-15 minutes after the end of
the presentation, choose the best
option
Develop a unified system, the
discussion
Listen.
Can a self-assessment
mutual evaluation
and
Express their opinions
Appendix № 1.
The theoretical part
"The course of carditis in children. Etiology, pathogenesis, clinical manifestations, diagnosis,
treatment and prevention. Tactics GPs’ ”
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 is probably different. In acute carditis matter exposure to
infectious factor (the trigger), the selection of mediators of inflammation, 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 antikardialnye) and / or sensitized lymphocytes
autoallergenami 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 T-suppressors,
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 nonrheumatic 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).
Period of disease
Classification of non-rheumatic carditis
Congenital (antenatal) early and late acquired
Causative factor
Viral, bacterial, viral, bacterial, parasitic, fungal,
iersienozny, allergic, idiopathic
Form
Carditis
The defeat of the cardiac conduction system
Flow
Sharp - up to 3 months
Subacute - up to 18 months
Chronic - more than 18 months
(relapsing, primary chronic): static, hypertrophic,
restrictive options
The severity of carditis
easy
moderate
heavy
The form and extent of CH
Left ventricular I, IIA, IIB, III degree
Right ventricular I, IIA, IIB, III degree
total
Infarction, myocardial hypertrophy,
rhythm and conduction disturbances, pulmonary
hypertension,
valvular
lesion,
constrictive
mioperikardit,
thromboembolic syndrome
Outcomes and complications
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 allocating
extent of left and right heart failure.
CONGENITAL cordites
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 2-3-year)
Criteria for diagnosis of early congenital carditis
Histories: genetic predisposition to cardiovascular diseases, diseases of the mother during
pregnancy, decreased body weight at birth. The first symptoms appear zabbolevaniya in the first half of
life, the children postmiokardicheskim elastofibrozom - 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.
Cardiac: 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 levozhulodochkovoy
Paraclinical:
Laboratory: erythrocyte sedimentation rate, white blood cells, protein fractions of blood serum
titer ASL and AST 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
Clinical:
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.
Paraclinical:
ECG dominated elektropotentsialy left ventricular arrhythmias and conduction, ST-segment lower
contours.
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 cordites
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 the child's prior sensitization and / or allergic mood. As the symptoms of SARS subsided
extracardiac 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.
Clinical:
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.
Cardiac: 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.
Paraclinical:
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: dyspnea ¸ 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 antioventrikulyarnoy 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 in non-rheumatic cordites in children
degree
I
II A
II B
III
failure
Left ventricular
Right ventricular
Symptoms of heart failure at rest not in peace and there are no after exercise in the
form of tachycardia or shortness of breath
Heart rate and the number of breaths The liver performs at 2-3 cm from the costal
per minute, respectively increased
by 15-30 and 30-50% relative to the
norm
Heart rate and the number of breaths The liver performs at 3-5 cm from the edge
per minute, respectively increased of the arc, and swelling of the neck veins
by 30-50 and 50-70% relative to the
norm, the ability to acrocyanosis
navyaz chivy cough, wet finely
wheezing in the lungs
Heart rate and the number of breaths Heart rate and the number of breaths per
per minute, respectively increased minute, respectively increased by 50-60 and
by 50-60 and 70-100% relative to 70-100% relative to the norm, SC Kleene
the norm, SC Kleene predoteka and predoteka and lung edema
lung edema
To engage in the process of conducting system of heart attacks indicates persistence of
paroxysmal tachycardia.
The diagnostic criteria for acute cordites 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 cordites 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 cordites may be torpid development with a gradual increase in heart failure in 4-6
months after the SARS (primary subacute cordites) 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 dilated version) expressed
cardiosclerosis, it is based on preemptive violation of myocardial contractile function of the left ventricle;
- With normal or slightly reduced left ventricular cavity due to severe cardiac hypertrophy (hypertrophic
variant), and a sharp decrease in 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 cordites 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 dilatation
carditis typical high or low voltage curve, rhythm and conduction disturbances in two thirds of patients,
the symptoms of moderate predsekrdy 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
In acute non-rheumatic cordites laboratory data contain little information. Blood tests - increased
erythrocyte sedimentation rate, leukocytosis, increased ά2 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
Before considering the question of differential diagnosis of syndromes discuss the main characteristic
of the non-rheumatic carditis in children:
• Chronological relationship with acute nasopharyngeal (often viral) infection
• Shortening (less than 5 - 7 days) or no latency
• Gradual development of the disease
• Lack of arthritis and arthralgia expressed
• Active and emotionally charged nature of cardiac complaints
• Clear clinical and ECG signs of myocarditis
• No valvulita
• A rare discovery of pericarditis
• The symptoms of asthenia, violation of thermoregulation in the debut of the disease
• The dissociation of clinical and laboratory parameters
• Slow dynamics under the influence of anti-inflammatory therapy
In young children causes significant difficulties differential diagnosis of cordites with congenital heart
defects. This is the case of incomplete forms of atrioventricular communication anomaly Ebstein
corrected transposition of the great arteries.
For atrioventricular communication is characterized by two different timbre and localization systolic
murmur, signs of hypertrophy of the right ventricle and right atrium, incomplete blockade veivi right
bundle branch block in the ECG, increased lung markings on the arterial bed in combination with
satisfactory pulsation amplitude of left ventricular X-ray examination.
In favor of Ebstein anomaly shows no association between the occurrence of the disease and
transferred SARS, the prevalence in clinical signs of right heart failure in the absence of data on
pulmonary hypertension, the increase of the right atrium, the ECG is no evidence of left ventricular
hypertrophy and hypoxia.
Corrected transposition differ on ECG deflection EOS left, no Q waves in the left chest leads in the
presence of their rights.
In young children with clinical fibroelastoza endomiokarda should be suspected abnormal discharge
of the left coronary artery from the pulmonary artery (Bland-White syndrome-Garlyanda) on
sistolodiastolicheskomu noise in the second intercostal space on the left, alone or in combination with
mitral valve insufficiency, sudden bouts of anxiety, deep Q waves in leads I, aVL, V5, V6.
At older ages, when mitral valve to differential diagnosis with rheumatic fever.
Syndrome, characteristic of rheumatic heart disease
• The chronological relationship with the A strep throat (pharyngitis, tonsillitis)
• The latent period of 2 - 4 weeks
• The young age of the patient
• Mainly acute or subacute onset
• Polyarthritis or acute disease in the opening arthralgia
• «passive" nature of cardiac complaints
• Availability valvulita combined with myocarditis or pericarditis
• High mobility symptoms of carditis
• Correlation of laboratory and clinical signs of disease activity
Treatment of non-rheumatic cordites
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 developed. Antibiotic therapy 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 ½ tablets - 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, plakvinil) 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
oliguria. 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 CH otvolitsya diuretics. Depending on
the stage of heart failure can recommend the following plan of diuretics with carditis:
Left ventricular failure stage I-IIA - veroshpiron, left ventricular stage IIA + right ventricular IIAB - inside and furosemide veroshpiron; total IIB-III - Lasix furosemide or 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 of 2.4% solution). Inpatient diuretics appointed
day for 1-1.5 months, if left ventricular, and the more total CH kept within IIA-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
tableke 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 the disease in order
to prevent 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 β-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 of 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.
Prophylaxis
Primary prevention involves prevention of infection of the fetus during pregnancy, hardening of
the child, treatment of acute and chronic focal infection, dispensary observation of children at risk for
cardiovascular disease.
Secondary prevention is aimed at preventing complications and recurrence of the process, achieved a
clear focus of follow-up of patients.
Forecast
Depends on the version. Early congenital carditis occur, usually hard and often lead to death in the
early years and months of life. In case of late congenital cardia with adequate and timely administration
of therapy process may acquire chronic progression-free change of heart, perhaps, and recovery.
Acute carditis option in 44.1% of children complete recovery, approximately 50% of patients with
subacute or becomes chronic and often fatal if slowly, gradually evolving process, persistent arrhythmia
Subacute carditis occurs less favorably with higher mortality, are resistant to therapy, and often becomes
chronic variant
In chronic carditis also often unfavorable weather, especially in the development of cardiosclerosis,
progressive heart failure, pulmonary hypertension, persistent arrhythmias and conduction that can lead to
the formation of arrhythmogenic cardiomyopathy.
Clinical examination and rehabilitation of children with cordites
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: the frequency of intercurrent diseases, fatigue, temperature, signs of
NC, heart size, volume, tones, noise, their dynamics, and the adequacy of response to physical stress.
More research:
Complete blood count - 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
Total urine 2 times a year
FEKG - 1 time in 3 months, then 1 every 6 months
X-ray of the heart in 3 projections veloergometry
Functional tests
The main ways of healing:
Remediation of foci of chronic infection. Treatment of intercurrent diseases. In the presence of
chronic infection - prevention of seasonal bitsilino 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 of transfer from 15 years under the supervision of the doctor's office teen
Appendix № 2
Instructions for independent work in analyze and solve practical situation
List analysis of the situation
Stages
Recommendations and advice
1. Familiarization with First check with case
case
Reading, Do not try to analyze the situation
2. Acquaintance with a Once again, read the information, select the paragraphs that seemed
given situation
important to you.
Try to describe the situation. Determine that it is important and what is
secondary.
3.
Identification, The problem:
formulation
and Choice of tactics and determination of the need for hospitalization in patients
justification of the key with carditis in a hovercraft.
issues
and
subproblems
4. Diagnostic analysis When analyzing the situation, answer the following questions:
of the situation
What range of common and dangerous diseases are accompanied by carditis?
What nosologies to make a differential diagnosis and determine the most
likely causes of carditis.
Which diagnostic methods must be applied, make a plan and justify the level
survey hovercraft.
What additional advice specialists needed for a final diagnosis?
Determine the degree of need for follow-up (medical and non-medical
treatment)
5.
Selection
and List all the possible ways of solving this problem in a given situation
justification of the
methods and means of
addressing
6. Development and Put the diagnosis, decide the issue in a hovercraft.
resolution
of
the
problem situation
Appendix № 4
Solution to case study teacher-keysologom
Based on complaints: a boy and, 3 years, joined the SVP gravity. From history we know that 5
days ago, he suffered a respiratory viral infection. Received inadequate treatment. Soon she began to
notice the boy periodically raises the temperature to subfebrile figures catarrhal symptoms were not. Go
to a doctor, it was a blood test, which revealed no changes. Was diagnosed with the flu, asthenic
syndrome. Oxacillin received within 7 days without effect, connection with which the patient was
hospitalized. When you receive a serious condition, the boy whiny, irritable, tires easily. Complaints of
shortness of breath and weakness. In the lungs, vesicular breathing, wheezing stagnant. Visual area of the
heart is not changed. The border of the heart: the right - on the right edge of the sternum, the top - at the
edge III, left - 1 cm medially from the mid - clavicular line. Heart sounds - moderately suppressed,
tachycardia, structurally unstable auscultated systolic murmur at the apex, the weakening of one tone,
rhythm golopa.
Complete blood count: Hb - 90 g / l, Air - 3.5 h1012 / l Lake - 10.5 x 10 ^ 9, p / n - 2%, c 46%, E-2%, L48%, m -2%, ESR-20 mm / hour. C - Recto protein + +.
General urine analysis: Shares - 1018, protein - as, leukocytes -2-3 in p / s, red blood cells - are absent.
The diagnosis:
Community: Acquired nonrheumatic cordites, acute flow.
Collateral: Anemia of 1 degree.
Differential diagnosis: CHD.
Hospitalization in cardiology department.