Download 2. carditis

MINISTRY OF PUBLIC HEALTH REPUBLIC OF UZBEKISTAN
THE TASHKENT MEDICAL ACADEMY
"CONFIRM"
The pro-rector on study
professor Teshaev O.R.
___________________
____ ___________ 2012
DEPARTMENT OF "INFECTIOUS DISEASES AND
PEDIATRICS"
Subject: CHILDREN'S DISEASE
TECHNOLOGY TRAINING
On practical training on the topic:
NORHEUMATIC CARDITIS
Tashkent – 2012
Compiled by:
Khalmatova B.T. – Head of Department, Doctor of Medical Sciences
Mirrakhimova M. Kh. – docent, Ph.D.
Education technology approved:
At the faculty meeting report №
from «___ » ____________ 2012
Flow chart classes
2
№
1
2
Stage of learning
Form of learning
Lead-in teacher (Ad practice
session topics, goals, learning
outcomes, the characteristics of
the studies, indicators and
evaluation criteria)
Discussion of the topic of practical The
survey,
an
lessons, baseline assessment of explanation
students' knowledge with the use
of new educational technologies
3
Summing up the discussion
4
Supervision
on
patients,
performing skills
Hear and discuss students'
individual work
Determination of the degree of
achievement based on the lessons
mastered
the
theoretical
knowledge and the results of the
development of practical skills
The conclusion of the teacher in
this lesson. Assessing the students
on a 100 point system and its
announcement. Dacha job to the
next class
5
6
7
Duration
5
30
5
100
30
Oral
survey,
case
studies, discussion
45
Information. Questions
for self-training
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Topic: Norheumatic carditis. Etiology, pathogenesis, clinical manifestations,
diagnosis, treatment and prevention. Tactics GPs.
3
1. Location classes
- Department of Infectious Diseases and Pediatrics, Hospital.
2. Duration of study subjects
Number of hours – 6,0
3. Purpose of classes
To consolidate and deepen the students' knowledge of non-rheumatic carditis, develop
skills of early diagnosis, differential diagnosis and tactics GPs on remediation and clinical
examination.
4. Pedagogical tasks:
- To teach students the criteria for diagnosing carditis 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 carditis.
- Organization of specialized advice to the sick child with carditis.
- To teach students draw up a plan recreational activities.
- To introduce the prevention of carditis in children.
5. Learning outcomes
The student should know:
- Know the AFI cardiovascular
- Tell the etiology, pathogenesis and clinical non-rheumatic carditis.
-to give 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 of carditis.
- Know the indications for consultation cardiologist.
The students should be able:
- 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. Teaching methods and techniques
Brainstorming, case studies, technology: 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. Learning conditions
Auditory, chamber
10. Monitory and marking
Oral control: control issues, the implementation of learning tasks in groups, performing skills,
IWS.
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11. Motivation
Knowing the characteristics of a carditis in children will allow general practitioners to diagnose
and choose the tactics. Pay attention to the nature of the heart disease, the nature of the flow and
the state of blood circulation (with a mandatory assessment of premorbid background, presence
of chronic foci of infection), pay attention to the most characteristic symptoms of the disease, in
the different character of the disease, with or without complications.
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
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.
Etiology and pathogenesis. Cordites 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 par influenza viruses, measles, mumps,
cytomegalovirus, etc. MN can be caused by bacteria, rickets, fungi, and other infectious agents.
Funds are also MH infectious origin, in particular, allergic and toxic myocarditis. Bacterial
cordites in infants often arise in connection with an umbilical, skin, ontogeny 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 cordites occur in patients with chronic
diseases receiving long-term antibiotic therapy.
In recent years, attracting the attention of hereditary factors in non-rheumatic cordites. Cordites
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 cordites is probably different. In acute cordites 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. Auto allergy 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 cordites.
During the chronic pathogen is not critical and the basis of the disease are autoimmune disorders.
In this case, the interaction of auto antibodies (antibodies antikardialnye) and / or sensitized
lymphocytes autoallergenami amid altered immune tolerance. In response to auto antigens
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 hyper
stimulation and B-lymphocytes. Especially chronic cordites (self-sustaining process, systemic,
malignant and recurrent, refractory to therapy) can think of autoimmune mechanism as the basis
of their formation.
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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 cordites
Congenital (antenatal) early and late acquired
Causative factor
Viral, bacterial, viral, bacterial, parasitic, fungal,
iersienozny, allergic, idiopathic
Form
Cordites
The defeat of the cardiac conduction system
Flow
Sharp - up to 3 months
Sub acute - 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,
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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 cordites
Clinical:
Extra cardiac: 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
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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.
Para clinical:
ECG dominated elektropotentsialy left ventricular arrhythmias and conduction, STsegment 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 cordites 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 cordites 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 cordites
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
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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 carditis 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 cordites
subacute and chronic.
Subacute carditis may be torpid development with a gradual increase in heart failure in 46 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:
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- 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 cordites 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 cordites causes of late diagnosis,
typical lag not only in body weight, but also growth, crimson cyanosis, apnea-type dispend,
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 cordites. 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, faces.
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
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• 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 Epstein 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 vivid 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 Exstein 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 syndromeGarlyanda) 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 carditis
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 200300 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
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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 IIA-B - 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
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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, silica 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
12. Analytical part (on the subject developed a case study).
13.3. The practical part
Technique to determine the relative boundaries of the heart in children
13
Purpose: To determine the relative ability of the heart border in children. Performs step (steps):
№
Execution
No
answer
0
Full answer
Percussion determine the upper limit of the heart to mediumclavicular line down, taking the first edge of the clavicle. In
normal children:
- Up to 2 years - 2 edge
- 2 - 7 years - the second intercostal space
- 7 - 12 - 3 edge
0
10
0
0
10
10
Percussion define the right border of the heart - after
determining hepatic dullness up 1 intercostal space up and
make a percussion towards the sternum. In normal children:
- Up to 2 years old - right parasternal line
- 2 - 7 years old-medially from the right parasternal line
- 7 - 12 years - from the right edge of the sternum one inch to
the right
Percussion determine the left border of the heart, in terms of
the location of the apical impulse, from the right axillary line.
In normal children:
- Up to 2 years - 1.5 - 2 cm laterally from the mid-clavicular
line
- 2 - 7 - 0.5 - 1.5 cm outwards from the mid-clavicular line
- 7 - 12 years - to the mid-clavicular line, and medially from it
by 0.5 - 1.0 cm
Total:
0
10
0
0
10
10
0
10
0
0
10
10
0
100
Lay the baby on its back
1
2
3
4
5
6
7
8
9
10
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
№
1
Progress in (%) and points
96-100
Mark
The level of knowledge of the student
Depending on the situation, to make the
right decision and concludes.
In preparation for practical training uses
additional literature (both native and
English)
Analyzes the nature of the problem
independently of cordites in children.
Themselves can examine the patient and
correct diagnoses cordites, appoints a
plan of treatment and prevention of
14
Excellent
«5»
2
91-95
3
86-90
4
76-80
cordites
Shows high activity, creativity during
interactive games
Correctly solve situational problems
with full justification response
During the discussion of the CDS is
actively asking questions, making
additions
Practical skill performs confidently,
understand the essence.
In preparation for practical training uses
additional literature (both native and
English)
Analyzes the nature of the problem
independently of cordites.
Themselves can examine the patient and
correct diagnoses (cordites), assigns a
plan of treatment and prevention of
cordites. Shows high activity, creativity
during interactive games.
Correctly solve situational problems
with full justification of the answer.
During the discussion of the CDS is
actively asking questions, making
additions. Practical skill performs
confidently, understand the essence.
Analyzes the nature of the problem
independently of cordites.
Shows high activity, creativity during
interactive games.
Correctly solve situational problems,
justifies treatment is prevention plan.
AFI knows SS system, says confidently.
There is an exact representation of the
etiology, pathogenesis, clinical picture,
can carry differential diagnosis,
prescribe treatment, can be prevented
cordites.
Practical skill performs confidently,
understand the
Properly collect history, examines the
patient, and makes a preliminary
diagnosis. Can interpret research data.
Actively involved in the discussion
IWS.
Shows high activity during interactive
games.
Correctly solve situational problems, but
cannot assign a specific treatment,
confuses dosages. AFI knows SS
system, says confidently. There is an
exact representation of the etiology,
15
Good
«4»
6
71-75
7
66-70
Satisfactorily
«3»
8
61-65
pathogenesis, clinical picture, can carry
differential
diagnosis,
prescribe
treatment, but cannot be prevented
disease.
Practical skill to perform, but confusing
steps.
Properly collect history, examines the
patient, and makes a preliminary
diagnosis. These laboratories can
interpretation of the study. Actively
involved in the discussion IWS.
Correctly solve situational problems,
knows how to put on the classification
of the clinical diagnosis, but cannot
assign a plan of treatment and
prevention.
AFI knows SS system, says confidently.
There is an exact representation of the
etiology, pathogenesis, clinical picture
and differential diagnosis, but cannot
prescribe medication
Practical skill to perform, but confusing
steps.
Properly collect history, examines the
patient, and makes a preliminary
diagnosis. Can interpret laboratory
findings. Actively involved in the
discussion IWS.
Correctly solve situational problems, but
cannot justify the clinical diagnosis
AFI knows SS system, said confidently
There is an exact representation of the
etiology, pathogenesis and clinical, but
cannot carry out differential diagnosis
and prescribe treatment.
Properly collect history, examines the
patient with cordites, but cannot assess
the severity. Partly to interpret
laboratory findings. Actively involved
in the discussion IWS.
Making mistakes in solving situational
problems (cannot put a diagnosis on
classification)
Cordites knows clinic, says no
confidence
There is an exact representation of the
etiology of cordites, but cannot relate to
the pathogenesis of clinic
History was not focused, not on the
inspection scheme. Cannot interpret the
data of laboratory research. Passive
when discussing IWS.
16
9
55-60
10
54 -30
11
20-30
Has a general idea of the cardio, tells
not confident
SS system confuses AFIs
Alone cannot interrogate and examine a
sick child. Cannot interpret the research
data. Does not participate in the
discussion of IWS.
Unsatisfactorily Do not have an exact idea of the cardio
«2»
AFI does not know the SS system
For the presence of the student in class,
Unsatisfactorily
in due form, have a notebook,
«2»
stethoscope
16. Flow chart classes
№
1
2
3
4
5
6
7
Stage of learning
Lead-in teacher (Ad practice session
topics, goals, learning outcomes, the
characteristics of the studies, indicators
and evaluation criteria)
Discussion of the topic of practical
lessons, baseline assessment of students'
knowledge with the use of new
educational technologies
Summing up the discussion
Supervision on patients, performing
skills
Hear and discuss students' individual
work
Determination of the degree of
achievement based on the lessons
mastered the theoretical knowledge and
the results of the development of
practical skills
The conclusion of the teacher in this
lesson. Assessing the students on a 100
point system and its announcement.
Distribution job to the next class
Form of learning
Duration in
minutes
5
The survey, an explanation
30
5
100
30
Oral survey, case studies,
discussion discussion
45
Information. Questions for
self-training
5
Overall 270 min – 45= 235 – 15 = 220 min duration of learning.
17. Test questions
1. Define carditis in children;
2. Classification of carditis in children, WHO (2000);
3. Etiology and pathogenesis of carditis in young children;
4. What are the symptoms of clinical-radiological and bacteriological features of carditis?
5. Diagnostic criteria carditis
6 In what appears clinical radiological and bacteriological features of carditis?
17
7. Diagnosis and differential diagnosis of carditis in children;
8. Algorithm ditakar antibiotics in children;
9. The principles of treatment of carditis in children.
10. Tactics GPs with carditis in children.
18. Recommended reading
Main
1.
2.
3.
4.
5.
6.
Childhood diseases, ed. LA Isayeva. 1994.
Propaedeutics childhood diseases A.V.Mazurin, I.M.Vorontsov, 1995
Childhood diseases, ed. H P. Shabalova, 2002
Childhood diseases, ed. H P. Shabalova, 2010
Childhood diseases, ed. AA Baranova, 2010
Childhood diseases T.O.Daminov, B.T. Khalmatova, U.R. Babaeva, 2012
Extra
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Belokon NA, Kuberger MB Diseases of the heart and blood vessels in children. M., 1987, p.303338.
Belozerov YM Pediatric Cardiology. M. 2004. 597 s.
"Diseases of young children" - a guide for physicians, edited A.A.Baranova - Moscow-Ivanov,
1998, p.241-257.
Moschich PS V.M.Sidelnikova, D.Yu.Krivchenya. "Cardiology childhood." Moscow, 2004
Pathology older children - edited A.A.Baranova, M, -1998
Directory GP. Edited by Acad. RAMS. N.R.Paleeva. EKSMO 2002
Reference pediatrician. St. Petersburg, Moscow, 2004
"Directory of the family doctor" (Pediatrics) - Minsk, 2000 - s.390-398, 417-420.
The five Minute child Health Advisor/ - M. William Schwartz, MD., - 1998, USA
A therapist’s guide to pediatric assessment, - Linda King-Thomas, Bonnie J. Hacker, 1987, USA
Pediatrics, - Margaret C. Heagarty., William J. Moss, -1997, USA
www.tma.uz
www.medlincs.ru
www.medbook.ru
www.medafarm.ru
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