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急性心功能不全

2018-01-07 15页 doc 44KB 9阅读

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急性心功能不全急性心功能不全 急性心功能不全又叫急性心力衰竭,最常见的是急性左心衰竭所引起的急性肺水肿。心功能不全被定义为由不同病因引起的心脏舒缩功能障碍,发展到使心排血量在循环血量与血管舒缩功能正常时不能满足全身代谢对血流的需要,从而导致具有血流动力异常和神经激素系统激活两方面特征的临床综合征。其中心瓣膜疾病、冠状动脉硬化,高血压、内分泌疾患、细菌毒素,急性肺梗塞、肺气肿或其他慢性肺脏疾患等均可引起心脏病而产生心力衰竭的表现。妊娠,劳累、静脉内迅速大量补液等均可加重有病心脏的负担,而诱发心肌衰竭。 1 症状体征 2 治疗方法 3 ...
急性心功能不全
急性心功能不全 急性心功能不全又叫急性心力衰竭,最常见的是急性左心衰竭所引起的急性肺水肿。心功能不全被定义为由不同病因引起的心脏舒缩功能障碍,发展到使心排血量在循环血量与血管舒缩功能正常时不能满足全身代谢对血流的需要,从而导致具有血流动力异常和神经激素系统激活两方面特征的临床综合征。其中心瓣膜疾病、冠状动脉硬化,高血压、内分泌疾患、细菌毒素,急性肺梗塞、肺气肿或其他慢性肺脏疾患等均可引起心脏病而产生心力衰竭的现。妊娠,劳累、静脉内迅速大量补液等均可加重有病心脏的负担,而诱发心肌衰竭。 1 症状体征 2 治疗 3 饮食保健 4 预防护理 5 病理病因 6 疾病诊断 7 检查方法 8 并发症 症状体征 根据心脏排血功能减退的程度,速度和持续时间的不同,以及代偿功能的差别有下列四种不同表现。 (一)昏厥 心脏本身排血功能减退,心排血量减少引起脑部缺血,发生短暂的意识丧失,称为心源性昏厥(cardiogenic syncope),昏厥发作持续数秒钟时可有四肢抽搐,呼吸暂停,紫绀等表现,称为阿-斯综合征(Adams-Stokes syndrome),发作大多短暂,发作后意识常立即恢复,主要见于急性心脏排血受阻或严重心律失常。 (二)休克 由于心脏排血功能低下导致心排血量不足而引起的休克,称为心原性休克(cardiogenicshock),心排血量减少突然且显著时,机体来不及通过增加循环血量进行代偿,但通过神经反射可使周围及内脏血管显著收缩,以维持血压并保证心和脑的血供,临床上除一般休克的表现外,多伴有心功能不全,体循环静脉瘀血,如静脉压升高,颈静脉怒张等表现。 三)急性肺水肿 为急性左心功能不全或急性左心衰竭的主要表现,多因突发严( 重的左心室排血不足或左心房排血受阻引起肺静脉及肺毛细血管压力急剧升高所致,当肺毛细血管压升高超过血浆胶体渗透压时,液体即从毛细血管漏到肺间质,肺泡甚至气道内,引起肺水肿,典型发作为突然,严重气急;每分钟呼吸可达30,40次,端坐呼吸,阵阵咳嗽,面色灰白,口唇青紫,大汗,常咯出泡沫样痰,严重者可从口腔和鼻腔内涌出大量粉红色泡沫液,发作时心率,脉搏增快,血压在起始时可升高,以后降至正常或低于正常,两肺内可闻及广泛的水泡音和 奔马律,但常被肺部水泡音掩盖,X线片可见典型蝴蝶形哮鸣音,心尖部可听到 大片阴影由肺门向周围扩展,急性肺水肿(acutepulmonary edema)早期肺间质水肿阶段可无上述典型的临床和X线表现,而仅有气促,阵阵咳嗽,心率增快,心尖奔马律和肺部哮鸣音,X线示上肺静脉充盈,肺门血管模糊不清,肺纹理增粗for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 和肺小叶间隔增厚,如及时作出诊断并采取治疗措施,可以避免发展成肺泡性肺水肿。 (四)心脏骤停 为严重心功能不全的表现,心脏骤停或心原性猝死的临床过程可分为4个时期:前驱期,发病期,心脏停搏和死亡期。 前驱期:许多病人在发生心脏骤停前有数天或数周,甚至数月的前驱症状,诸如心绞痛,气急或心悸的加重,易于疲劳,及其他非特异性的主诉,这些前驱症状并非心原性猝死所特有,而常见于任何心脏病发作之前,有资料显示50%的心原性猝死者在猝死前一月内曾求诊过,但其主诉常不一定与心脏有关,在医院外发生心脏骤停的存活者中,28%在心脏骤停前有心绞痛或气急的加重,但前驱症状仅提示有发生心血管病的危险,而不能识别那些属发生心原性猝死的亚群。 发病期:亦即导致心脏骤停前的急性心血管改变时期,通常不超过1小时,典型表现包括:长时间的心绞痛或急性心肌梗塞的胸痛,急性呼吸困难,突然心悸,持续心动过速,或头晕目眩等,若心脏骤停瞬间发生,事前无预兆警告,则95%为心原性,并有冠状动脉病变,从心脏猝死者所获得的连续心电图记录中可见在猝死前数小时或数分钟内常有心电活动的改变,其中以心率增快和室性早搏的恶化升级为最常见,猝死于心室颤动者,常先有一阵持续的或非持续的室性心动过速,这些以心律失常发病的患者,在发病前大多清醒并在日常活动中,发病期(自发病到心脏骤停)短,心电图异常大多为心室颤动,另有部分病人以循环衰竭发病,在心脏骤停前已处于不活动状态,甚至已昏迷,其发病期长,在临终心血管改变前常已有非心脏性疾病,心电图异常以心室停搏较心室颤动多见。 心脏骤停期:意识完全丧失为该期的特征,如不立即抢救,一般在数分钟内进入死亡期,罕有自发逆转者。 心脏骤停是临床死亡的标志,其症状和体征依次出现如下: ?心音消失。 ?脉搏扪不到,血压测不出。 ?意识突然丧失或伴有短阵抽搐,抽搐常为全身性,多发生于心脏停搏后10秒内,有时伴眼球偏斜。 ?呼吸断续,呈叹息样,以后即停止,多发生在心脏停搏后20,30秒内。 ?昏迷,多发生于心脏停搏30秒后。 ?瞳孔散大,多在心脏停搏后30,60秒出现,但此期尚未到生物学死亡,如予及时恰当的抢救,有复苏的可能,其复苏成功率取决于: ?复苏开始的迟早。 ?心脏骤停发生的场所。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet ?心电活动失常的类型(心室颤动,室性心动过速,心电机械分离抑心室停顿)。 ?在心脏骤停前病人的临床情况,如心脏骤停发生在可立即进行心肺复苏的场所,则复苏成功率较高,在医院或加强监护病房可立即进行抢救的条件下,复苏的成功率主要取决于病人在心脏骤停前的临床情况:若为急性心脏情况或暂时性代谢紊乱,则预后较佳;若为慢性心脏病晚期或严重的非心脏情况(如肾功能衰竭,肺炎,败血症,糖尿病或癌肿),则复苏的成功率并不比院外发生的心脏骤停的复苏成功率高,后者的成功率主要取决于心脏骤停时心电活动的类型,其中以室性心动过速的预后最好(成功率达67%),心室颤动其次(25%),心室停顿和电机械分离的预后很差,高龄也是一个重要的影响复苏成功的因素。 生物学死亡期:从心脏骤停向生物学死亡的演进,主要取决于心脏骤停心电活动的类型和心脏复苏的及时性,心室颤动或心室停搏,如在头4,6分钟内未予心肺复苏,则预后很差,如在头8分钟内未予心肺复苏,除非在低温等特殊情况下,否则几无存活,从统计资料来看,目击者的立即施行心肺复苏术和尽早除颤,是避免生物学死亡的关键,心脏复苏后住院期死亡的最常见原因是中枢神经系统的损伤,缺氧性脑损伤和继发于长期使用呼吸器的感染占死因的60%,低心排血量占死因的30%,而由于心律失常的复发致死者仅占10%,急性心肌梗塞时并发的心脏骤停,其预后取决于为原发性抑或继发性:前者心脏骤停发生时血液动力学并无不稳定;而后者系继发于不稳定的血液动力学状态,因而,原发性心脏骤停如能立即予以复苏,成功率应可达100%;而继发性心脏骤停的预后差,复苏成功率仅约30%左右。 治疗方法 一、镇静 皮下或肌肉注射吗啡5-10mg或杜冷丁50-100mg,使病人安静,扩张外周血管,减少回心血量,减轻呼吸困难。对老年人,神志不清,已有呼吸抑制,休克或合并肺部感染者禁用。 二、吸氧 加压高流量给氧每分钟6,8升,可流经25,70,酒精后用鼻管吸入,加压可减少肺泡内液体渗出,酒精能降低泡沫的表面张力使泡沫破裂,从而改善通气,也可使用有机硅消泡剂消除泡沫。 三、减少静脉回流 患者取坐位或卧位,两腿下垂,以减少静脉回流,必要时,可加止血带于四肢,轮流结扎三个肢体,每5分钟换一肢体,平均每肢体扎15分钟,放松5分钟,以保证肢体循环不受影响。 四、利尿 静脉给予作用快而强的利尿剂如速尿20,40mg或利尿酸钠25,40mg加入葡萄糖内静脉注射,以减少血容量,减轻心脏负荷,应注意防止或纠正大量利尿时所伴发的低血钾症和低血容量。 五、血管扩张剂 静脉滴注硝普钠或酚妥拉明以降低肺循环压力,但应注意勿引起低血压,也可舌下含化硝酸甘油或二硝酸异山梨醇降低肺循环静脉压。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 六、强心药 如近期未用过洋地黄类药物者,可静脉注射快速作用的洋地黄类制剂,如西地兰、毒毛旋花子甙K等,对二尖瓣狭窄所引起的肺水肿,除伴有心室率快的心房颤动外,不用强心药,以免因右心室输出量增加而加重肺充血。 七、氨茶碱 对伴有支气管痉挛者可选用,氨茶碱0.25g加入10,葡萄糖液20ml稀释后静脉缓慢注入,可减轻支气管痉挛,扩张冠状动脉和加强利尿。副作用:室性早搏和,或室性心动过速。故应慎用。 八、皮质激素 氢化考的松100,200mg或地塞米松10mg加入葡萄糖液中静滴亦有助肺水肿的控制。 九、原有疾病和诱发因素治疗 如有发作快速性心律失常,应迅速控制。 饮食保健 宜食的食物: 1)粮食类 大米、面粉、小米、玉米、高粱。 2)豆类 豆浆、豆腐等。 3)禽、畜肉类 鸡肉、鸭肉、猪肉、牛肉。 4)油脂类 植物油为主,动物油少用。 5)水产类 淡水鱼及部分含钠低的海鱼。 6)奶、蛋类 牛奶(250毫升),鸡蛋或鸭蛋。 7)蔬菜类 含钠量高者除外。 8)水果 各种新鲜水果。 9)调味品 酷、糖、胡椒、 预防护理 如何减少心衰的发生,首先要预防冠心病,要从改善生活方式着手,饮食方面不要吃过于油腻的东西,比如带鱼,蛋黄以及动物内脏和肥肉等,天天大鱼大肉绝不是好现象,高脂饮食是引起“三高”(高血糖,高血压,高血脂)症的重要因素,要尽量避免;运动方面要加强锻炼,每星期要进行两三次,每次30分钟的有氧运动,对于防止冠心病大有裨益;心情方面要愉快而不过分激动,动不动就要与他人争执,争强好胜,容易生气等都会导致心脏病的高发。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 冬季不能只要风度,不要温度,要注意保暖,避免感冒,出现发烧,贫血,甲亢等疾病,一定要及时到医院就诊,做到早发现,早诊断,早治疗,不要呆在家里讳疾忌医。 心衰患者一定要控制饮水量,过量饮茶喝咖啡,对心衰是绝对不利的,心衰主要是心脏的泵血有问题,如果喝水过多就会增加心脏的负担,发现水喝多了,要吃点利尿剂,把水排出去。 心衰患者可以适当地运动,循序渐进,重症心衰患者,开始先在床边坐一下,然后扶着床沿走几步,再走到屋子门口,直至慢慢走上大街,走向公园,去参加运动。 病理病因 1,急性弥漫性心肌损害 引起心肌收缩无力,如急性心肌炎,广泛性心肌梗塞等, 2,急起的机械性阻塞 引起心脏阻力负荷加重,排血受阻,如严重的瓣膜狭窄,心室流出道梗阻,心房内球瓣样血栓或粘液瘤嵌顿,动脉总干或大分支栓塞等, ,急起的心脏容量负荷加重 如外伤,急性心肌梗塞或感染性心内膜炎引起的瓣3 膜损害,腱索断裂,心室乳头肌功能不全,间隔穿孔,主动脉窦动脉瘤破裂入心腔,以及静脉输血或输入含钠液体过快或过多, 4,急起的心室舒张受限制 如急性大量心包积液或积血,快速的异位心律等, 5,严重的心律失常 如心室颤动(简称室颤)和其他严重的室性心律失常,心室暂停,显著的心动过缓等,使心脏暂停排血或排血量显著减少。 疾病诊断 根据典型症状和体征,诊断急性心功能不全并不困难,主要应与其它原因(特别是血管功能不全)引起的昏厥,休克和肺水肿相鉴别,昏厥当时,心律,心率无明显过缓,过速,不齐或暂停,又无引起急性心功能不全的心脏病基础的,可以排除心原性昏厥,心原性休克时静脉压和心室舒张末期压升高,与其它原因引起的休克不同,肺水肿伴肺部哮鸣音时应与支气管哮喘鉴别,此时心尖部奔马律有利于肺水肿的诊断,其他原因引起的肺水肿,如化学或物理因素引起的肺血管通透性改变(感染,低蛋白血症,过敏,有毒气体吸入和放射性肺炎等),肺间质淋巴引流不畅(肺淋巴组织癌性浸润等)或胸腔负压增高(胸腔穿刺放液过快或过多),支气管引流不畅(液体吸入支气管或咳嗽反射消失等)等,根据相应的病史和体征不难与急性心功能不全引起的肺水肿鉴别,但心脏病患者可由非心原性原因引起肺水肿,而其他原因引起的肺水肿合并心原性肺水肿的也并不罕见,应全面考虑,作出判断。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 检查方法 根据典型的症状和体征,一般不难作出诊断,其它的辅助检查方法有: 1,体格检查:呼吸频率常达每分钟30,40次,听诊时两肺满布湿性啰音和哮鸣音,心尖部第一心音减弱,频率快,同时有舒张早期第3心音而构成奔马律,肺动脉瓣第二心音亢进,血压测定可发现病人可有一过性的高血压,病情如不缓解,血压可持续下降直至休克。 2,心电图检查:心电图可显示出病人有心律失常的表现。 3,心电图检查:可显示出心影的大小及外形,根据心脏扩大的程度和动态变化可间接反映心脏的功能,也可以诊断有无肺淤血,由于肺动脉压力增高可见右下肺动脉增宽,进一步出现间质性肺水肿可使肺野模糊,Kerley B线是在肺野外侧清晰可见的水平线状影,是肺小叶间隔内积液的表现,是慢性肺淤血的特征性表现。 4,超声心动图检查:可比X线检查提供更准确的各心腔大小的变化及心瓣膜结构及功能情况,还可以用于估计心脏的收缩和舒张功能。 并发症 本病常见的并发症主要有以下几种: 1,急性心原性肺水肿 急性肺水肿是肺毛细血管压进一步升高,肺毛细血管渗出血浆成份,使肺组织间隙,肺泡和细支气管内充满液体成份而形成的一种危象,临床上多见于急起的弥漫性心肌损害,如广泛性心肌梗死,急性心肌炎;急性机械性阻塞,如严重瓣膜狭窄,心房粘液瘤;急起的心脏容量负荷过重,如瓣膜穿孔损伤,腱索断裂,室间隔穿孔,主动脉窦破裂,静脉输血,输液过多,过快;急性心室舒张受限,如急性大量心包积血积液;严重心律失常等。 ,心房颤动 2 心房颤动是一种常见的心律失常,60 岁以上的人有1 %的发生率,心房颤动患者死亡率较无房颤者高1. 5,1. 9 倍,心房颤动的发生与年龄和所患的心血管疾病类型有关,而心功能不全是最易并发心房颤动的心血管疾病之一,心功能不全伴发心房颤动发生栓塞性并发症如缺血性脑卒中的风险明显增加。 3,心原性休克 由于心脏排血功能低下导致心排血量不足而引起的休克,称为心原性休克(cardiogenicshock),心排血量减少突然且显著时,机体来不及通过增加循环血for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 量进行代偿,但通过神经反射可使周围及内脏血管显著收缩,以维持血压并保证 心和脑的血供,临床上除一般休克的表现外,多伴有心功能不全,体循环静脉瘀 血,如静脉压升高,颈静脉怒张等表现。 4,心脏骤停 为严重心功能不全的表现,心脏骤停或心原性猝死的临床过程可分为4个时期。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet
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