精品心包积液 上海第二医科大学课件

心包积液 病理解剖 l包绕心脏的纤维浆膜囊，分脏壁两层。 l正常时有1030ML液体，起润滑作用。 l正常时超声不能分辨出心包腔，仅显示 l为明亮的强回声。 l心包腔在心尖、心前区及膈面范围较大 ， l能容纳较大量的积液。 l保护作用，限制心脏过分扩张，有助心 房充盈。 病因 l结核、风湿、病毒、化脓性炎症、 l非特异性心包炎、肿瘤、外伤、 l尿毒症、SLE l甲状腺疾病、急性心梗、 l心功能不全。 心包积液性质与病因 l浆液性：充血性心衰、低蛋白血症等 l纤维性：细菌性、结核性心外膜炎、胶原性疾 l 病、急性心肌梗死、尿毒症、医源性 l出血性：医源性（心脏手术、心导管）、急性 l 心肌梗死、肿瘤。 l化脓性：化脓性感染并有多房局限性粘连 l胆固醇性：甲减、结核、风湿性 血流动力学 lPE心包腔压力上升右心回流受阻 l心室舒张充盈受限心充盈量急剧下降 l心排量减少收缩压下降休克、脉压 l差缩小，奇脉（吸气时回流量少，血压 l明显下降） 转归 l吸收 l维持不变 l缩窄性心包炎 l心包填塞（与心包积液量不成正比） 超声表现 l等级 ML 液体宽度 部位 l微量 3050 23MM 房室沟 l少量 50200 5MM 左室后壁 l中量 200500 510MM 右室前壁 l 1020MM 左室后壁 l大量 500 15MM 右室前壁 l 20MM 左室后壁 超声表现 l心包腔内无回声液性暗区 l积液内水草状、飘带状光带漂动 l心包填塞时，右室受压缩小，室壁塌陷 ， l 呼吸时相性变化显著。 鉴别诊断 l心外脂肪垫 l左侧胸腔积液 临床意义 l一 诊断迅速、动态判断积液量的变化 l二 引导心包穿刺，定位定深度，监测进 针路径，提高穿刺成功率。 存在问题 l一定性 诊断：符合率90%以上，仍有少 量假阳性和假阴性。 l二 定量诊断：半定量，不能达到精确程 l度。 l三 定位穿刺：宜左不宜右，宜下不宜上 ，宜外不宜内，宜直不宜斜。 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