《临概》（三十三） | 笔记分享——心力衰竭
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 一种填空题叫完全不会，有一种<span style="color: black;">选取</span>题叫看起来都对，有一种名解叫边做边流泪，有一种分析题叫做起来崩溃，有一种考试范围叫[整本书都要考」，有一种考试重点叫「我讲过的都是重点」!想只靠重点对付期末考，<span style="color: black;">青年</span>人，你的思想很危险啊!</span></p><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">1、</span> </span></strong><strong style="color: blue;"><span style="color: black;">心力衰竭</span></strong></span><span style="color: black;">心力衰竭<span style="color: black;">指的是</span>在静脉回流正常的<span style="color: black;">状况</span>下，<span style="color: black;">因为</span>原发心脏损害<span style="color: black;">导致</span>心血量减少；<span style="color: black;">不可</span>满足组织代谢<span style="color: black;">必须</span>的<span style="color: black;">综合症</span>。</span><span style="color: black;">心肌收缩力下降使心排血量<span style="color: black;">不可</span>满足机体代谢的<span style="color: black;">必须</span>，器官、组织血液灌注不足，肺循环和(或)体循环淤血为<span style="color: black;">重点</span>表现。极少<span style="color: black;">状况</span>下<span style="color: black;">指的是</span>舒张性心力衰竭。故多<span style="color: black;">叫作</span>充血性心力衰竭。</span><span style="color: black;">（一）病因</span><span style="color: black;">1．基本病因</span><span style="color: black;">（1）<strong style="color: blue;">原发性心肌损害</strong></span><span style="color: black;">1）<strong style="color: blue;">缺血性心肌损害</strong>：节段性心肌损害有<strong style="color: blue;">冠心病心肌缺血</strong>和(或)<strong style="color: blue;">心肌梗死</strong>，<strong style="color: blue;">心肌炎</strong>，2）<strong style="color: blue;">心肌代谢<span style="color: black;">阻碍</span>性<span style="color: black;">疾患</span></strong>：、糖尿病心肌病，维生素B1缺乏性心脏病</span><span style="color: black;">（2）<strong style="color: blue;">心脏负荷过重</strong></span><span style="color: black;">1）<strong style="color: blue;">前负荷（容量复合）过重</strong>：①<span style="color: black;">心脏瓣膜关闭不全，血液返流</span>，<strong style="color: blue;">主动脉瓣关闭不全、二尖瓣关闭不全</strong>等；②<span style="color: black;"><span style="color: black;">上下</span>心或动静脉分流性先天性心血管病，</span><strong style="color: blue;">房间隔<span style="color: black;">缺失</span>或室间隔<span style="color: black;">缺失</span>、动脉导管未闭</strong>；③<span style="color: black;">伴有全身血容量<span style="color: black;">增加</span>或循环血量<span style="color: black;">增加</span>，</span><strong style="color: blue;">慢性贫血动脉静脉瘘，脚气病等、甲状腺功能亢进症</strong>。容量负荷<span style="color: black;">增多</span><span style="color: black;">初期</span>，心室腔代偿性扩大，以维持正常心排血量，但超过<span style="color: black;">必定</span>限度即<span style="color: black;">显现</span>失代偿表现。</span><span style="color: black;">2）<strong style="color: blue;">后负荷（压力负荷）过重</strong>：<strong style="color: blue;">高血压、主动脉瓣狭窄（左心室）、肺动脉高压、肺动脉瓣狭窄（右心室）</strong>等<span style="color: black;">左、右心室收缩期射血阻力<span style="color: black;">增多</span></span>。为克服<span style="color: black;">升高</span>的阻力，心室肌代偿性肥厚以<span style="color: black;">保准</span>射血量，持久的负荷过重，心肌必然<span style="color: black;">出现</span>结构和功能改变而终至失代偿，心脏排血量下降。（<strong style="color: blue;">体循环高压</strong>）</span><span style="color: black;">2．诱因：<span style="color: black;">感染、<span style="color: black;">心率</span>失常和治疗<span style="color: black;">欠妥</span>是心力衰竭最<span style="color: black;">重点</span>的诱因。</span></span><span style="color: black;">（1）感染：<strong style="color: blue;"><span style="color: black;">呼气</span>道感染是最<span style="color: black;">平常</span>，最<span style="color: black;">要紧</span>的诱因，老年<span style="color: black;">也</span>如此</strong>；感染性心内膜炎，全身感染</span><span style="color: black;">（2）<span style="color: black;">心率</span>失常：<span style="color: black;">尤其</span>是心室率快的心房颤动和其他快速<span style="color: black;">心率</span>失常</span><span style="color: black;">（3）治疗<span style="color: black;">欠妥</span>：洋地黄用量<span style="color: black;">欠妥</span>（过量或不足），合并<span style="color: black;">运用</span>了<span style="color: black;">控制</span>心肌收缩力（异搏定、β阻断剂）或<span style="color: black;">引起</span>水钠潴留（大剂量非甾体类消炎药）的<span style="color: black;">药品</span>。</span><span style="color: black;">（4）肺动脉栓塞。 （5）体力或精神<span style="color: black;">包袱</span>过大</span><span style="color: black;">（6）合并代谢需求<span style="color: black;">增多</span>的<span style="color: black;">疾患</span>，如甲状腺功能亢进、动静脉瘘等。</span><span style="color: black;">（二）病理生理</span><span style="color: black;">1．代偿机制</span><span style="color: black;">（1）Frank Starling机制，左心室功能曲线，考生要理解其含义。</span><span style="color: black;">（2）心肌肥厚，即心肌代偿重构过程，当肥厚不足以克服室壁应力时，左室<span style="color: black;">出现</span>不可逆的功能<span style="color: black;">衰退</span>。</span><span style="color: black;">（3）神经体液的代偿机制，神经内分泌激活可<span style="color: black;">加强</span>心肌收缩力使心排量<span style="color: black;">增多</span>，外周血管收缩，<span style="color: black;">增多</span>水钠潴留加重心脏<span style="color: black;">包袱</span>。</span><span style="color: black;">1）交感神经兴奋性<span style="color: black;">加强</span>。</span><span style="color: black;">2）肾素—血管紧张素系统(RASS)激活。</span><span style="color: black;">3）心力衰竭时<span style="color: black;">各样</span>体液因子的改变</span><span style="color: black;">①心钠素有很强的利尿<span style="color: black;">功效</span>。</span><span style="color: black;">②VP(ADH)发挥缩血管、抗利尿、<span style="color: black;">增多</span>血容量的<span style="color: black;">功效</span>。</span><span style="color: black;">③缓激肽</span><span style="color: black;">3．关于舒张功能不全</span><span style="color: black;">（1）主动舒张功能<span style="color: black;">阻碍</span>心室压力容量曲线向左上移位。因能量供应不足Ca2+<span style="color: black;">不可</span><span style="color: black;">即时</span>地被肌浆网回摄及泵出胞外而<span style="color: black;">导致</span>。</span><span style="color: black;">（2）<span style="color: black;">因为</span>心室肌的顺应性<span style="color: black;">衰退</span>及充盈障碍，它<span style="color: black;">重点</span>见于心室肥厚如高血压及肥厚性心肌病时。</span><span style="color: black;">（三）心力衰竭的类型</span><span style="color: black;">1．左心衰、右心衰和全心衰 2．急性和慢性心衰</span><span style="color: black;">3．收缩性和舒张性心衰</span><span style="color: black;">（四）<strong style="color: blue;">心功能的分级（NYHA）的分级</strong></span><span style="color: black;">（1）<span style="color: black;">重点</span>是<span style="color: black;">按照</span><span style="color: black;">病人</span>自觉的活动能力划分为四级：</span><span style="color: black;">I级：<span style="color: black;">身患</span>心脏病，但活动量不受限制，平时<span style="color: black;">通常</span>活动不<span style="color: black;">导致</span>疲乏、心悸、<span style="color: black;">呼气</span>困难或心绞痛。</span><span style="color: black;">Ⅱ级（心衰Ⅰ度）：心脏病<span style="color: black;">病人</span>的体力活动受到轻度限制，<span style="color: black;">休憩</span>时<span style="color: black;">没</span>自觉症状，但平时<span style="color: black;">通常</span>活动下可<span style="color: black;">显现</span>疲乏、心悸、<span style="color: black;">呼气</span>困难或心绞痛。</span><span style="color: black;">Ⅲ级（心衰Ⅱ度）：心脏病<span style="color: black;">病人</span>的体力活动<span style="color: black;">显著</span>受限，＜平时的<span style="color: black;">通常</span>活动<span style="color: black;">就可</span><span style="color: black;">导致</span><span style="color: black;">以上</span>症状。</span><span style="color: black;">Ⅳ级（心衰Ⅲ度）：心脏病<span style="color: black;">病人</span><span style="color: black;">不可</span>从事任何体力活动。<span style="color: black;">休憩</span>状态下<span style="color: black;">亦</span><span style="color: black;">显现</span>心衰的症状，体力活动后加重。</span><span style="color: black;">（2）第二种是客观的<span style="color: black;">评定</span>，即<span style="color: black;">按照</span>客观的<span style="color: black;">检测</span>手段如心电图、负荷<span style="color: black;">实验</span>、X线、超声心动图等来<span style="color: black;">评定</span>心脏病变的严重程度，分为A、B、C、D四级：</span><span style="color: black;">A级：<span style="color: black;">没</span>心血管<span style="color: black;">疾患</span>的客观依据。</span><span style="color: black;">B级：客观<span style="color: black;">检测</span>示有轻度心血管<span style="color: black;">疾患</span>。</span><span style="color: black;">C级：有中度心血管<span style="color: black;">疾患</span>的客观证据。</span><span style="color: black;">D级：有严重心血管<span style="color: black;">疾患</span>的表现。</span><span style="color: black;">（3）<strong style="color: blue;">急性心肌梗死<span style="color: black;">导致</span>泵衰竭的Killip分级</strong></span><span style="color: black;">Ⅰ级：尚<span style="color: black;">没</span><span style="color: black;">显著</span>的心力衰竭；</span><span style="color: black;">Ⅱ级：有左心衰竭，肺部啰音＜50%肺野；</span><span style="color: black;">Ⅲ级：</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">肺部有啰音，且啰音的范围大于l／2肺野(急性肺水肿)</span></strong><span style="color: black;">;</span></span><span style="color: black;">Ⅳ级：心源性休克，有不同<span style="color: black;">周期</span>和程度的血流动力学变化。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">2、</span> </span></strong><strong style="color: blue;"><span style="color: black;">慢性心力衰竭：</span></strong><strong style="color: blue;"><span style="color: black;">中国，瓣膜<span style="color: black;">疾患</span>为首要病因，高血压和冠心病次之</span></strong></span><span style="color: black;">1．临床表现</span><span style="color: black;">（1）低心输出量的表现：①疲劳、<span style="color: black;">没</span>力、倦怠；②劳动耐量下降；③夜尿次数<span style="color: black;">增加</span>、少尿；④焦虑、头痛、失眠。</span><span style="color: black;">（2）<span style="color: black;">左心衰竭</span>：<span style="color: black;">重点</span>表现为<strong style="color: blue;">肺淤血、肺水肿（这是最先<span style="color: black;">导致</span>的病变）和心排量降低</strong></span><span style="color: black;">1）症状</span><span style="color: black;">①程度不同的<span style="color: black;">呼气</span>困难：<strong style="color: blue;">左心衰最早<span style="color: black;">显现</span>的是劳力性<span style="color: black;">呼气</span>困难</strong>；<strong style="color: blue;">夜间阵发性<span style="color: black;">呼气</span>困难又<span style="color: black;">叫作</span>心源性哮喘</strong>，其<span style="color: black;">出现</span>与<span style="color: black;">睡觉</span>平卧血液重新分配使肺血流量<span style="color: black;">增多</span>，夜间迷走神经张力增加，小支气管收缩，横膈高位，肺活量减少等<span style="color: black;">原因</span><span style="color: black;">相关</span>。<strong style="color: blue;">为了减轻<span style="color: black;">呼气</span>困难常采取的半坐位或坐位即端坐<span style="color: black;">呼气</span></strong><span style="color: black;">病人</span>采取的坐位愈高说明左心衰程度越严重，<strong style="color: blue;">左心衰<span style="color: black;">呼气</span>困难最严重的形式是急性肺水肿</strong>。</span><span style="color: black;">②<strong style="color: blue;">咳嗽、咳痰、咯血</strong>：咳嗽，咳白色浆液<span style="color: black;">泡泡</span>状痰、痰中带血丝，可<span style="color: black;">导致</span>大咯血。</span><span style="color: black;">③<strong style="color: blue;">乏力、疲倦、头昏、心慌</strong>，<strong style="color: blue;">少尿及肾功能损害症状</strong></span><span style="color: black;">2)体征：除<span style="color: black;">基本</span>心脏病固有体征外，<span style="color: black;">病人</span><span style="color: black;">通常</span>均有<strong style="color: blue;">心脏扩大</strong>（单纯舒张性心衰除外）、<strong style="color: blue;">肺动脉瓣区第二心音亢进及舒张期奔马律</strong>。<strong style="color: blue;">两肺部湿性啰音</strong>：<span style="color: black;">特点为<span style="color: black;">平常</span>于两肺底，并随体位变化而变化。</span></span><span style="color: black;">（3）<span style="color: black;">右心衰竭</span>以<span style="color: black;">体静脉淤血</span>的表现为主。<strong style="color: blue;">下垂性对<span style="color: black;">叫作</span>性水肿、肝颈静脉回流征阳性、胸腔积液、颈静脉怒张</strong>属右心衰竭体征</span><span style="color: black;">1)症状</span><span style="color: black;">①<strong style="color: blue;">腹胀、食欲不振、恶心、呕吐等是右心衰最<span style="color: black;">平常</span>的症状</strong>。继发于左心衰或单纯性的右心衰均可有劳力性<span style="color: black;">呼气</span>困难的症状。</span><span style="color: black;">2)体征</span><span style="color: black;">①<strong style="color: blue;">身体下垂部位水肿为其特征</strong>，常为对<span style="color: black;">叫作</span>性可压陷性。<span style="color: black;">通常</span>来讲，非卧床病人，<strong style="color: blue;">对<span style="color: black;">叫作</span>性双下肢凹下性水肿为右心衰竭较早<span style="color: black;">显现</span>的临床表现</strong>。右心衰竭时产生水肿的<strong style="color: blue;">始动<span style="color: black;">原因</span>是毛细血管滤过压<span style="color: black;">升高</span></strong>。<strong style="color: blue;">胸腔积液</strong>多见于<strong style="color: blue;">全心衰</strong>时，以双侧为多见，<strong style="color: blue;">单侧则以右侧更为多见</strong>。</span><span style="color: black;">②<strong style="color: blue;">颈静脉征（颈静脉搏动<span style="color: black;">加强</span>、充盈、怒张），肝颈静脉反流征阳性</strong>则更具特征性。</span><span style="color: black;">③<strong style="color: blue;">肝大压痛</strong>：心源性肝硬化晚期可<span style="color: black;">显现</span><strong style="color: blue;">黄疸、肝功能受损及<span style="color: black;">海量</span>腹水</strong>。</span><span style="color: black;">④心脏体征胸骨左缘3～4助间舒张期奔马律(右心奔马律)右心衰时可<strong style="color: blue;">因右心室<span style="color: black;">明显</span>扩大而<span style="color: black;">显现</span>三尖瓣关闭不全的反流性杂音。</strong></span><span style="color: black;">⑤<strong style="color: blue;">胸水和腹水</strong>，腹水和心源性肝硬化<span style="color: black;">相关</span>，胸水多为双侧，单侧时多在右侧，左侧胸水可有肺栓塞。</span><span style="color: black;"><span style="color: black;">（3）<span style="color: black;">全心衰竭</span></span></span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">右心衰继发于左心衰而形成的全心衰</span></strong><span style="color: black;">，当右心衰<span style="color: black;">显现</span>之后，右心排血量减少，<span style="color: black;">因此呢</span>阵发性<span style="color: black;">呼气</span>困难等肺淤血症状反而有所减轻。</span></span><span style="color: black;">扩张型心肌病等表现为左、右心室<span style="color: black;">同期</span>衰竭者，肺淤血征<span style="color: black;">常常</span>不很严重，<strong style="color: blue;">左心衰的表现<span style="color: black;">重点</span>为心排血量减少的<span style="color: black;">关联</span>症状和体征，心尖部奔马律，脉压减少。</strong></span><span style="color: black;">（4）并发症：<span style="color: black;">心率</span>失常；电解质：<span style="color: black;">错乱</span>低钾较<span style="color: black;">平常</span>；淤血肝，严重者可<span style="color: black;">出现</span>心源性肝硬化；血栓栓塞：可<span style="color: black;">引起</span>肺栓塞。</span><span style="color: black;">2．实验室<span style="color: black;">检测</span>：</span><span style="color: black;">(1)X线<span style="color: black;">检测</span>：心脏的<span style="color: black;">体积</span>和外形的动态变化、肺淤血的有<span style="color: black;">没</span></span><span style="color: black;">(2)超声心动图：比X线<span style="color: black;">检测</span>更准确，<span style="color: black;">认识</span>心脏形态、射血功能及有<span style="color: black;">没</span>赘生物等</span><span style="color: black;">(3)放射性核素检查：<span style="color: black;">表示</span>心肌、心血管<span style="color: black;">状况</span></span><span style="color: black;">(4)心－肺吸氧运动<span style="color: black;">实验</span></span><span style="color: black;">(5)有创血流动力学<span style="color: black;">检测</span></span><span style="color: black;">3.诊断：心力衰竭的诊断是综合病因、病史、症状、体征及客观<span style="color: black;">检测</span>而做出的。<span style="color: black;">首要</span>应有<span style="color: black;">知道</span>的器质性心脏病的诊断。<strong style="color: blue;">左心衰竭的肺淤血<span style="color: black;">导致</span>不同程度的<span style="color: black;">呼气</span>困难</strong>，<strong style="color: blue;">右心衰竭的体循环淤血<span style="color: black;">导致</span>的颈静脉怒张、肝肿大、水肿等是诊断心衰的<span style="color: black;">要紧</span>依据</strong></span><span style="color: black;">4．鉴别诊断</span><span style="color: black;">（1）<strong style="color: blue;">支气管哮喘</strong>：心源性哮喘多见于老年人有高血压或慢性心瓣膜病史，<span style="color: black;">爆发</span>时<span style="color: black;">必要</span>坐起，重症者肺部有干湿性啰音，<span style="color: black;">乃至</span>粉红色<span style="color: black;">泡泡</span>痰；支气管哮喘多见于青少年有过敏史，并不<span style="color: black;">必定</span>强迫坐起，咳白色粘痰后<span style="color: black;">呼气</span>困难常可缓解，，<span style="color: black;">爆发</span>时双肺可闻及典型哮鸣音</span><span style="color: black;">（2）<strong style="color: blue;">心包积液、缩窄性心包炎</strong>时，<span style="color: black;">因为</span>腔静脉回流受阻<span style="color: black;">一样</span><span style="color: black;">能够</span><span style="color: black;">导致</span><strong style="color: blue;">肝大、下肢浮肿</strong>等表现，应<span style="color: black;">按照</span>病史、心脏及<span style="color: black;">周边</span>血管体征鉴别，<strong style="color: blue;">超声心动图<span style="color: black;">检测</span>可得以确诊。</strong></span><span style="color: black;">（3）肝硬化腹水伴下肢浮肿应与慢性右心衰竭鉴别，除<span style="color: black;">基本</span>心脏病体征有助于鉴别外，非心源性肝硬化不会<span style="color: black;">显现</span>颈静脉怒张等上腔静脉回流受阻的体征。这是很<span style="color: black;">要紧</span>的鉴别要点。</span><span style="color: black;">4．治疗</span><span style="color: black;">（1）治疗目的：①预防：预防心力衰竭进行性加重，或防止由心功能不全<span style="color: black;">发展</span>为心力衰竭；②改善或保持病人的生活质量；③延长病人的寿命，<span style="color: black;">加强</span>存活率。<strong style="color: blue;">治疗原则为去除病因（<span style="color: black;">基本</span>病因的诱因）改善心力衰竭状态</strong>。</span><span style="color: black;">治疗<span style="color: black;">办法</span></span><span style="color: black;">(1）去除病因：针对<span style="color: black;">基本</span>心脏病进行治疗，如<span style="color: black;">掌控</span>高血压，<span style="color: black;">增多</span>缺血心肌的血供，<span style="color: black;">纠正</span>瓣膜结构的<span style="color: black;">反常</span>等；<span style="color: black;">同期</span><span style="color: black;">重视</span>消除心力衰竭的诱因，感染、快速<span style="color: black;">心率</span>失常和治疗<span style="color: black;">欠妥</span>是最<span style="color: black;">平常</span>的诱因，应<span style="color: black;">重视</span>识别和治疗。</span><span style="color: black;">(2）<span style="color: black;">膳食</span>：适当的热量摄入，以防<span style="color: black;">出现</span><span style="color: black;">肥壮</span>；<span style="color: black;">掌控</span>水钠摄入，对<strong style="color: blue;">严重心力衰竭者24小时液体摄入量应＜1000～1500ml</strong></span><span style="color: black;">(3）<span style="color: black;">休憩</span>：避免体力过劳和精神刺激，但不宜<span style="color: black;">长时间</span>卧床，应进行适量的活动。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">药品</span>治疗：</span></strong><strong style="color: blue;"><span style="color: black;">基本用4大类药。</span></strong></span><span style="color: black;">(1）利尿剂的应用：利尿剂仍是治疗心衰的<span style="color: black;">重点</span><span style="color: black;">药品</span>，它能缓解心力衰竭的“充血”症状，疗效确切而<span style="color: black;">快速</span>。<span style="color: black;">按照</span>利尿剂<span style="color: black;">功效</span>部位的不同，分为3类：（记得讲<span style="color: black;">药品</span>的<span style="color: black;">重点</span>副<span style="color: black;">功效</span>）。</span><span style="color: black;"> ①<span style="color: black;">功效</span>于Henle袢的利尿剂：这类<span style="color: black;">药品</span><span style="color: black;">重点</span>有<strong style="color: blue;">呋塞米（速尿）</strong>，用法为20～40mg次，1～3次/d，或20～40mg/次静脉注射，有时用量可高达100mg/d。这类<span style="color: black;">药品</span>的利尿<span style="color: black;">功效</span>最强，即使在肾小球滤过率低下时<span style="color: black;">也</span>有<span style="color: black;">显著</span>的利尿剂<span style="color: black;">功效</span>。</span><span style="color: black;"> ②<span style="color: black;">功效</span>于远曲小管的利尿剂：<span style="color: black;">表率</span>制剂有<strong style="color: blue;">氢氯噻嗪（双氢克尿塞）</strong>，用法为25mg/次，1～3次/d；这类<span style="color: black;">药品</span><span style="color: black;">功效</span>时间长，但利尿效果不如袢利尿剂，并且依赖于肾小球滤过率。(高尿酸血症、干扰糖胆固醇代谢、钾低)</span><span style="color: black;">③<span style="color: black;">功效</span>于远曲小管的利尿剂：<span style="color: black;">重点</span><span style="color: black;">药品</span>有<strong style="color: blue;">螺内酯（安体舒通）</strong>，用法为20～40mg/次，3～4次/d；<strong style="color: blue;">氨苯蝶啶</strong>用法50～100mg/次，1～3次/d，这类<span style="color: black;">药品</span><span style="color: black;">功效</span>相对较弱，但<span style="color: black;">拥有</span>保钾（<span style="color: black;">控制</span>H+-K+交换）<span style="color: black;">功效</span>，或有直接对抗醛固酮的<span style="color: black;">功效</span>，常与其他利尿<span style="color: black;">药品</span>联合<span style="color: black;">运用</span>。</span><span style="color: black;">(2）血管扩张剂：扩血管<span style="color: black;">药品</span>用于治疗慢性心衰是治疗学上的里程碑。</span><span style="color: black;">①<strong style="color: blue;">硝普钠</strong>：<strong style="color: blue;"><span style="color: black;">同期</span>扩张动脉和静脉，降低心室的前、后负荷</strong>。<span style="color: black;">重点</span>用于以心排出量降低、左室充盈压和体循环阻力<span style="color: black;">升高</span>为特征的晚期心力衰竭<span style="color: black;">病人</span>。用法为静脉滴注，<span style="color: black;">初始</span>剂量为0.3μg/（<span style="color: black;">公斤</span> min），<span style="color: black;">而后</span><span style="color: black;">按照</span>血压反应缓慢<span style="color: black;">增多</span>剂量，<strong style="color: blue;">最大剂量<span style="color: black;">不可</span>超过10μg/（<span style="color: black;">公斤</span> min）</strong>。最<span style="color: black;">平常</span>的副<span style="color: black;">功效</span>是低血压。大剂量，<span style="color: black;">尤其</span>是伴有肾功能不全时，易<span style="color: black;">出现</span>硫氰酸盐或氰化物中毒。</span><span style="color: black;">②<strong style="color: blue;">硝酸酯类</strong>：<strong style="color: blue;"><span style="color: black;">重点</span>扩张静脉和肺小动脉</strong>。<strong style="color: blue;">硝酸酯类是急性心梗的首选<span style="color: black;">药品</span>。</strong>口服制剂有<strong style="color: blue;">硝酸甘油0.5mg含服</strong>；二硝酸异山梨酯20mg，2次/日；单硝酸异山梨酯20mg，2次/日，此药生物利用度高，<span style="color: black;">功效</span><span style="color: black;">连续</span>时间长。但<span style="color: black;">运用</span>时要<span style="color: black;">重视</span><span style="color: black;">夜晚</span><span style="color: black;">最少</span>保持数小时“<span style="color: black;">没</span>硝酸酯类<span style="color: black;">药品</span>期”，<span style="color: black;">这般</span>有可能避免硝酸酯类耐药。硝酸甘油10mg加入5%葡萄糖液250ml中静滴，<strong style="color: blue;">初始滴速为10μg/（<span style="color: black;">公斤</span> min），可<span style="color: black;">逐步</span>递增5～10μg/（<span style="color: black;">公斤</span> min）</strong>，<span style="color: black;">重视</span>反射性心动过速及低血压。<strong style="color: blue;"><span style="color: black;">通常</span>的<span style="color: black;">药品</span>剂量都不<span style="color: black;">必须</span>记忆,这是一个极<span style="color: black;">要紧</span>的常用药,剂量要牢记.</strong></span><span style="color: black;">③<strong style="color: blue;">血管紧张素转换酶<span style="color: black;">控制</span>剂（ACEI）</strong>：<span style="color: black;">重点</span>功能是<strong style="color: blue;"><span style="color: black;">控制</span>循环中及局部组织中血管紧张素Ⅱ的生成，兼有扩张小动脉和静脉的<span style="color: black;">功效</span></strong>。能缓解消除症状，改善血流动力学变化与左室功能，逆转左室肥厚，<span style="color: black;">加强</span>运动耐力。更为<span style="color: black;">要紧</span>的是其降低病死率的<span style="color: black;">功效</span>优于单纯血管扩张剂，宜<span style="color: black;">首要</span><span style="color: black;">选择</span>，但<strong style="color: blue;">不宜用于伴严重肾衰竭、双侧肾动脉狭窄和低血压的病人</strong>。最<span style="color: black;">重点</span>的副<span style="color: black;">功效</span>是低血压，尤其是首剂低血压反应，故应<span style="color: black;">重视</span>监测血压，肾功能和血钾。<span style="color: black;">通常</span>不与钾盐或保钾利尿剂合用，<span style="color: black;">以避免</span><span style="color: black;">出现</span>高钾血症。<span style="color: black;">另一</span>咳嗽是这类<span style="color: black;">药品</span>最<span style="color: black;">平常</span>的副<span style="color: black;">功效</span>。常用制剂为普利（－pril）类<span style="color: black;">药品</span>：如卡托普利（开博通、巯甲丙脯酸），初始用量6.25mg，最大剂量为50mg，3次/日；依那普利，初始剂量2.5mg，最大剂量为10～20mg，2次/日；蒙诺初始剂量为5～10mg ，最大剂量为40mg，<span style="color: black;">每日</span>一次。</span><span style="color: black;">(3)洋地黄类<span style="color: black;">药品</span>：洋地黄类<span style="color: black;">药品</span>：是治疗心力衰竭的<span style="color: black;">重点</span><span style="color: black;">药品</span>,为<strong style="color: blue;">正性肌力<span style="color: black;">药品</span></strong>。</span><span style="color: black;">a常用洋地黄制剂及剂量：地高辛片0.25mg/d， 约经5个半衰期（5～7天）后<span style="color: black;">达到</span>稳态治疗血浓度。毛花甘丙（西地兰）注射剂0.2～0.4mg/次，<span style="color: black;">按照</span>病情珂重复<span style="color: black;">运用</span>多次，24小时总量1.0～1.6mg静注；毒毛花苷K注射剂0.25～0.5mg/次，静注。</span><span style="color: black;">b适应征：中重度收缩性心力衰竭<span style="color: black;">病人</span>，<strong style="color: blue;">对心室率快速的心房颤动<span style="color: black;">病人</span><span style="color: black;">尤其</span>有效</strong></span><span style="color: black;"><span style="color: black;">c</span><strong style="color: blue;"><span style="color: black;">不宜应用的<span style="color: black;">状况</span></span></strong><span style="color: black;">：</span></span><span style="color: black;">洋地黄中毒时禁用；血钾<span style="color: black;">小于</span>3.5mmol/L，心率<span style="color: black;">小于</span>60次/分，预激<span style="color: black;">综合症</span>合并心房颤动；二度或高度房室传导阻滞；病态窦房结<span style="color: black;">综合症</span>，<span style="color: black;">尤其</span>是老年人；单纯性舒张性心力衰竭如肥厚型心肌病；单纯性重度二尖瓣狭窄伴窦性<span style="color: black;">心率</span>而<span style="color: black;">没</span>右心衰竭的<span style="color: black;">病人</span>；急性心肌梗死，尤其在最初24小时内，除非合并心房颤动或（和）心腔扩大。</span><span style="color: black;">d（适应症）影响剂量的<span style="color: black;">原因</span>：老年人、心肌缺血缺氧或有急性病变（如急性心肌梗死、肺心病、急性弥漫性心肌炎）、重度心力衰竭、低钾血症或（和）低镁血症。肾功能<span style="color: black;">衰退</span>等<span style="color: black;">状况</span>，对洋地黄类<span style="color: black;">药品</span>较<span style="color: black;">敏锐</span>，应予<span style="color: black;">减少</span>应用。</span><span style="color: black;">e与其他<span style="color: black;">药品</span>的相互<span style="color: black;">功效</span>：<span style="color: black;">非常多</span><span style="color: black;">药品</span>奎尼丁、普罗帕酮、维拉帕米、胺碘酮等与地高辛合用时，后者血清浓度可<span style="color: black;">上升</span>70%～100%，宜将地高辛剂量减半应用。治疗溃疡病的制酸剂可减弱地高辛的<span style="color: black;">功效</span>，宜<span style="color: black;">掰开</span><span style="color: black;">吃下</span>。</span><span style="color: black;"><span style="color: black;">f</span><strong style="color: blue;"><span style="color: black;">洋地黄毒性反应的症状</span></strong><span style="color: black;">：</span></span><span style="color: black;">A胃肠道反应 食欲不振最早<span style="color: black;">显现</span>，继以恶心、呕吐，属中枢性</span><span style="color: black;">B 神经系统表现 如头痛、忧郁、<span style="color: black;">没</span>力、视力模糊、(色视)黄视或绿视等</span><span style="color: black;">C心脏毒性，<span style="color: black;">重点</span>表现为<span style="color: black;">各样</span>类型的<strong style="color: blue;"><span style="color: black;">心率</span>失常，最<span style="color: black;">平常</span>者</strong>为<strong style="color: blue;">室性期前收缩</strong>，多表现为室性二联律、三联律、交界性逸搏<span style="color: black;">心率</span>和非阵发性交界性心动过速、房性期前收缩、房颤及房室传导阻滞等，快速性<span style="color: black;">心率</span>失常又伴有房室传导阻滞是洋地黄中毒的特征性表现</span><span style="color: black;">D慢性房颤<span style="color: black;">病人</span>在用洋地黄<span style="color: black;">时期</span>心室率<span style="color: black;">忽然</span>变得规则时，应<span style="color: black;">警觉</span>中毒的可能；</span><span style="color: black;">E 地高辛的血药浓度为1.0-2.0ng/ml.</span><span style="color: black;"><span style="color: black;">g</span><strong style="color: blue;"><span style="color: black;">洋地黄中毒的治疗<span style="color: black;">办法</span></span></strong><span style="color: black;">：</span></span><span style="color: black;">A<span style="color: black;">初期</span>治疗和<span style="color: black;">即时</span>停药是治疗<span style="color: black;">重要</span></span><span style="color: black;">B<span style="color: black;">显现</span>快速性<span style="color: black;">心率</span>失常可应用苯妥英钠（用于阵发性室性心动过速）或利多卡因（用于室性心动过速）；<span style="color: black;">显现</span>缓慢性<span style="color: black;">心率</span>失常可应用阿托品；</span><span style="color: black;">C异位快速性<span style="color: black;">心率</span>失常伴低钾血症时，可予钾盐静脉点滴，房室传导阻滞者禁用 D多种<span style="color: black;">办法</span><span style="color: black;">没</span>效时，可<span style="color: black;">思虑</span>小能量直流电复律（<span style="color: black;">通常</span>属禁忌，因可致室颤）</span><span style="color: black;">E 缓慢性<span style="color: black;">心率</span>失常者，可用阿托品治疗F<span style="color: black;">运用</span>地高辛特异性抗体</span><span style="color: black;">(4）其他正性肌力<span style="color: black;">药品</span>：为终末期心力衰竭者的非胃肠道用药，<span style="color: black;">通常</span>仅在心脏移植或心力衰竭急性恶化时短期<span style="color: black;">运用</span>。</span><span style="color: black;">②多巴酚丁胺：是多巴胺的衍生物，<span style="color: black;">拥有</span><span style="color: black;">剧烈</span>的<span style="color: black;">选取</span>性β1受体<span style="color: black;">功效</span>，可使心肌收缩力<span style="color: black;">增多</span>，仅有静脉制剂，可产生短期<span style="color: black;">显著</span>的动力学效果。常用剂量为2.5～7.5μg/（<span style="color: black;">公斤</span> min），静脉滴注。每疗程<span style="color: black;">通常</span>不超过1周。该药可<span style="color: black;">增多</span>心室性失常和死亡率。</span><span style="color: black;">②米力农：为磷酸二酯酶<span style="color: black;">控制</span>剂。<span style="color: black;">运用</span><span style="color: black;">办法</span>为：50μg/<span style="color: black;">公斤</span>静脉注射，<span style="color: black;">而后</span>0.25～0.5μg/（<span style="color: black;">公斤</span> min）静脉注射。因其有<span style="color: black;">增多</span>心脏猝死的可能性，不宜<span style="color: black;">长时间</span>用于心衰的治疗。</span><span style="color: black;"> ③钙增敏剂：如Levosimendan，它能降低急性心肌梗死后3天～6月的病死率，安全性优于多巴酚丁胺。</span><span style="color: black;">(5）β-阻断剂：尽管它不是心力衰竭的一线治疗<span style="color: black;">药品</span>，但在标准治疗（强心剂、利尿剂和血管紧张素转换酶<span style="color: black;">控制</span>剂）的<span style="color: black;">基本</span>上，<span style="color: black;">没</span>论是缺血性或非缺血性的稳定性轻、中、重度心力衰竭<span style="color: black;">病人</span>均应<span style="color: black;">运用</span>β-阻断剂。该类<span style="color: black;">药品</span>为洛尔或地洛类<span style="color: black;">药品</span>：如<strong style="color: blue;">美托洛尔、卡维地洛等。这两个<span style="color: black;">药品</span>为<span style="color: black;">举荐</span><span style="color: black;">运用</span>的β-阻断剂。</strong></span><span style="color: black;">(6）抗<span style="color: black;">心率</span>失常：<span style="color: black;">重点</span>用于合并房颤、非阵发性或阵发性室性心动过速。<span style="color: black;">因为</span>Ⅰ类抗<span style="color: black;">心率</span>失常<span style="color: black;">药品</span>（如<span style="color: black;">心率</span>平）有<span style="color: black;">显著</span>的致<span style="color: black;">心率</span>失常<span style="color: black;">功效</span>，以及不良的血流支力学效应，<span style="color: black;">因此</span>应<span style="color: black;">尽可能</span>避免<span style="color: black;">运用</span>。Ⅲ类抗<span style="color: black;">心率</span>失常<span style="color: black;">药品</span>，如胺碘酮。</span><span style="color: black;">(7）抗凝治疗：可<span style="color: black;">按照</span><span style="color: black;">基本</span><span style="color: black;">疾患</span>和临床表现<span style="color: black;">运用</span>阿司匹林、肝素等，但<span style="color: black;">长时间</span><span style="color: black;">运用</span>这些<span style="color: black;">药品</span>对心力衰竭的影响仍需进一步的观察</span><span style="color: black;">3．器械和外科治疗</span><span style="color: black;">（1）血管重建：尚<span style="color: black;">没</span>对照<span style="color: black;">科研</span>资料支持血运重建（介入疗法或外科手术）治疗能够改善心力衰竭病人的症状。</span><span style="color: black;">（2）起搏器和<span style="color: black;">移植</span>型心脏转复除颤器（ICD）：<strong style="color: blue;">心力衰竭合并心动过缓时，应优先<span style="color: black;">思虑</span>房室<span style="color: black;">次序</span>起搏；对<span style="color: black;">药品</span><span style="color: black;">没</span>效的反复室性心动过速/室颤<span style="color: black;">爆发</span>的心力衰竭<span style="color: black;">病人</span>可<span style="color: black;">移植</span>ICD。</strong></span><span style="color: black;">（3）血液超滤：用于肺水肿/或顽固性充血性心力衰竭<span style="color: black;">病人</span>的短期治疗，以减轻前负荷或为心脏移植争取时间。</span><span style="color: black;">（4）心脏移植：心脏移植<span style="color: black;">显著</span>延长终末期心力衰竭<span style="color: black;">病人</span>的寿命，<span style="color: black;">加强</span>运动能力。改善生活质量。<span style="color: black;">日前</span>以及移植的5年<span style="color: black;">存活</span>率<span style="color: black;">达到</span>70%～80%。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">3、</span> </span></strong><strong style="color: blue;"><span style="color: black;">急性左心衰竭(<span style="color: black;">要紧</span>考点)</span></strong></span><span style="color: black;">急性心力衰竭<span style="color: black;">指的是</span><span style="color: black;">因为</span>急性心脏病变<span style="color: black;">导致</span>心排血量急骤降低<span style="color: black;">引起</span>组织器官灌注不足和急性淤血<span style="color: black;">综合症</span>。临床以上<strong style="color: blue;">急性心衰</strong><span style="color: black;">平常</span>，<span style="color: black;">重点</span>表现为<strong style="color: blue;">急性肺水肿</strong>。</span><span style="color: black;">（一）病因和发病机制</span><span style="color: black;">1.急性心肌缺血或梗死。</span><span style="color: black;">2.急性心肌梗死合并症：乳头肌断裂<span style="color: black;">导致</span>的急性二尖瓣反流、室间隔穿孔、心脏游离破裂和心脏压塞。</span><span style="color: black;">3.急性瓣膜穿孔（二尖瓣或主动脉瓣）。</span><span style="color: black;">4.<span style="color: black;">掌控</span>欠佳的严重高血压。</span><span style="color: black;">5.心肌炎。</span><span style="color: black;">6.<span style="color: black;">连续</span>性<span style="color: black;">心率</span>失常。</span><span style="color: black;">7.急性肺栓塞。</span><span style="color: black;">病理生理<span style="color: black;">基本</span>为心脏收缩力<span style="color: black;">忽然</span>严重减弱，心排血量急剧减少，或左室瓣膜性急性反流，左室内压<span style="color: black;">快速</span><span style="color: black;">上升</span>，肺静脉回流不畅。<span style="color: black;">因为</span>肺静脉压快速<span style="color: black;">上升</span>，肺毛细血管压随之<span style="color: black;">上升</span>使血管内液体渗入到肺间质和肺泡内形成急性肺水肿。</span><span style="color: black;">（二）临床表现，<strong style="color: blue;"><span style="color: black;">重点</span>为急性肺水肿</strong>。</span><span style="color: black;">1． 症状：<strong style="color: blue;">突发严重<span style="color: black;">呼气</span>困难</strong>，<span style="color: black;">呼气</span>频率常达每分钟30～40次，强迫坐位、面色灰白、发绀、大汗、烦躁，<span style="color: black;">同期</span>频繁<strong style="color: blue;">咳嗽，咳粉红色<span style="color: black;">泡泡</span>状痰。</strong>极重者可因脑缺氧而致神志模糊。肺水肿<span style="color: black;">初期</span>，<span style="color: black;">因为</span>交感神经激活致血管收缩，<strong style="color: blue;">血压可一过性<span style="color: black;">上升</span></strong>；但随着病情<span style="color: black;">连续</span>，<strong style="color: blue;">血压下降</strong>。严重者可<span style="color: black;">显现</span>心源性休克。</span><span style="color: black;">2．体征：听诊时两肺布满湿啰音和哮鸣音，心尖部<span style="color: black;">第1</span>心音减弱，频率快，<span style="color: black;">同期</span>有舒张<span style="color: black;">初期</span>第三心音而<span style="color: black;">形成</span>奔马律，肺动脉瓣第二心音亢进。</span><span style="color: black;">（三）诊断与鉴别诊断</span><span style="color: black;"><span style="color: black;">按照</span>典型症状与体征，<span style="color: black;">重视</span>急性<span style="color: black;">呼气</span>困难与支气管哮喘的鉴别，咳粉红色<span style="color: black;">泡泡</span>痰和心尖部舒张期奔马律有助于诊断肺水肿与肺水肿并存的心源性休克与其他<span style="color: black;">原由</span><span style="color: black;">导致</span>休克的鉴别。</span><span style="color: black;">（四）<strong style="color: blue;">治疗(考生须牢记，多为临床分析题或问答题)</strong></span><span style="color: black;">1．<strong style="color: blue;"><span style="color: black;">病人</span>取坐位，双腿下垂，以减少静脉回流</strong>。</span><span style="color: black;">2．<strong style="color: blue;">吸氧：</strong><strong style="color: blue;">立即高流量鼻管给氧</strong>（10～20mL／min纯氧鼻管吸入对病情<span style="color: black;">尤其</span>严重者应给以面罩用<span style="color: black;">麻木</span>机加压给氧。在吸氧的<span style="color: black;">同期</span><span style="color: black;">运用</span>抗<span style="color: black;">泡泡</span>剂使肺泡内的<span style="color: black;">泡泡</span>消失，<span style="color: black;">增多</span>气体交换面积，<span style="color: black;">通常</span>可用50%酒精置于氧气的滤瓶中。若动静氧分压<span style="color: black;">不可</span>维持60mmHg，宜加用正压<span style="color: black;">呼气</span>(PEEP)）</span><span style="color: black;">3．<strong style="color: blue;">吗啡5～10mg静脉缓注</strong>，必要时每间隔15分钟重复一次，共2-3次。</span><span style="color: black;">4．<strong style="color: blue;">快速利尿</strong><span style="color: black;">呋塞米20～40mg静注，在2min内推完<strong style="color: blue;"><span style="color: black;">重点</span>的治疗<span style="color: black;">办法</span></strong></span></span><span style="color: black;">5．<strong style="color: blue;">血管扩张剂（禁用于重度二尖瓣狭窄伴窦性<span style="color: black;">心率</span>者）</strong>（1）硝普钠：<span style="color: black;">按照</span>血压<span style="color: black;">调节</span>用量，维持收缩压在100mmHg<span style="color: black;">上下</span>；对原有高血压者血压降低幅度(绝对值)以不超过80mmHg为度，<strong style="color: blue;">用药时间不宜连续超过24小时</strong>。（2）硝酸甘油。（3）酚妥拉明。（4）有低血压，宜与多巴酚丁胺合用</span><span style="color: black;">6．<strong style="color: blue;">洋地黄类<span style="color: black;">药品</span>：</strong><strong style="color: blue;">毛花苷丙</strong>0.4mg，静脉注射，是<strong style="color: blue;">改善急性左心衰最有效的<span style="color: black;">药品</span></strong>。适用于心房颤动伴快速心室率或已知有心脏增大伴左心室收缩功能不全者，禁用于重度二尖瓣狭窄伴窦性<span style="color: black;">心率</span>者。</span><span style="color: black;">7．氨茶碱，为有效解除支气管痉挛<span style="color: black;">药品</span>，还有正性肌力<span style="color: black;">功效</span>，外周血管扩张<span style="color: black;">功效</span>，利尿<span style="color: black;">功效</span>。</span><span style="color: black;">8．其他应用四肢轮流三肢结扎法减少静脉回心血量，待急性症状缓解后，应着手对诱因及基本病因进行治疗。</span><span style="color: black;"><span style="color: black;"> 白学病，又<span style="color: black;">叫作</span>伴学渣综合症。</span></span><span style="color: black;">好发于学期末，男性多于女性。<span style="color: black;">一般</span>认为是<span style="color: black;">身体</span>懒细胞<span style="color: black;">反常</span>增殖扩散<span style="color: black;">导致</span>。临床表现为狂躁，焦虑，失眠赖床综合症，可伴有手机依赖症的加剧;严重者只要见到书本便会头痛困倦恶心干呕，并<span style="color: black;">显现</span>「劳资裸考<span style="color: black;">亦</span>会过」的妄想症状。</span><span style="color: black;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">本病有<span style="color: black;">必定</span>传染性，<span style="color: black;">日前</span><span style="color: black;">重点</span>有画重点法，学霸辅导法，友人抽醒法等支持疗法，联合<span style="color: black;">运用</span>效果好，偷试卷法和作<span style="color: black;">坏处</span>法等靶向治疗<span style="color: black;">因为</span>副<span style="color: black;">功效</span>过大已不<span style="color: black;">意见</span><span style="color: black;">运用</span>。本病如不<span style="color: black;">即时</span>治疗会<span style="color: black;">引起</span>挂科补考<span style="color: black;">乃至</span>重修等一系列严重<span style="color: black;">副作用</span>，预后不良。</p>
</span><span style="color: black;">划重点，划重点啦！</span><span style="color: black;">下面的话很<span style="color: black;">要紧</span>啊！<span style="color: black;">大众</span>在看完我写的推送后，能<span style="color: black;">不可</span>动动自己的</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">手点一下在看呢。</span></strong><strong style="color: blue;"><span style="color: black;"><span style="color: black;">或</span>“赞赏</span></strong><strong style="color: blue;"><span style="color: black;">”我<span style="color: black;">亦</span><span style="color: black;">能够</span>啊。</span></strong></span><span style="color: black;">谢谢<span style="color: black;">大众</span>啦！</span><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">想<span style="color: black;">作为</span>大佬的生物狗</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">solededlfc@163.com</span></p>
感谢楼主的分享！我学到了很多。 论坛的成功是建立在我们诚恳、务实、高效、创新和团结合作基础上，我们要把这种精神传递下去。 你的话语如春风拂面，让我感到无比温暖。
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