17) Viêm Màng Ngoài Tim - Done

VIM MNG NGOI TIM
PGS.TS. NGUYN VN KHI

Ph Gim c Bnh vin Ch Ry
Ph Hiu Trng i hc Y Dc TP.HCM
I. GII PHU V SINH L THNG
MNG NGOI TIM (MNT)
Mng ngoi tim: pericardium
A. GII PHU = l thnh (Parietal Pericardium) + l tng
(Visceral Pericardium/Epicardium)
MNT gm 2 thnh phn:

Ngoi tm mc (l thnh): l ti x hnh
chai bt bao bc tim
Thng tm mc (l tng): l din tch
ngoi ca tim
Hai l tip gip ha nhau kn gc mch
mu ln, to thnh khoang kn gi l
khoang MNT
MNG NGOI TIM (MNT)
A. GII PHU Nu dch tng t t th c th tng n 1-2 L
Khoang MNT bnh thng cha 30 50 ml

dch, thnh phn nh huyt thanh. gip tim co bp d dng
Phn MNT ph ln cc mch mu ln to thnh
hai ng cun:
ng cun 1: mc treo M tim bao gm:
MC ln, M phi
ng cun 2: mc treo tnh mch tim bao
gm: TM ch trn, TM ch di v 4 TM
phi
MNG NGOI TIM (MNT)
A. GII PHU
Xoang cho l phn MNT bao bc mt sau
tm nh tri
Xoang ngang l phn MNT bao bc gia mc
treo M tim v TM tim, xoang ngang ng vai
tr c ngha v ngoi khoa, v khi tch dch
nhim trng trong khoang ny s lm nh
hng n nng sut ca M phi v M ch
MNG NGOI TIM (MNT)
A. GII PHU
y ca hnh chai bt dnh vo c honh, mt
trc dnh vo xng c to thnh dy chng c
- mng ngoi tim, chc nng treo tim
B dy l thnh MNT bnh thng dy khong
0,8 1mm Nu vim, c th dy n 15 mm, vim mn c th > 20 mm
ng bch mch ca MNT ng vai tr quan
trng v ngha lm sng ln, v ng bch
mch phi v ngc mt phn chy qua ng
ny.
MNG NGOI TIM (MNT)
B. SINH L MNT
MNT khng c nh hng g n chc nng tim, v
thiu MNT bm sinh m tim vn hot ng bnh
thng (Eli, Hering)
Mt s tc gi cho rng:
MNT c nhim v c nh tim trong lng ngc
Bo v tim trong trng hp cc bung tim gin n
bt thnh lnh
Chng gin n qu ng ca ring bung tim bn
tri hoc bn phi v lm mu d tr v tm nh
trong th tm thu
MNG NGOI TIM (MNT)
B. SINH L MNT
Cht dch trong khoang MNT, lm tim trt d
dng
Lm chm s ly lan nhim trng t phi, khoang
mng phi vo tim
iu ha s hot ng nhp nhng ca hai na tri
tim
Ct b 1 phn MNT l cn thit trong cc bnh l
MNT
II. VIM MNG NGOI TIM (VMNT)
VMNT lin h n nhiu bnh nhim trng v vim

nhim, ty theo khi pht nhanh lc u hay tin trin v
c chia thnh:
VMNT cp
VMNT mn tnh = co tht mng ngoi tim (chronic pericarditis)
II. VIM MNG NGOI TIM (VMNT)
T ngy 1-10
A. VIM MNG NGOI TIM CP:
Gp tr em, ngi tr tui
T l Nam so vi N: 2 2,5/1
A. VIM MNG NGOI TIM CP (tt)
1. Hon cnh pht hin:
Pht hin rt khc nhau, c khi gi n vi chn

on ban u: vim phi v mng phi cp, p xe
gan v trn dch mng phi, gan to, lch to, ung
th phi, u trung tht, u mng ngoi tim, nhi
mu c tim .
Chn on ng ban u chim 1/3 vi vim
mng ngoi tim cp tnh v chn p tim
2. Nguyn nhn:
C nhiu nguyn nhn, sp xp theo th t
thng gp l:
a) Vim mng ngoi tim do m, hay gp, chim
65%, do cc vi trng S.aurus, Entrobacter,
P.aeruginosa. thng nui cy khng thy
vi trng ph n v tr em
2. Nguyn nhn:
b) VMNT do lao trc thi i khng sinh l

nguyn nhn ch yu Chu u v Bc M.
Th ny ngy nay xp ngang vi VMNT do
m
2. Nguyn nhn:
c) VMNT do khi u thng l th pht di cn n
d dy, ph qun, tuyn v .
d) VMNT do thp chim 11 30%
2. Nguyn nhn:
e) VMNT do nhi mu c tim gp nc ta
f) VMNT khng r nguyn nhn, thng do siu vi
trng
g) VMNT sau chn thng v sau m, ngy nay
gp loi VMNT do ur mu tng cao
VMNT sau chy thn nhn to, lc mu
3. Gii phu bnh:

VMNT kh v c trn dch, VMNT kh c tnh l
thuyt, khi no trong khoang MNT c t 200 300
ml n vi lt dch th gi l VMNT c trn dch,
thng do huyt thanh; t huyt; m hoc xut
huyt
3. Gii phu bnh:

VMNT thanh huyt, dch c nhiu Albumine,
thng tm mc mt tnh lng v c si thanh t
lng ng ln trn.
VMNT t huyt, bch cu n nhn v a nhn
xm ln vo MNT, thng tm mc c t bo k
3. Gii phu bnh:

VMNT thng kt hp vi th t huyt, loi ny
thy c bch cu a nhn v tit m, c nhiu
vim m thng tm mc.
VMMT xut huyt, phn bit vi chy mu
khoang MNT, loi ny thng do lao, do thp.
4. Sinh l bnh:
a) Chn p tim cp:
Dch trong khoang MNT a n thay i
huyt ng hc.
Chn p tim c hiu rng: s cn tr tm
tht gin ra trong k tm trng do p lc
trong khoang MNT tng ln.
Bnh thng trong khoang MNT c khong
50ml dch, chn p tim ph thuc vo tc
tng khi lng dch
4. Sinh l bnh:
a. Chn p tim cp (tt)
Lng dch ti a khng gy thay i huyt
ng hc l t 100 150 ml, nhng nu lng
dch tng nhanh 150ml th gy cht ngi,
nhng nu tng t t th khoang MNT c th
cha 1000 ml dch (Fiehring, Schenetten)
4. Sinh l bnh:
b) Mch nghch:
Bock v Wood: trong th th vo c honh h
xung ng thi ko cng MNT vn cng
v lm tng p lc trong khoang MNT, mu tr
v tim gim i, do khi lng nht bp tim,
lu lng tim v huyt p cng gim
4. Sinh l bnh:
b) Mch nghch: (tt)
Reddy: khi chn p tim n mt mc nng
no gy ra ri lon huyt ng hc hai
bung tim th mu chy vo hai bung tim u
phi i u vi mt sc p cng do dch trong
khoang MNT gy ra
b) Mch nghch: (tt)

Mun gy ra mch nghch phi c 2 iu kin:
Mu vo 2 bung tim phi cng i u vi
mt sc p cng.
Phi c s thay i p lc tnh mch gia tnh
mch phi, mao mch phi vi tnh mch h
thng to iu kin cho khi th mu v tht
phi nhiu hn, khi th mu v tht tri
nhiu hn.
5. Triu chng:
a) Du hiu ton thn :
Suy sp st 3805 n 3905 (trn m # 400)
b) Du hiu ch quan v thc th
au ngc v kh th: 100 % gp, au trc
tim v sau xng c, ti i ti li. Th
nhanh nng, nhp th 60 ln / pht, phi
ngi m ly u gi th th d.
5. Triu chng:
b) Du hiu ch quan v thc th (tt)
Gan to: tnh mch c ni, gp 80% trng
hp, nu chn p nhiu gy chn p kh
qun, ph qun, thc qun.
G: din c ca tim lan rng, mm tim
kh s thy.
5. Triu chng:
b) Du hiu ch quan v thc th (tt)
Nghe: Kirk v Cosh gp 80% trng hp c
ting c mng tim vng M phi hoc b
tri xng c. Nghe r th th ra ht v phi
thu nh li khng cn che mt trc tim.
Ting c mng tim ch c trong nhng gi u, sau rt kh nghe c
Du in tm :
Xut hin sm, ch yu l thay i on ST v
sng T, gin bin QRS. Spodick chia 4 giai
on:
Giai on 1: ST chnh ln tt c cc o trnh
tr aVR v V1, tn ti khong 3 ngy, khng
ko di qu 3 tun.
Du in tm (tt)
Giai on 2: xut hin ri lon ti phn cc, sng
T dn dn tr thnh dt, ST tr v ng ng
in
Giai on 3: Sng T m cc o trnh n cc
chi v trc tim
Giai on 4: cc sng tr v bnh thng sau
nhiu tun hoc 2 3 thng sau.
5. Triu chng:
c) Du hiu X-quang:
Tim to u 2 bn hnh qu l hay bnh nc v
tng theo chiu ngang, b phi tim to vi c
honh gc t.
Chc ht dch khoang MNT v bm hi vo
gip ta phn bit r kch thc ca tim v
dy ca MNT
Chp X-quang nhiu ln trong iu kin nh
nhau pht hin khi lng ca tim thay i.
5. Triu chng:
d) Du hiu siu m:
Pht hin trn dch, khi u v k c
bnh l ca tim.
Pht hin chn p tim, VMNT co tht
Gip chc d khoang MNT chnh xc, an
ton
5. Triu chng:
e) Chp ct lp in ton (CT) v Cng hng
t (MRI)
Brown: nh gi bnh l MNT
MRI: c u im lm tng s tng phn
ca t chc phn mm
CT: gii quyt v khng gian tt v nhy
cm vi hin tng vi ha
5. Triu chng:
g) Chp X-quang tim mch (angiocardiography)
Pht hin h qu huyt ng hc
Chn on chn p tim v VMNT co tht
S dng ng thng qua sinh thit
phn bit bnh c tim hn ch vi VMNT
co tht
5. Triu chng:
h) Chn p tim:
Trong VMNT cp chn p tim chim 80 85%
trng hp.
Lm sng: khng s c mm tim, din c
tim rng, ting tim m, in tm thy in
th thp v so le, X-quang thy tim to b ra hai
bn, soi thy tim khng p.
5. Triu chng:
h) Chn p tim (tt)
p lc tm trng tng
p lc tnh mch tng
Khi p lc khoang MNT ti hn mc 150 mm nc th
gim nht bp tim v lu lng tim, huyt p tt. Khi
chc ht dch khoang MNT th cc triu chng trn
gim hoc bin mt
5. Triu chng:
i) Chc ht dch khoang MNT
Gip chn on xc nh, nhng khi chc ht
khng ra dch th cng cha loi tr VMNT
Chc ht dch cn c tc dng gii cu chn p
tim
Chc ht ra dch gi lm xt nghim vi trng
v lm KS
5. Triu chng:
i) Chc ht dch khoang MNT (tt)
V tr chc: cch b tri xng c khong 6cm
v tr lin sn 5 hoc 6, theo Bishop; Etes
v MC Intosh nn gn kim vo my o in
tim m bo an ton. V khi chm vo c
tim th thy ST chnh ln v gy ra ngoi tm
thu kiu QT.
6. Chn on phn bit

Nhm ln VMNT cp vi :
Nhi mu c tim cp
U trung tht
U gan km theo trn dch MNT v mng phi
7. iu tr
Bin php u tin l chc d khoang MNT
nhm 2 mc ch:
iu tr
Chn on v chn on phn bit:
Chc d nhm gii phng chn p tim
Dch chc d gi i lm xt nghim
iu tr ngoi khoa l chnh, tin lng tt
7. iu tr
Ty nguyn nhn, ch nh v iu tr VMNT c
khc nhau:
a) M MNT:
Trc y chc ht v bm ra bng
streptokinase hoc m ca s MNT v kt
hp iu tr khng sinh ton thn
Ct MNT mt phn mt trc tim t kt
qu tt # 82%
7. iu tr
a) M MNT (tt)
Ch nh ct mt phn MNT trong:
iu tr ni khoa, chc ht, m ca s
khng hiu qu
Trn m hoc trn mu m sau chc ht
dch ti lp nhanh, nht l trong trn m
c.
C lao MNT gy chn p tim
7. iu tr
a) M MNT (tt)
Ct MNT sm v cp cu trong m
MNT nhm:
Gii phng chn p tim
Trnh dy dnh MNT
Thoi ha c tim
M x kh khn v nguy him:
VMNT co tht
7. iu tr
b) VMNT do lao:
Chim 1 2% lao phi, lan trc tip t phi,
mng phi, bch huyt
Dch trong khoang MNT c th trong, vng
rm, mu
Cy dch tm thy BK (+)
7. iu tr
b) VMNT do lao:
iu tr:
c tr thuc lao
Chc ht dch trnh chn p tim
Th mn tnh dn lu khoang MNT
Ct MNT qua ng m xng c
7. iu tr
c) VMNT khng r nguyn do:
Trn dch khoang MNT
Nguyn nhn c th do siu vi trng
coxsackie a v b, cm a v b (Waller)
7. iu tr
c) VMNT khng r nguyn do:
iu tr trc tin:
Thuc khng vim khng steroid nh :
Ibuprofen, indomethacin (lu lm gim
ti mu mch vnh), aspirin
Khng iu tr corticosteroid
Ni khoa tht bi ct MNT 1 th hoc 2 th
+
Nu tng trng bnh nhn tt th c th m ni soi 1 th qua lin
sn IV, V
Bn tng trng khng tt th mnh m 2 th, ln u dn
lu, sau m ct MNT
7. iu tr
d) VMNT do ur mu cao:
Bnh sinh cha r
Nh chy thn nhn to, ghp thn c thay
i c bn, tuy nhin cn 10% chn p tim
Compty, Wray, Connors: dch ti pht v
chy thn t 10 60 ngy khng kt qu
ct MNT
T ngy 10-14 l th trung gian
B. VIM MNG NGOI TIM CO THT

(VMNTCT) HAY MN TNH
L bin chng ca VMNT cp tnh, t chc si lm

dy dnh hai MNT vi nhau
Chim 0,5 1,5% trng hp
T l Nam/N = 2/1 n 4/1
Sau ngy 14, xut hin 1 lp gi mc gia 2 l thnh v tng gy dnh 2 l

li -> co tht mng tim
(VMNTCT) HAY MN TNH
1. Nguyn nhn:
Nguyn nhn chnh l VMNT do lao
nc ta nguyn nhn chnh l VMNT do m,
t cp sang mn khong 3 tun
Hoa K do: m tim, chy tia, siu vi .
(VMNTCT) HAY MN TNH
2. Nguyn nhn:
MNT dy v co tht li to thnh p gip bc
tim
Hu qu: cn tr mu tr v tim th tm trng,
v gim khi lng mu y i th tm thu.
Dn n: p lc TM trung tm cao, ng mu
phi, trn dch mng phi, x gan c chng,
ph chn, tim phi tng nhp p.
(VMNTCT) HAY MN TNH
3. Triu chng:
a) Lm sng:
Kh th khi ngh ngi
Gan to, c chng
Mi v t chi tm
Vng da nh, chn ph
au sau xng c, tc vng thng v
(VMNTCT) HAY MN TNH
3. Triu chng:
b) Du hiu X-quang
Tim to t 60 65% trng hp
MNT lng ng vi
Soi X-quang thy tim p yu hoc khng
p
(VMNTCT) HAY MN TNH
3. Triu chng:
c) Du hiu in tm :
Sng P c mc v rng
Lon nhp th Flutter nh vi lon nhp tht
ST lm xung v sng m do thng tm mc
tn thng
QRS thp th hin teo c tim
(VMNTCT) HAY MN TNH
3. Triu chng:
d) Thng tim:
ng vai tr quan trng trong chn on
o p lc bung tim: p lc tm trng tng
cao TM ch trn v di, nh phi, tht
phi, ng mch v mao mch phi
(VMNTCT) HAY MN TNH
3. Triu chng
e) CT v MRI
MRI dy v teo c tim
(VMNTCT) HAY MN TNH
4. Chn on phn bit:

a) VMNTCT vi Hp van 2 l
Nh tm thanh
Trong hp van 2 l c ting clc m van
Trong VMNTCT c ting tim th ba (ting
ny ri vo khong 100/1.000 giy sau ting
tim th hai )
(VMNTCT) HAY MN TNH
4. Chn on phn bit:(tt)

b) VMNTCT vi vim c tim
VMNTCT p lc nh tri cao hn nh phi
trung bnh t 2 4mmHg
Trong vim c tim chnh lch ny ln n
12mmHg
(VMNTCT) HAY MN TNH
4. Chn on phn bit:(tt)

c) VMNTCT vi x c tim
Rt kh phn bit k c thng tim
(VMNTCT) HAY MN TNH
5. iu tr:
Duy nht l m ct b rng ri MNT ton b
mt trc tim, tnh mch ch trn v di, t
kt qu t 30 90%
Hi chng hiu sut tim thp sau khi ct b
MNT thng t vong
T l t vong trong m l 5%
Hi xa cha c
SA, nh gi
dy MNT th
rt ra bt 1 lng
dch ri bm kh
vo v chp XQ
Gi mc
Mt dch khng u
Gi mc lm kt dnh 2 lp ca mng ngoi tim, lm chuyn t G cp sang co tht
mng ngoi tim
Ct rng trc 2 tht, gii phng tht tri trc

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17) Viêm Màng Ngoài Tim - Done

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VIM MNG NGOI TIM

PGS.TS. NGUYN VN KHI

MNT gm 2 thnh phn:

A. GII PHU Nu dch tng t t th c th tng n 1-2 L

Khoang MNT bnh thng cha 30 50 ml

VMNT lin h n nhiu bnh nhim trng v vim

A. VIM MNG NGOI TIM CP:

Gp tr em, ngi tr tui

Pht hin rt khc nhau, c khi gi n vi chn

b) VMNT do lao trc thi i khng sinh l

3. Gii phu bnh:

3. Gii phu bnh:

3. Gii phu bnh:

b) Mch nghch: (tt)

6. Chn on phn bit

A. VIM MNG NGOI TIM CP (tt)

B. VIM MNG NGOI TIM CO THT

L bin chng ca VMNT cp tnh, t chc si lm

Sau ngy 14, xut hin 1 lp gi mc gia 2 l thnh v tng gy dnh 2 l

4. Chn on phn bit:

4. Chn on phn bit:(tt)

4. Chn on phn bit:(tt)

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