Analiza Auscultatorie a Suflurilor Cardiace

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  • 7/28/2019 Analiza Auscultatorie a Suflurilor Cardiace

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    19.03.2013 Analiza auscultatorie a suflurilor cardiace

    www.mymed.ro/analiza-auscultatorie-a-suflurilor-cardiace.html

    Analizaauscultatorieasuflurilorcardiace

    Suflurile reprezint grupuri de vibraii acustice cu

    durat lung (spredeosebire de zgomotele supraadugate, care au durat scurt) aprute ca

    urmareaunorturbuleneproduelacurgereasngeluiprincavitilecardiacesauvaselemari.

    Dupmoduldeproducere,suflurilecardiacepotfi:

    organice(prinleziuniorganicealestructurilorcardiacevalve,aparatsubvalvular,septuri)

    funcionale(suntsuflurideflux,nupresupunleziuniorganicecidoarunsindromcirculator

    hiperkineticprinafeciuniextracardiaceanemie,hipertiroidism,febr)

    anorganice(numiteisufluriinocente,aparlacopiiitineri)

    Analizasuflurilor

    Auscultaiacardiacsefaceattndecubitdorsal,ctindecubitlateralstnginpoziiaaplecat

    nainte(ncazuluneisuspiciunidestenozmitral,respectiv insuficienaortic).Deasemenea,

    pacientulpoatefirugatsinspireadncsausexpireadncnmomentul auscultaiei,nvederea

    accenturii unor sufluri localizate n cordul drept, respectiv cordul stng (manevra Rivero-

    Carvalho).

    Launsuflucardiactrebuieanalizaiurmtoriiparametri:

    localizareanciclulcardiac:sistolic,diastolicsaucontinuu.Ulterior,sevancercadelimitarea

    maiprecisasuflului:proto-,mezo-,sautele-(pre-)sistolic/diastolic.

    localizarea anatomic a focarului de maxim intensitate:focarulaortic, pulmonar, mitral,

    tricuspidian.

    iradierea

    intensitatea:sevaevaluapeoscardela1la6gradul1(seaudecudificultate,dupmai

    multencercri, estenecesarateniespecialilinitecomplet),gradul2(seaudeslab,dar

    esteuordedetectat),gradul3(intensitatemoderat),gradul4(intensitatemare),gradul5

    (intensitate foartemare),gradul6 (se audei ladistan detorace, chiar fr stetoscop).

    SuflurilecuintensitatemaimaredegradIVsuntnsoiteidefreamt.

    tonalitatea:naltsaujoas

    timbru:aspru,rugos,suflant,aspirativ,muzical.

    calitate:crescendo,descrescendo,nband,romboidal(aspectfonocardiografic)

    variaiacudiversemanevre(Valsalva,Muller,ortostatism,statpevine,Rivero-Carhalho)

    1.Suflurileinocente

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    Caracteristici:

    localizarenciclulcardiac:nusuntniciodatdiastolice,cidoarsistolice

    durat:suntscurte,ocupdoaropartedinsistol(proto-,mezo-sautele-)

    localizareanatomic:nuauunfocarbinedelimitat,suntmaximaudibileparasternalsprebaza

    cordului

    iradiere:nuiradiaz

    intensitate:slab,nudepeteniciodatgradulIII

    timbru:dulce

    variaie:disparlamodificareapoziiei

    Auscultaiesufluinocent

    2.Suflurileorganice

    i)Suflurisistolice

    A.Ejecionalenstenozelevalvelorsigmoide

    Caracteregenerale:

    suntintense

    suntmezotelesistolice:ncepladistandezg.I,fiinddespritedeacestadeuninterval

    distinct,carecorespundecontracieiizovolumice

    nunglobeazzg.II

    auunaspectfonocardiograficromboidal(crescendo-descrescendo),cuunmaxim

    mezosistolic

    Stenoza aortic: suflu mezo(tele)sistolic, cu maxim de intensitate n focarul aortic, aspru,

    rzuitor, iradiaz pe vasele de la baz gtului i spre vrf (n stenoza aortic degenerativ

    intensitatealavrfpoatefichiarmaimaredectnfocarulaorticefectulGallavardiniarsuflulestemaimuzical).Deobiceiestensoitidefreamt, iarintensitateasecoreleazcuseveritatea

    stenozei(ostenozfoartestnspoatedaunsufluslabsaupoatesnuaibsuflustenozaaortic

    mut). Diagnosticul diferenial se face cu suflul din stenoza pulmonar (manevra Rivero-

    Carvalho), din insuficiena mitral (acesta iradiaz n axil, este holosistolic i are aceeai

    intensitatepe toatdurata sa),din CMHO(suflulestemaximaudibil nplinstern,nuare click

    ejecionalicretenintensitatelainhalareadenitritdeamil,trecereanortostatismsauntimpul

    manevreiValsalvascdereavolumuluitelediastolicducelacretereagraduluideobstrucieprin

    aspirarea ctre sept a valvei mitrale), din coarctaia de aort (suflul este maxim audibil

    interscapulovertebral,la examenulobiectiv seconstatdiferena tensional ntremembre) icu

    sufluldeateromaortic(suflulHuchard,audibillabazacordului,cuiradierenearfsprevrfi

    friradierepevaseledelabazagtului).

    Auscultaiesufludestenozaortic+aspectfonocardiografic

    Stenozapulmonar:aceleaicaracterecaistenozaaortic

    Auscultaiesufludestenozpulmonar

    Efectul radiaiilor asupra funciei reproductive...am aflat pe 14 m artie k sunt insarcinata, nu

    am s tiut iar pe iar pe 6 m artie am facut ...

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    B.deregurgitaie

    Caractere:

    suntholosistolice

    auaspectfonocardiograficnband

    nglobeazzg.II

    Insuficienamitral:sufluholosistolic,detonalitatenalt,timbrunniturdevapori,maxil

    audibil la apex i n decubit lateral stng, iradiaz n axial i posterior (uneori circular).

    Diagnosticuldiferenialsefacecusufluldinstenozaaorticiceldininsuficienatricuspidian.

    Auscultaiesufludeinsuficienmitral+aspectfonocardiografic

    Prolapsuldevalvmitral (sindromulclick-suflu,sindromulBarlow): suflumezotelesistolic,

    introdusdeclick,cuintensitatemaximlaapex,caracterpiolant,muzical.

    Auscultaiesufludeprolapsdevalvmitral+aspectfonocardiografic

    Insuficienatricuspidian: suflu cuaceleaicaractereca icel din insuficiena mitral,maxil

    audibillabazasternului,iradiaznepigastru,spreficatsauspreapexulcordului,seaccentueazn

    apneepostinspiratorie(manevraRivero-Carvalho),sensoetedepulsaiehepaticsistolic.

    C.Altesuflurisistolice

    Defectulseptal interatrial (DSA, DSIA): se potauzi unul sau2 sufluri, n funciede mrimea

    defectuluiide gradulde creterea debitului pulmonar unsuflusistolic,mezocardiaci unul

    diastolic,tricuspidian,cudedublarefixdezg.II.

    AuscultaiesufluDSA

    Defectul septal interventricular (DSV, DSIV): sufluaspru, ejecional, similar celui din stenoza

    aortic,darncepeimediatdupzg.Iiseprelungetedupzg.II,maximaudibilmezocardiacsaula

    apex,cuiradierecaracteristicnspiederoat.

    AuscultaiesufluDSV

    http://www.mymed.ro/files/fono/fono%20pvm.jpghttp://www.mymed.ro/files/fono/fono%20im.jpg
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    ii)Sufluridiastolice

    A.nstenozelevalvelorAV

    Caractere:

    este maxim protodiastolic, n timpul umplerii rapide, apoi diminu n intensitate spre

    mezodiastol.

    lapacienii n ritm sinusal suflulde insuficien valvularAVare o ntrire telediastolic

    (presistolic),datdecontraciaatrialcarempingesngempotrivaunuiobstacol

    suflulesteprecedatdeunclacmentdedeschiderealvalveirespective,caretraducerigidizarea

    ingroareaacesteia,cuscdereamobilitii

    nuiradiaz

    Stenozamitral:suflude tonalitatejoas, cucaracter deuruitur diastolic,maximaudibil n

    focarul mitral i cu pacientul n decubit lateral stng, se intensific dup efort moderat (n

    tahicardieextremnusemaiaude),esteprecedatdeclacmentuldedeschiderealmitralei(zgomot

    pocnit,aparela0,06-0,12secdeA2)iestentritdeunsuflupresistolic(lapacieniinfibrilaie

    atrial ntrirea presistolic dispare). Durata uruiturii se coreleaz direct proporional cu

    severitateastenozei.Elementeleauscultatoriialestenozeimitraleaufostgrupatesubnumelede

    onomatopeeaDuroziez ru-f-t-ta-ta("f" -suflupresistolic,"t"- zg. I ntrit,datde nchiderea

    valveimitralerigide,"ta" zg.II,poatefidedublatdatoritHTPu,"ta"-CDM,datdedeschiderea

    valveimitralerigide,"ru"-uruituraprotomezodiastolicdatdecurgereaturbulentprinorificiul

    mitral).

    Semnedeseveritatenstenozamitral:intervalQ-Z1prelungit(nchidereaVMsefaceatuncicnd

    presiuneaVSdepetevalorilecrescutealepresiuniiAS,ceeacefacecalapacieniicustenoz

    sever,zg.Isfientrziat),apropiereazg.IIdeCDM(VMseredeschideatuncicndpresiuneaVS

    scadesubceadinAS,fcndcalaunpacientcupresiunemarenAS,CDMsaparrapiddupzg.

    II),scdereaintensitiiCDMizg.I(traducomobilitateredusaVM),sufluGraham-Steel(suflu

    de insuficien pulmonar funcional aprut ca urmare a HTPu fixe, de rezisten), pulsaiesistolichepatic(indicinsuficientricuspidian).

    Diagnosticuldiferenialsefacecu:suflulCarey-Coombs(dinRAA,estemezodiastolic,aretonalitate

    nalt,este foartevariabil),suflul dinmixomatrial sauvegetaiimari nendocardit infecioas

    (diagnosticuldiferenialsefaceecocardiografic),uruituraAustin-Flint(sufulaudibilninsuficiena

    aorticca urmare a lovirii VMA dectre jetul regurgitant), insuficiena mitral cu auscultaie

    diastolic(aprutprintr-unfluxcrescutndiastol,caurmareaadugriivolumuluiregurgitat).

    Auscultaiesufludestenozmitral+aspectfonocardiografic

    Stenozatricuspidian:similarstenozeimitrale,doarcasociazpulsaiediastolichepatic.

    B.ninsuficienavalvelorsigmoide

    Insuficienaaortic:sufluprotomezo-sauholodiastolic,descrescendo(scadenintensitatepe

    msurcediminugradientuldepresiuneaortoventricularndiastol:ntimpcepresiuneadinAo

    rmneconstantsauchiar scade,presiuneadinVS creteprinumplereaprinmitralicujetul

    regurgitat),maximaudibilnfocarulAosaufocarulErb,cutonalitatenalt,dulce,aspirativ,nsoit

    deomultitudinedesemneperiferice:ocapexianglobulos,puternic(endomeetenmasse-Bard),

    hippuspupilar,pulscapilar(Quincke),dansarterial,pulsceleretaltus,formulsfingomanometric

    http://www.mymed.ro/files/fono/fono%20stm.jpg
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    0

    divergentTAScrescut,TADsczut.

    Auscultaiesufludeinsuficienaortic+aspectfonocardiografic

    iii)Sufluricontinue

    suntsuflurisistolo-diastolice,auunmaximdeintensitatelngzg.II

    aparcaurmareauneicomunicrintrecaviticardiacesauvase,caremeninungradient

    presionalpetoatduratacicluluicardiac:persistenacanaluluiarterial,fistulearteriovenoase

    sistemicesaucoronariene,anevrismruptdesinusValsalva.

    potapreacaurmareafluxuluicrescutprintr-unsegmentvascular:suflulmamaresteun

    sufluinocent,continuu(sausistolic),audibillanivelulsnilorgravidelornultimultrimestru,

    murmurulvenoscervicalsuflucontinuudetonalitateiintensitatesczut,audibilpevasele

    delabazagtului,aparelacopiiilabolnaviicuascitipresiunevenoascrescut.

    iv)Frecturapericardic

    Frecturapericardicesteunzgomotuscat,aspru,rugos,asemntorscrituluiprodusdepaii

    pezpad,caracteristicpericarditeiuscate(fibrinoide),cu3componente(1sistolic,unulproto-iunul tele diastolic). Este clare pezgomotelecardiace ise aude mai bine apsnd uor cu

    stetoscopulpetorace.Diagnosticuldiferenialsefacecufrecturapleural(auscultaiasevaface

    napnee).

    Auscultaiefrecturpericardic

    Auscultaiefrecturpleural

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