李丽君急性胸痛.ppt

Chest pain,Differential diagnosis of chest pain 以急性胸痛主诉就诊， 你应考虑那些可能诊断？,Li - Jun Li Department of Emergency Medicine Second Hospital,胸痛鉴别的重要性,胸痛(chest pain)指原发于胸部或由躯体其他部位放射到胸部的疼痛。 原因多样，程度不一，且不一定与疾病的部位和严重程度相一致。由于解剖、生理和心理因素的相互影响，牵扯痛、应激反应及心理暗示等机制的作用，使得许多严重疾病被误以为普通疾病，而相反情况也时有发生。有些可能发生猝死的疾病如ACS、主动脉夹层、肺动脉主干栓塞等与某些非致命性疾病如食管疾病、肺部疾病甚至出疹前的带状疱疹等，同样可有胸痛或胸背部不适。 以急性胸痛、胸部不适为主诉来医院急诊的患者十分常见。虽然没有准确的统计资料，但在我国大中城市的三级甲等医院急诊科，估计这类患者约占5-10%。 胸痛作为多种疾病的首发症状，其中隐匿着一些致命性疾病, 除最常见的急性冠脉综合征（ACS）外，还有近几年被逐步重视的急性肺栓塞（PE）、主动脉夹层等，它们都具有发病急，病情变化快，死亡率高的特点；而早期快速诊断，及时治疗，可以显著改善预后。虽然这些疾病仅占胸痛病人的1/4左右，但由于医务人员受专业知识和检测手段的限制不能将其迅速准确甄别，使得一些具有严重疾病的胸痛患者混于一般病人，延误了救治时间，甚至造成严重后果。 及时正确地识别和诊治各种胸痛有着非常重要的临床意义。,重点,认识心绞痛的不典型症状 区分心源性与非心源性胸痛，即鉴别有生命威胁的、需要紧急救治的疾病 。 警惕误诊：急性心肌缺血，急性肺栓塞，动脉夹层。 区分抗凝与不能抗凝的疾病：比如：急性心肌梗死与主动脉夹层的识别,思考病例,病例1 男，56岁，弯腰抱起小孩突然左侧胸背部痛，不剧烈，持续1小时到西安市某三甲医院就诊。心电图大致正常，胸部X片示肺纹理加重，血白细胞和中性粒细胞略增高，血压160/90mmHg,高血压病史3-4年，间断服用降压药。该院医生诊断肺部感染、高血压病，抗感染和降血压治疗半月，因上楼梯右下肢痛而再次就诊。？ 病例2 男，气短、胸痛、呼吸困难2周，当地医院诊断缺血性心脏病，心衰，治疗无效，且咳血3天主诉急诊入我院。患者端坐呼吸，全身紫绀，大汗，血压90/40mmHg，心率150次/分。？,Causes of chest pain,需要宽视野！ 避免窄思维！,首先区分,Some are life-threatening and require prompt diagnosis and treatment whereas others are more benign. 鉴别有生命威胁的、需要紧急救治的疾病。 Differentiation: cardiac and non cardiac chest pain. 鉴别心源性（如急性心肌梗死，动脉夹层）和非心源性胸痛。,Why do we differentiate cardiac and non cardiac chest pain?,Why?,为什么鉴别心源性和非心源性胸痛？,The reason to differentiate Cardiac and non-caardiac chest pain,thrombolysis is indicated in acute myocardial infarction, pulmonary embolus; thrombolysis is contraindicated in pericarditis and dissection of the thoracic aorta. 急性心肌梗死、急性大面积肺栓塞需要紧急血管再通、抗凝抗血小板及溶栓等。 心包炎和动脉夹层是溶栓、抗凝抗血小板禁忌症。 血栓性疾病有治疗时间窗。 急性动脉夹层有极高的死亡率。,Characteristic of chest pain 心源性和非心源性胸痛特征,Distinguishing characteristic of cardiac and non-cardiac chest pain,心源性和非心源性胸痛特征,心源性 非心源性 疼痛 沉重，压榨， 钝痛，刀割样，锐痛 部位 中心部位 左乳房下 放射到左臂、颈、牙， 诱因 用力，精神因素，寒冷， 体位变动，触痛,心绞痛症状-典型与不典型 -2007AHA/ACC急性冠脉综合症指南,典型心绞痛 部位：胸骨中下部位 胸痛性质：压榨性、压迫、紧缩、沉重感； 放射：颈部、下颌、肩、背、单臂或双臂。 不典型 伴随胸部不适或不能解释的消化不良、烧心、恶心、和或呕吐。 持续气短。 虚弱、头晕、轻微头痛、意识丧失。胸膜炎痛（呼吸或咳嗽时锐痛）。 非创伤性胸痛或严重上腹部痛。单独的上或下腹痛，指尖痛，非常短暂的痛（几秒或更短）。,Past medical history will give you clue to diagnosis 既往病史提供诊断线索,A history ischeamic heart disease; 心脏病史 A history of peptic ulcer disease or or non-steroidal anti-inflammatory drugs; 溃疡病史或者非甾类药物使用史。 Recent operations-cardiothoracic surgery may be complicated by Dresslers syndurme, mediastinitis, ischaemic heart disease or pulmonary embolus(PE); 最近心胸手术史者有可能伴随纵隔炎，缺血性心脏病，肺拴塞。 Pericaarditis may be preceded by a prodromal viral illness;先前病毒感染已有心包炎。 Pulmonary embalus may be preceded by a period of inactivity (e.g. a recent operation, illness, or long jourmey); 肺栓塞可能伴随不活动，手术，等。 Hyptertension is risk for both ischeamic heart disease and dissection of the thoracic aorta. 高血压是缺血性心脏病，动脉夹层的危险因素。,提示疾病的征象,Signs of shock (e.g. pallor, sweating)-indicate myocardial infarction, dissecting aorta, pulmonary embolus;休克征象（苍白、出汗）：心梗、动脉夹层、肺拴塞 Laboured breathing-may indicate myocardial infarction leading to left ventricular failure or a pulmonary cause;呼吸困难：心衰或肺部原因 Signs of vomiting-suggests myocardial infarction or on oesophageal cause;呕吐：提示心梗或食道原因 Coughing-suggests left ventricular failure, pneumonia.心衰或肺部原因,Investigation 检查,Test 检查,Diagnosis 诊断,动脉血气,严重低氧血症提示：肺拴塞、左心衰、肺炎,心肌酶,可能在心梗最初4小时内正常，但CK-MB将增加,ECG,如果正常除外心梗，但是在急性期需要动态观察,胸片,宽纵隔提示动脉夹层；可以显示胸腔积液，肺实变,B超/CT,怀疑有动脉夹层立即作B超/CT,First-line tests to exclude a chest pain emergency 急诊胸痛一线检查,胸痛的危险分层 -心电图及缺血性胸痛患者危险程度的可能性,高危组（1） 有心肌梗死病史，致命性心律失常 晕厥，已诊断冠心病 确定为冠心病 伴有症状的ST改变 前壁导联T波明显改变,中危组（=1） 青年人心绞痛 老年人可能心绞痛 可能有心绞痛 糖尿病和另外3个危险因素 ST压低或=1mm，R波直立,低危组（1） 可疑心绞痛 1个危险因素、无糖尿病 T波倒置1mm 正常心电图， T波倒置或=1mm,胸痛的危险分层 -可疑缺血性胸痛患者近期死亡和非致命性心梗的危险性,高危组： 胸痛20分钟，休息不缓解 与缺血有关的肺水肿 ST或R波降低 合并高血压 静息心绞痛半晕厥 ST1mm 肌钙蛋白增高,中危组 胸痛20分钟，已缓解 中度可能的冠心病 静息心绞痛20分钟 1个危险因素，但非糖尿病 年龄65岁 心绞痛和T波动态改变 病理性Q波或多个导联ST压低压低1mm,低危组 胸痛的频率、时间 程度增加 活动耐量降低 2周至2个月内新发心绞痛 心电图无改变,Algorithm for investigation of chest pain,At rest,Worse on exertion,Consider pulmonary embolus in all patients,Chest pain,Worse on inspiration,Not worse on inspiration,Investigate for angina (ECG, angiogram),Raised ST segment,Consider MI,ST depression T wave inversion T wave flatening,Widespread concave ST elevation,Consider unstable angina, investigate futher,pericarditis,Pleurisy secondary to pneumonia, pneumothorax, poumonary embolus, Dresslers syndrom,Central pain,Musculoskeletal oesophagitis,lateral,Musculoskeletal Shingles (herpes zoster),Dresslers syndrome,Pulmonary embolus,肺栓塞,Pulmonary embolus,Pulmonary emboli may present as acute chest pain in an ill patients or as intermittent chest pain in a relatively well patient. For this reason it is crucial to suspect PE in all patients who have chest pain that is not typically anginal!,Symptoms and signs of PE,The pain of a PE may be pleuritic or tight in nature and may be located anywhere in the chest. It may be accompanied by the following symptoms and signs: Dyspnoea; Dry cough or haemoptysis; Hypotension and sweating; Sudden collapse with syncope. A sense of “impending doom” or profound anxiety.,Electrocardiography of PE,Sinus tachycardia (or atrial fibrillation). Ventricular tachyarrhythmias or sinus rhythm with electromechanical dissociation Tall P waves in lead II (right atrial dilatation). Right axis deviation and right bundle branch block. S wave in lead I, Q wave in lead III, and invented T wave in lead III ( SI QIII pattern seen only with very large PE).,Dissection of the thoracic aorta 主动脉夹层,Predisposing factors,Hypertension Bicuspid aortic valve Pregnancy Marfan等 Connective tissue disease-SLE等 Menwomen Middle age,主动脉夹层发病率、死亡率,发病率：每百万人口五至三十人之间，男性高于女性。 死亡率：急性夹层不治疗，48小时内死亡率约36-72%，一周内死亡率62-91%；院内保守治疗，其平均死亡率也高达27.4%；夹层累及重要血管分支引起脏器缺血，其死亡率更高。,Pathophysiology,Damage to the media and high introluminal pressure causing an intimal tear; Blood enters and dissencts the luminal plane of the media creating a fals lumen.,Stanford classification,Type A-all dissections involving the ascending aorta; Type B-all dissection not involving the ascending aorta.,Symptoms,Central tearing chest pain radiating to the back; Further complications as the dissection involves branches of the aorta: Coronary ostia-myocardial infarction; Carotid or spinal arteries-hemiplegia, dysphasia, or paraplegia; Mesenteric arteries-abdominal pain.,Signs,shocked, cyanosed, sweating; Blood pressure and pulses differ between extremities： Aortic regurgitation; Cardiac tamponade; Cardiac failure.,Investigation,CXR-widened mediastinum +/- fluid in costophrenic angle; ECG-may be ST elevation; CT/MRI-best investigations, show aortic false lumen; Transoesophageal echo if available also very sensitive; Echocardiography-may show pericardial effusion if dissection extends proximally; tamponade may occur.,Summary,The importance of this subject is that this situation represents a medical emergency requiring rapid diagnosis and treatment. It is necessary in this situation to distinguish between: MI; unstable angina; pericaditis; dissect