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EmergencyMedicineandTechnique,Dr.FengQi-ming(MD,PhD封启明)TheEmergencyDepartment,the6thpeopleshospitalofShanghai,ShanghaijiaotongUniversity,.,EmergencyMedicineandTechniqueDifferentialdiagnosis症状鉴别诊断Chestpain胸痛Abdominalpain腹痛Fever发热,Theintroductionofemergencymedicine急诊医学简介,Non-trauma非创伤性急诊(内科、外科、儿科)trauma创伤Disastermedicine灾难医学firstaid院前急救,Whatarequalifiedemergencyphysicianneeds,Richinelementaryknowledgeofmedicine(丰富的医学基础知识)Havingrichclinicalexperience(丰富的临床经验)Mastertheprincipalsofdecision-makinginemergencymedicine(正确的急诊临床思维),Skilledtechniquesforemergency(娴熟的急救技术)Trachealintubation气管插管,Venipuncture深静脉穿刺,Cardiopulmonaryresuscitation心肺复苏Emergencyphysiciandiathesis(良好的心理素质)Theabilitytodealtwithaccidentappropriately(镇静处理突发事件),AcuteChestPain急性胸痛,.,Decision-makingonAcuteChestpainatEarlyStage早期识别高危胸痛,Recognizethedangerousofacutechestpain,especiallywiththoselife-threatening识别胸痛的危险程度,特别是威胁生命的胸痛Establishpainmanagementcentertoofferacomprehensiverangeofservicesforpatientswithtreatmentonacutechestpain.国外建立疼痛中心建立一系列胸痛诊疗程序,High-riskChestPain急诊常见的高危胸痛,Cardiogenicpain:AcuteCoronarySyndrome(UAP、AMI)高危心源性疼痛:急性冠脉综合征Non-cardiogenicpain:aorticdissection,pulmonaryembolismandtensionpneumothorax高危非心源性疼痛:主动脉夹层、肺栓塞、张力性气胸,DiagnosisonAcuteChestPain急性胸痛诊断思路,Medicalhistory,physicalexamination,laboratoryexaminationandspecialexaminationandtests(EKG、ChestX-ray、enzymology)病史、体格检查、辅助检查(EKG、胸片、酶学等)chestpaindivision(CardiogenicandNoncardiogenic)区分胸痛系心源性或非心源性Juddgementtheriskdegree判断危险度,characteristicsofchestpain有助于胸痛的诊断和鉴别诊断的特点,Locationofpain疼痛的部位,retrosternal,substernalQuality疼痛的性质,pressure,tightness,sharp,pleuritic,burningDuration,aggravationandalleviationofpain疼痛的时间及影响因素、缓解因素,exertion,cold,psychologicstress,nitroglycerinSimultaneoussymptomsofpain疼痛的伴随症状Previousmedicalhistory即往史,locationofchestpain胸痛的部位,AnginaPectorisandacutemyocardialinfarctionareusuallyretrosternal.mostpatientsdonotlocalizethepaintoanysmallarea.Theyaretypicallydescribedastightness,pressure,orsqueezing.Painmayradiatetothejaw,neck,arms,back,andepigastria.Theleftarmisaffectedmorefrequently.心绞痛与急性心肌梗死的疼痛常位于胸骨后或心前区,且放射到左肩和左上臂内侧。,Thepainofesophagealdisease,mediastinalherniaandmediastinaltumerisalsoaretrosternal.食管疾患、隔疝、纵隔肿瘤的疼痛也位于胸骨后。spontaneouspneumothorax,acutepleuritisandpulmonaryembolismet.aloftenunilateralandpleuritic.自发性气胸、急性胸膜炎、肺栓塞等常呈患侧的剧烈胸痛。,QualityofChestPain胸痛的性质,Intercostalneuralgiacausesparoxysmalburningpainorprickingpain.肋间神经痛呈阵发性的灼痛或刺痛。Myosalgiaoftenoccurswithachingpain.肌痛则常呈酸痛;Ostalgiaoccurswithachingpainorboringpain骨痛呈酸痛或锥痛;Esophagitisanddiaphragmatoceleoftenoccurswithburningpainorheatburn食管炎、膈疝常呈灼痛或灼热感;,QualityofChestPain胸痛的性质,AnginaPectorisormyocardialinfarctionisusuallydescribedasaheaviness,pressure,orsqueezing心绞痛或心肌梗死常呈压榨样痛并常伴有压迫感或窒息感。Borningpainiscausedbytheerosionofaneurysmofaortawhenitcorrodeschestpain主动脉瘤侵蚀胸壁时呈锥痛。Thechestsuffocationcanbediagnosedbyprimarilylungcancerormediastinalmass原发性肺癌、纵隔肿瘤可有胸部闷痛。,Associatedfeatures影响胸痛的因素,AnginaPectorisisoftenindusedbytension.Itcanbereleasedbytakingnitroglycerintablets.Myocardialinfarctioncanbeindentifiedwithcontinuingpainwhichisnottobereleasedbytakingnitroglycerintablets.心绞痛常于用力或精神紧张时诱发,呈阵发性,含服硝酸甘油片迅速缓解;心肌梗死常呈持续性剧痛,虽含服硝酸甘油片仍不缓解,Cardiacneurosisisoftenthereasonofchestpain.Itcanberelievedbymovement.心脏神经官能症所致胸痛则常因运动反而好转Thechestpainofpleurisy,pneumothorax,andpericarditiscanoftenbeexacerbatedbycoughordeepbreathing胸膜炎、自发性气胸、心包炎的胸痛常因咳嗽或深呼吸而加剧,Associatedfeatures影响胸痛的因素,NeuromusculoskeletalConditions:Directpressureonthechondrosternalandcostochondraljunctionsmayreproducethepainfromtheseandothermusculoskeletalsyndromes.Itisintensifiedbythoracicactivity;Esophagealdiseasesisoftenexacerbatedbyswallowingfood胸壁疾病所致的胸痛常于局部压迫或胸廓活动时加剧;食管疾病的胸痛常于吞咽食物时发作或加剧,Simultaneousphenomenonofchestpain胸痛的伴随症状,Cough:trachea,bronchiandpleuraldiseases胸痛常伴咳嗽:气管、支气管、胸膜疾病所致。Dysphagia:diseasesofesophagealandmediastinum胸痛常伴吞咽困难:食管、纵隔疾病所致的,Hemoptysis:tuberculosis,pulmonaryembolismandprimarylungcancer.胸痛常伴有咯血:肺结核、肺栓塞、原发性肺癌。Sneeze:brustwirbledisease胸痛常伴有深吸气或打喷嚏加重:胸椎病变,Simultaneousphenomenonofchestpain胸痛的伴随症状,Hypertentionand/orhistoryofcoronaryheartdisease:anginapectoris,myocardialinfarction胸痛常伴有高血压和(或)冠心病史:心绞痛、心肌梗死,Dyspnea:pneumonia,pneumothorax,pleurisy,pulmonaryembolismandhyperventilationsyndrome,etc.胸痛常伴有呼吸困难:肺炎、气胸、胸膜炎、肺栓塞、过度换气综合征等Abatementposition:cardiopericarditis:sittingupandleaningforward;esophagealhiatalhernia:erectposition胸痛常伴有特定体位缓解:心包炎坐位及前倾位;食管裂孔疝立位,Simultaneousphenomenonofchestpain胸痛的伴随症状,Onsetsuddenly:thoracicorganruptureisconcluedbythesymptomsofrapidseverechestpain.suchandissectionofaorta,aerothorax,andmediastinalemphysemaetc.胸痛伴起病急剧,胸痛迅速达高峰,往往提示胸腔脏器破裂,如主动脉夹层、气胸、纵隔气肿等,Haemodynamics:fatalsymptomsareappearedashypotension/venousengorgementsuchaspericardialtamponade,acutemyocardialinfarction,severepulmonaryembolism,dissectionofaorta胸痛伴血流动力学异常低血压及静脉怒张则提示致命性胸痛(心包填塞、急性心肌梗塞、巨大肺栓塞、主动脉夹层),EvaluationCardiogenicChestPain心源性胸痛的急诊评价方法,Historyandphysicalexamination病史、查体12Leads-ECG(DynamicObservation)-myocardialischemia(30%)increaseST12导ECG(动态观察)-心肌缺血(30%)ST抬高,ChestpainwithouttypicalECGchange:serummyocardiummakertreadmillexerciseUCGnuclearcardiology(Non-abnormal50%AMIduringthediagnoseof20%AMI)dynamicoberservation对ECG无明显变化的胸痛-血清标志物检查运动平板UCG核素检查(50%AMI的ECG无异常-观察期间20%AMI)-动态观察易误诊,EvaluationonCardiogenicChestPain心源性胸痛的急诊评价方法,Cardiacmarkertesting(TNT、TNI、CPK-MB、GOT、LDH)血清标志物检测(TNT、TNI、心肌酶谱)CTNTforecaststheacutemyocardialischemiaCTNT是急性心肌缺血独立危险预报因子,Radionuclide:myocardialischemiaaftersixhours核素心肌缺血或梗死6小时后Identifiedasnon-cardiacchestpainifECGdoesnotchangethroughobservation若胸痛经动态观察ECG等无变化,考虑非心源性胸痛。,Charactersofchestpaininemergency急诊常见疾病的胸痛特点,.,心绞痛AnginaPectoris,疼痛部位在胸骨上,中段,少数在心前区或剑突下,放射于左胸、左背、左肩、左上臂前内侧直达无名指及小指;亦可放射到颈、咽、下颌及乳突。疼痛性质为紧缩压榨感,闷胀窒息感、刺痛、锐痛、灼痛甚至刀割样疼痛,偶有濒死样恐惧,迫使患者立即停止活动。Mostpatientswithanginapectorisareidentfeidasretrosternalchestdiscomfortratherthanasfrankpain.Theformerisusuallydescribedasapressure,heaviness,squeezing,burning,orchokingsensation.Anginalpainmaylocateprimarilyintheepigastrium,back,neck,jaw,orshoulders.Typicallocationsforradiationofpainareatarms,shoulders,andneck.Fewpresentsscaresonthebrinkofdeathandisforcedtoquitthework.,Symptomsandsigns,疼痛持续时间约15分钟,休息或含服硝酸甘油后13分钟内可缓解症状。Itlastsforapproximately1-5minutesandisrelievedbyrestorbynitroglycerinafter1-3minutes.疼痛常因用力、劳累、饱食、情绪激动而诱发Anginaisprecipitatedbyexertion,diet,exposuretocold,oremotionalstress.发作时心电图检查可见ST段压低和T波改变。TheSTsegmentisusuallydepressedandT-wavechangedduringanginainEKG.心肌酶学无改变NegativechangesinCardiacmarker,Cardiacmarker,急性心肌梗死Acutemyocardialinfarction,胸痛的性质和部位与心绞痛相似,但较剧烈而持久,持续时间达数小时至数日,休息或含服硝酸甘油不能缓解。Natureandlocationofchestpainaresimilartothatofangina.However,theyaremoresevererandlong-lasting.Itcanlastfromseveralhourstoseveraldayswhichcannotbealleviatedwithrestorbytakingnitroglycerin.,常伴有发热、恶心、呕吐、面色苍白、呼吸困难、心律不齐、血压降低、心力衰竭等。Sometimesitisaccompaniedwithfever,nausea,vomiting,paleness,difficultyinbreathing,arrhythmia,lowerbloodpressureandheartfailure.心电图和酶学检查有相应的特异性演变。PositiveresultinCardiacmarkerandECGexamination,急性下壁心肌梗死Acuteinferiormyocardialinfarction,主动脉夹层aorticdissection,本病多见于40岁以上的男性,多有高血压和动脉粥样硬化病史。Commoninmiddle-agedpatientswithhypertensionandartherosclerosis.,widenedmediastinum,Cardiovascularmagneticresonance(CMR)ofatype-Aaorticdissection.,突发性撕裂样或刀割样胸痛,向胸前及背部放射,随夹层血肿波及范围可延至腹部、下肢、臂及颈部,极为剧烈,疼痛的高峰一般较急性心梗的高峰早。止痛药常无效。Almostallpatientswithacutedissectionspresentwithseverechestpain,sharp,stabbing,tearing,orrippingpainalthoughsomepatientswithchronicdissectionsareidentifiedwithoutassociatedsymptoms.Unlikethepainofischemicheartdisease,symptomsofaorticdissectiontendtoreachpeakseverityimmediately,oftencausingthepa

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