医学知识一急性腹胸痛4

EmergencyMedicineandTechniqueDr.FengQi-ming(MD,PhD封启明)TheEmergencyDepartment,the6thpeoples’hospitalofShanghai,ShanghaijiaotongUniversityEmergencyMedicineandTechniqueDifferentialdiagnosis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WhatarequalifiedemergencyphysicianneedsRichinelementaryknowledgeofmedicine(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AnginaPectoris

andacutemyocardialinfarctionareusuallyretrosternal.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,mediastinalherniaandmediastinal

tumerisalsoaretrosternal.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:serummyocardiummaker\treadmillexercise\UCG\nuclearcardiology(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1—5分钟，休息或含服硝酸甘油后1–3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S–T段压低和T波改变。TheSTsegmentisusuallydepressedandT-wavechangedduringanginainEKG.心肌酶学无改变NegativechangesinCardiacmarkerCardiacmarker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.widenedmediastinumCardiovascularmagneticresonance(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,