李丽君-急性胸痛PPT课件.ppt

Chestpain,Differentialdiagnosisofchestpain以急性胸痛主诉就诊，你应考虑那些可能诊断？,Li-JunLiDepartmentofEmergencyMedicineSecondHospital,胸痛鉴别的重要性,胸痛(chestpain)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。？,Causesofchestpain,需要宽视野！避免窄思维！,首先区分,Somearelife-threateningandrequirepromptdiagnosisandtreatmentwhereasothersaremorebenign.鉴别有生命威胁的、需要紧急救治的疾病。Differentiation:cardiacandnoncardiacchestpain.鉴别心源性（如急性心肌梗死，动脉夹层）和非心源性胸痛。,Whydowedifferentiatecardiacandnoncardiacchestpain?,Why?,为什么鉴别心源性和非心源性胸痛？,ThereasontodifferentiateCardiacandnon-caardiacchestpain,thrombolysisisindicatedinacutemyocardialinfarction,pulmonaryembolus;thrombolysisiscontraindicatedinpericarditisanddissectionofthethoracicaorta.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。,Characteristicofchestpain心源性和非心源性胸痛特征,Distinguishingcharacteristicofcardiacandnon-cardiacchestpain,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）。,Pastmedicalhistorywillgiveyoucluetodiagnosis既往病史提供诊断线索,Ahistoryischeamicheartdisease;心脏病史Ahistoryofpepticulcerdiseaseorornon-steroidalanti-inflammatorydrugs;溃疡病史或者非甾类药物使用史。Recentoperations-cardiothoracicsurgerymaybecomplicatedbyDresslerssyndurme,mediastinitis,ischaemicheartdiseaseorpulmonaryembolus(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。Pericaarditismaybeprecededbyaprodromalviralillness;先前病毒感染已有心包炎。Pulmonaryembalusmaybeprecededbyaperiodofinactivity(e.g.arecentoperation,illness,orlongjourmey);肺栓塞可能伴随不活动，手术，等。Hyptertensionisriskforbothischeamicheartdiseaseanddissectionofthethoracicaorta.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,Signsofshock(e.g.pallor,sweating)-indicatemyocardialinfarction,dissectingaorta,pulmonaryembolus;休克征象（苍白、出汗）：心梗、动脉夹层、肺拴塞Labouredbreathing-mayindicatemyocardialinfarctionleadingtoleftventricularfailureorapulmonarycause;呼吸困难：心衰或肺部原因Signsofvomiting-suggestsmyocardialinfarctionoronoesophagealcause;呕吐：提示心梗或食道原因Coughing-suggestsleftventricularfailure,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-lineteststoexcludeachestpainemergency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,Algorithmforinvestigationofchestpain,Atrest,Worseonexertion,Considerpulmonaryembolusinallpatients,Chestpain,Worseoninspiration,Notworseoninspiration,Investigateforangina(ECG,angiogram),RaisedSTsegment,ConsiderMI,STdepressionTwaveinversionTwaveflatening,WidespreadconcaveSTelevation,Considerunstableangina,investigatefuther,pericarditis,Pleurisysecondarytopneumonia,pneumothorax,poumonaryembolus,Dresslerssyndrom,Centralpain,Musculoskeletaloesophagitis,lateral,MusculoskeletalShingles(herpeszoster),Dresslerssyndrome,Pulmonaryembolus,肺栓塞,Pulmonaryembolus,Pulmonaryembolimaypresentasacutechestpaininanillpatientsorasintermittentchestpaininarelativelywellpatient.ForthisreasonitiscrucialtosuspectPEinallpatientswhohavechestpainthatisnottypicallyanginal!,SymptomsandsignsofPE,ThepainofaPEmaybepleuriticortightinnatureandmaybelocatedanywhereinthechest.Itmaybeaccompaniedbythefollowingsymptomsandsigns:Dyspnoea;Drycoughorhaemoptysis;Hypotensionandsweating;Suddencollapsewithsyncope.Asenseof“impendingdoom”orprofoundanxiety.,ElectrocardiographyofPE,Sinustachycardia(oratrialfibrillation).VentriculartachyarrhythmiasorsinusrhythmwithelectromechanicaldissociationTallPwavesinleadII(rightatrialdilatation).Rightaxisdeviationandrightbundlebranchblock.SwaveinleadI,QwaveinleadIII,andinventedTwaveinleadIII(SIQIIIpatternseenonlywithverylargePE).,Dissectionofthethoracicaorta主动脉夹层,Predisposingfactors,HypertensionBicuspidaorticvalvePregnancyMarfan等Connectivetissuedisease-SLE等MenwomenMiddleage,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,Damagetothemediaandhighintroluminalpressurecausinganintimaltear;Bloodentersanddissenctstheluminalplaneofthemediacreatingafalslumen.,Stanfordclassification,TypeA-alldissectionsinvolvingtheascendingaorta;TypeB-alldissectionnotinvolvingtheascendingaorta.,Symptoms,Centraltearingchestpainradiatingtotheback;Furthercomplicationsasthedissectioninvolvesbranchesoftheaorta:Coronaryostia-myocardialinfarction;Carotidorspinalarteries-hemiplegia,dysphasia,orparaplegia;Mesentericarteries-abdominalpain.,Signs,shocked,cyanosed,sweating;Bloodpressureandpulsesdifferbetweenextremities：Aorticregurgitation;Cardiactamponade;Cardiacfailure.,Investigation,CXR-widenedmediastinum+/-fluidincostophrenicangle;ECG-maybeSTelevation;CT/MRI-bestinvestigations,showaorticfalselumen;Transoesophagealechoifavailablealsoverysensitive;Echocardiography-mayshowpericardialeffusionifdissectionextendsproximally;tamponademayoccur.,Summary,Theimportanceofthissubjectisthatthissituationrepresentsamedicalemergencyrequiringrapiddiagnosisandtreatment.Itisnecessaryinthissituationtodistinguishbetween:MI;unstableangina;pericaditis;dissectionofthoracicaorta;PE;medi