急诊胸痛中英文双语教学ppt课件.ppt

EmergencyMedicineandTechnique Dr FengQi ming MD PhD封启明 TheEmergencyDepartment the6thpeoples hospitalofShanghai 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 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 oftencausingth