急性腹胸痛[4]课件

1、急性腹胸痛4Emergency Medicine and TechniqueDr. Feng Qi-ming (MD, PhD 封启明(qmng) The Emergency Department, the 6th peoples hospital of Shanghai, Shanghai jiaotong University 第一页，共四十五页。急性腹胸痛4Emergency Medicine and TechniqueDifferential diagnosis 症状(zhngzhung)鉴别诊断Chest pain 胸痛Abdominal pain 腹痛Fever 发热第二页，共四十

2、五页。急性腹胸痛4The introduction of emergency medicine急诊(jzhn)医学简介Non-trauma 非创伤性急诊（内科、外科、 儿科 ）trauma 创伤Disaster medicine 灾难医学(yxu)first aid 院前急救 第三页，共四十五页。急性腹胸痛4What are qualified emergency physician needsRich in elementary knowledge of medicine (丰富的医学基础知识)Having rich clinical experience (丰富的临床经验)Master t

3、he principals of decision-making in emergency medicine (正确的急诊临床(ln chun)思维)第四页，共四十五页。急性腹胸痛4Skilled techniques for emergency(娴熟的急救技术(jsh) Tracheal intubation气管插管, Venipuncture 深静脉穿刺，Cardiopulmonary resuscitation心肺复苏Emergency physician diathesis(良好的心理素质)The ability to dealt with accident appropriately

4、(镇静处理突发事件)第五页，共四十五页。急性腹胸痛4Acute Chest Pain急性急性(jxng)胸痛胸痛第六页，共四十五页。急性腹胸痛4Decision-making on Acute Chest pain at Early Stage早期(zoq)识别高危胸痛Recognize the dangerous of acute chest pain, especially with those life-threatening识别胸痛识别胸痛(xin tn)的危险程度的危险程度,特别是威胁生命的胸痛特别是威胁生命的胸痛(xin tn)Establish pain management c

5、enter to offer a comprehensive range of services for patients with treatment on acute chest pain. 国外建立疼痛中心建立一系列胸痛诊疗程序第七页，共四十五页。急性腹胸痛4High-risk Chest Pain急诊常见的高危(o wi)胸痛Cardiogenic pain:Acute Coronary Syndrome （UAP、AMI)高危心源性疼痛：急性冠脉综合征高危心源性疼痛：急性冠脉综合征Non-cardiogenic pain:aortic dissection, pulmonary em

6、bolism and tension pneumothorax高危非心源性疼痛：主动脉夹层高危非心源性疼痛：主动脉夹层(jicng)、肺、肺栓塞、张力性气胸栓塞、张力性气胸第八页，共四十五页。急性腹胸痛4Diagnosis on Acute Chest Pain急性胸痛(xin tn)诊断思路Medical history, physical examination , laboratory examination and special examination and tests (EKG、Chest X-ray、enzymology) 病史、体格检查、辅助检查（病史、体格检查、辅助检查（E

7、KG、胸片、酶学、胸片、酶学等）等）chest pain division (Cardiogenic and Non cardiogenic)区分胸痛区分胸痛(xin tn)系心源性或非心源性系心源性或非心源性Juddgement the risk degree 判断危险度判断危险度第九页，共四十五页。急性腹胸痛4characteristics of chest pain有助于胸痛(xin tn)的诊断和鉴别诊断的特点Location of pain疼痛的部位，疼痛的部位，retrosternal, substernalQuality 疼痛的性质疼痛的性质, pressure, tightne

8、ss, sharp,pleuritic,burningDuration, aggravation and alleviation of pain疼痛的时间及影疼痛的时间及影响因素响因素(yn s)、缓解因素、缓解因素(yn s), exertion, cold, psychologic stress, nitroglycerinSimultaneous symptoms of pain疼痛的伴随症状疼痛的伴随症状Previous medical history 即往史即往史 第十页，共四十五页。急性腹胸痛4 location of chest pain胸痛胸痛(xin tn)(xin tn)的

9、部的部位位Angina Pectoris and acute myocardial infarction are usually retrosternal. most patients do not localize the pain to any small area. They are typically described as tightness, pressure, or squeezing. Pain may radiate to the jaw, neck, arms, back, and epigastria. The left arm is affected more fre

10、quently.心绞痛与急性心肌心绞痛与急性心肌梗死梗死(xn j n s)的疼痛常位于胸骨后或心前区，且放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。射到左肩和左上臂内侧。第十一页，共四十五页。急性腹胸痛4The pain of esophageal disease, mediastinal hernia and mediastinal tumer is also a retrosternal .食管疾患、隔疝、纵隔食管疾患、隔疝、纵隔(zngg)肿瘤的疼痛也位于胸骨后。肿瘤的疼痛也位于胸骨后。spontaneous pneumothorax, acute pleuritis an

11、d pulmonary embolism et.al often unilateral and pleuritic.自发性气胸、急性自发性气胸、急性胸膜炎、肺栓塞等常呈患侧的剧烈胸痛。胸膜炎、肺栓塞等常呈患侧的剧烈胸痛。第十二页，共四十五页。急性腹胸痛4Quality of Chest Pain胸痛(xin tn)的性质Intercostal neuralgia causes paroxysmal burning pain or pricking pain. 肋间神经痛呈阵发性的灼痛或刺痛肋间神经痛呈阵发性的灼痛或刺痛(c tn)。Myosalgia often occurs with ach

12、ing pain.肌痛则常呈酸肌痛则常呈酸痛；痛；Ostalgia occurs with aching pain or boring pain骨痛骨痛呈酸痛或锥痛；呈酸痛或锥痛；Esophagitis and diaphragmatocele often occurs with burning pain or heatburn食管炎、膈疝常呈灼痛或灼食管炎、膈疝常呈灼痛或灼热感；热感；第十三页，共四十五页。急性腹胸痛4Quality of Chest Pain胸痛(xin tn)的性质Angina Pectoris or myocardial infarction is usually de

13、scribed as a heaviness, pressure, or squeezing 心绞痛心绞痛或心肌梗死或心肌梗死(xn j n s)常呈压榨样痛并常伴有压迫感或常呈压榨样痛并常伴有压迫感或窒息感。窒息感。Borning pain is caused by the erosion of aneurysm of aorta when it corrodes chest pain 主动脉瘤侵蚀胸壁主动脉瘤侵蚀胸壁时呈锥痛。时呈锥痛。The chest suffocation can be diagnosed by primarily lung cancer or mediastinal

14、 mass 原发性肺癌、纵隔肿瘤可原发性肺癌、纵隔肿瘤可有胸部闷痛。有胸部闷痛。第十四页，共四十五页。急性腹胸痛4Associated features影响胸痛(xin tn)的因素Angina Pectoris is often indused by tension. It can be released by taking nitroglycerin tablets. Myocardial infarction can be indentified with continuing pain which is not to be released by taking nitroglyceri

15、n tablets.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(xn s)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第十五页，共四十五页。急性腹胸痛4Cardiac neurosis is often the reason of chest pain. It can be relieved by movement.心脏神经官能症所致胸痛则常因运动反而好转The chest pain of pleurisy, pneumothorax, and pericarditis can often be exacerbated by cough or deep breath

16、ing 胸膜炎、自发性气胸、心包炎的胸痛常因咳嗽(k su)或深呼吸而加剧第十六页，共四十五页。急性腹胸痛4Associated features影响(yngxing)胸痛的因素Neuromusculoskeletal Conditions: Direct pressure on the chondrosternal and costochondral junctions may reproduce the pain from these and other musculoskeletal syndromes. It is intensified by thoracic activity; E

17、sophageal diseases is often exacerbated by swallowing food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(shgun)疾病的胸痛常于吞咽食物时发作或加剧第十七页，共四十五页。急性腹胸痛4 Simultaneous phenomenon of chest pain胸痛(xin tn)的伴随症状 Cough: trachea, bronchi and pleural diseases胸痛常伴咳嗽胸痛常伴咳嗽(k su)：气管、支气管、胸膜疾病所致。Dysphagia: diseases of esophageal and medias

18、tinum胸痛常伴吞咽困难胸痛常伴吞咽困难：食管、纵隔疾病所致的第十八页，共四十五页。急性腹胸痛4Hemoptysis: tuberculosis, pulmonary embolism and primary lung cancer.胸胸痛痛(xin tn)常伴有咯常伴有咯血：肺结核、肺栓塞、原发性肺癌。Sneeze: brustwirble disease胸痛常伴有深吸气或打喷嚏加重嚏加重：胸椎病：胸椎病变变第十九页，共四十五页。急性腹胸痛4Simultaneous phenomenon of chest pain 胸痛的伴随(bn su)症状Hypertention and/or his

19、tory of coronary heart disease: angina pectoris, myocardial infarction 胸痛胸痛(xin tn)常伴有高血压和常伴有高血压和 (或或) 冠心病史冠心病史：心绞痛、心肌梗死第二十页，共四十五页。急性腹胸痛4Dyspnea: pneumonia, pneumothorax, pleurisy, pulmonary embolism and hyperventilation syndrome, etc. 胸痛常伴有呼吸困难：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Abatement position: ca

20、rdiopericarditis:sitting up and leaning forward; esophageal hiatal hernia: erect position胸痛常伴有特定体位缓解：胸痛常伴有特定体位缓解：心包炎坐位(zu wi)及前倾位；食管裂孔疝立位第二十一页，共四十五页。急性腹胸痛4Simultaneous phenomenon of chest pain胸痛的伴随(bn su)症状Onset suddenly: thoracic organ rupture is conclued by the symptoms of rapid severe chest pain.

21、such an dissection of aorta, aerothorax,and mediastinal emphysema etc.胸痛伴起病急剧胸痛伴起病急剧，胸痛迅速达高峰，往往提示胸腔脏器破裂(pli)，如主动脉夹层、气胸、纵隔气肿等第二十二页，共四十五页。急性腹胸痛4Haemodynamics: fatal symptoms are appeared as hypotension/venous engorgement such as pericardial tamponade, acute myocardial infarction，severe pulmonary embol

22、ism , dissection of aorta胸痛伴血流动力学异常胸痛伴血流动力学异常低血压及静脉怒张则提示(tsh)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）第二十三页，共四十五页。急性腹胸痛4Evaluation Cardiogenic Chest Pain心源性胸痛的急诊评价(pngji)方法History and physical examination 病史、查体12 Leads-ECG (Dynamic Observation)- myocardial ischemia (30%) increase ST 12导 ECG(动态观察(gunch)-心肌缺血(30

23、%)ST抬高第二十四页，共四十五页。急性腹胸痛4Chest pain without typical ECG change: serum myocardium maker treadmill exercise UCG nuclear cardiology (Non-abnormal 50% AMI during the diagnose of 20%AMI) dynamic oberservation 对ECG无明显变化的胸痛(xin tn)-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)-动态观察易误诊第二十五页，共四十五页。急性腹胸痛4 Evalu

24、ation on Cardiogenic Chest Pain心源性胸痛的急诊评价(pngji)方法Cardiac marker testing (TNT、TNI、CPK-MB、 GOT、 LDH)血清标志物检测(TNT、TNI、心肌酶谱)CTNT forecasts the acute myocardial ischemia CTNT是急性心肌缺血独立危险预报(ybo)因子第二十六页，共四十五页。急性腹胸痛4Radionuclide ：myocardial ischemia after six hours核素心肌缺血或梗死6小时(xiosh)后Identified as non-cardia

25、c chest pain if ECG does not change through observation若胸痛经动态观察ECG等无变化，考虑非心源性胸痛。第二十七页，共四十五页。急性腹胸痛4Characters of chest pain in emergency急诊常见疾病的胸痛急诊常见疾病的胸痛(xin tn)(xin tn)特点特点第二十八页，共四十五页。急性腹胸痛4心绞痛Angina Pectoris 疼痛部位在胸骨上,中段，少数在心前区或剑突下，放射(fngsh)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(fngsh)到颈、咽、下颌及乳突。疼痛性质为紧缩压榨感，

26、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。Most patients with angina pectoris are identfeid as retrosternal chest discomfort rather than as frank pain. The former is usually described as a pressure, heaviness, squeezing, burning, or choking sensation. Anginal pain may locate primarily in the epigastri

27、um, back, neck, jaw, or shoulders. Typical locations for radiation of pain are at arms, shoulders, and neck. Few presents scares on the brink of death and is forced to quit the work.第二十九页，共四十五页。急性腹胸痛4Symptoms and signs第三十页，共四十五页。急性腹胸痛4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(zhngzhung)。It lasts for approxim

28、ately 1-5 minutes and is relieved by rest or by nitroglycerin after 1-3 minutes. 疼痛常因用力、劳累、饱食、情绪激动而诱发Angina is precipitated by exertion, diet, exposure to cold, or emotional stress. 发作时心电图检查可见ST段压低和T波改变。The ST segment is usually depressed and T-wave changed during angina in EKG.心肌酶学无改变 Negative chan

29、ges in Cardiac markerCardiac marker第三十一页，共四十五页。急性腹胸痛4急性急性(jxng)心肌梗死心肌梗死Acute myocardial infarction胸痛的性质和部位与心绞痛相似，但较剧烈而持久(chji)，持续时间达数小时至数日，休息或含服硝酸甘油不能缓解。Nature and location of chest pain are similar to that of angina. However, they are more severer and long-lasting. It can last from several hours to

30、 several days which can not be alleviated with rest or by taking nitroglycerin. 第三十二页，共四十五页。急性腹胸痛4常伴有发热、恶心、呕吐(u t)、面色苍白、呼吸困难、心律不齐、血压降低、心力衰竭等。Sometimes it is accompanied with fever, nausea, vomiting, paleness, difficulty in breathing, arrhythmia, lower blood pressure and heart failure. 心电图和酶学检查有相应的特异

31、性演变。Positive result in Cardiac marker and ECG examination第三十三页，共四十五页。急性腹胸痛4急性急性(jxng)下壁心肌梗死下壁心肌梗死Acute inferior myocardial infarction 第三十四页，共四十五页。急性腹胸痛4主动脉夹层主动脉夹层(jicng)(jicng) aortic dissection 本病多见于本病多见于40岁以上的男性，多有高血岁以上的男性，多有高血压和动脉粥样硬化压和动脉粥样硬化(ynghu)病史。病史。Common in middle-aged patients with hypert

32、ension and artherosclerosis. 第三十五页，共四十五页。急性腹胸痛4widened mediastinum 第三十六页，共四十五页。急性腹胸痛4Cardiovascular magnetic resonance (CMR) of a type-A aortic dissection. 第三十七页，共四十五页。急性腹胸痛4突发性撕裂样或刀割样胸痛突发性撕裂样或刀割样胸痛(xin tn)，向胸前及背，向胸前及背部放射，随夹层血肿波及范围可延至腹部、下肢、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臂及颈部，极为剧烈，疼痛的高峰一般

33、较急性心梗的高峰早。止痛药常无效。梗的高峰早。止痛药常无效。Almost all patients with acute dissections present with severe chest pain, sharp, stabbing, tearing, or ripping pain although some patients with chronic dissections are identified without associated symptoms. Unlike the pain of ischemic heart disease, symptoms of aortic

34、 dissection tend to reach peak severity immediately, often causing the patient to collapse from its intensity.It can radiates to the abdomen, limb, thr arm and the neck. Analgetica is invalid.第三十八页，共四十五页。急性腹胸痛4诊断(zhndun):diagnosis：X线见上纵隔线见上纵隔(zngg)或主动脉影增宽。或主动脉影增宽。X-ray:widen in superior mediastinum or aortaUCG CT、核磁（、核磁（MRI)主动脉造影诊断的准确率主动脉造影诊断的准确率aortic angiography: Lead to acurate diagnosis第三十九页，共四十五页。急性腹胸痛4肺栓塞 Pulmonary Embolism 体循环静脉或右心内血栓栓子脱落进入体循环静脉或右心内血栓栓子