上交大急救医学教案：总论、胸痛、腹痛、发热教案

上海交通大学医学院教案课程名称 ：急诊医学第2次课2007年2月28日教师姓名封启明职称主任医师教研室内科教研室教学时数2授课题目急诊医学总论、胸痛、腹痛、发热的诊断思路、急救处理教学对象六院临床医学五、七年制02级授课地点401教室教学方式双语授课本课的重点、难点：重点：如何做一名合格急诊医师，合格急诊科医生有哪些要求；急性胸痛的危险分类；如何早期识别高危胸痛，胸痛的鉴别诊断思路。腹痛的综合全面分析；腹痛的病因学鉴别方法。发热的诊断思路，明确诊断方法。难点：早期识别高危胸痛；腹痛的综合全面分析；发热的诊断思路，明确诊断方法。本次课应用的教具：英语讲课，双语多媒体。主要教学内容：（可另附页）急诊医学简介非创伤性急诊（内科、外科、儿科）创伤灾难医学院前急救合格急诊医师的要求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)Decision-makinginemergencymedicine(确定诊断)THEUSEOFCOGNITIVESHORTCUTSAcuteChestpain

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；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.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.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,oftencausingthepatienttocollapsefromitsintensity.Itcanradiatestotheabdomen,limb,thrarmandtheneck.Analgeticaisinvalid.诊断diagnosis：X线见上纵隔或主动脉影增宽。X-ray:wideninsuperiormediastinumoraortaUCGCT、核磁（MRI)主动脉造影诊断的准确率９５％aorticangiography:Leadto９５％acuratediagnosis肺栓塞

PulmonaryEmbolism体循环静脉或右心内血栓栓子脱落进入肺循环，堵塞肺动脉或其分支者称肺栓塞；由于肺栓塞或肺血栓形成，引起肺组织缺氧坏死者称肺梗死。常有诱因：心脏病、职业、长期卧床、新近手术或外伤Commonincentives:heartdisease,occupational,bedridden,recentsurgeryortrauma肺总动脉的一支堵塞，可胸痛、昏厥、休克而猝死。仅肺动脉一分支堵塞，则症状轻重随血管堵塞的大小而不同，主要表现为突发性胸痛、呼吸困难与紫绀。疼痛可为刺痛、绞痛，部位在胸骨后，向肩部放射，随呼吸加剧，同时伴有发热、咳嗽、咯血，白细胞增高与转氨酶GOT升高。检查病变部位有浊音，并可听到胸膜摩擦音。诊断D二聚体初步筛选preliminaryscreening:D-dimerECG;SIQ3T3少见，V1-４ST-T改变ECG:V1-4waveandST-Tchange,血气分析bloodgasanalysisX线摄片见梗死部位呈楔形致密影，底边近胸膜，尖端向肺门，亦可为圆形或多发性小片状影。选择性肺动脉造影和放射性核素肺扫描可确诊。Finaldiagnosticexamination.selectivearteriographyofpulmonaryarteriesandradioactivenuclidescan.自发性气胸spontaneouspneumothora胸痛的特点是：胸痛骤然发生；胸痛位于患侧腋下、锁骨下等处，有时向同侧肩、背或上腹部放射；疼痛随深呼吸而加剧，常伴气促、Chestpainisunderthearmpit,subclavianandotherplaces.Itsometimesspreadstotheipsilateralshoulder,backorupperabdominalradiation;Withdeepbreathandintensifiedpain,itisoftenaccompaniedbyshortnessofbreath.干咳和进行性呼吸困难，严重者可发绀和休克，但无全身中毒症状。Chestpainisreferredtotheshouldersorinfraclaviculaandisalsoradiatedtoarmoftheinvolvedsideandabdominalregion.Painwillbeaggravatedbydeepbreathing,tachypnea,nonproductivecoughandadvanceddyspnea.Cyanoseandshockwerefoundinseriouscaseswhensomeisoccurredwithsystematictoxicsymptom胸部x线检查可确诊。DefinitediagnosiscanbeidentifiedfromChestX-rayappearance主动脉瓣病AorticValvularDisease.主动脉瓣狭窄和(或)关闭不全均可引起类似心绞痛样发作。Attactionofaorticvalvularstenosisoraorticincompetenceresembletheheartstrok主动脉瓣狭窄患者于轻度体力活动时即可诱发疼痛，服用硝酸甘油可使症状加重，偶可引起昏厥。Patientswithaorticvalvularstenosissufferfromchestpainwhichappearatminersress.However,symptomsareaggravatedbyNitroglycerintreatmentandafewleadstofaint.主动脉瓣关闭不全者常于睡眠中发作胸痛，持续数分钟至1小时以上。发作时多伴收缩压升高、窦性心动过速及呼吸加快等。心脏听诊发现主动脉瓣区有收缩期和(或)舒张期杂音。Chestpainaccuredwhenpatientsareinsleep,whichappearsinaorticincompetence.Itpersistsfromafewminutesto1hourorover.Advacedsystolicpressure,sinustachycardiaandtachypneaarefoundinattackphase.SM/DMinaorticvalveareaisobtainedbycardiacauscultation超声心动图有助于诊断。Ultrasoniccardiogram(UCG)ishelpfultoestablishdiagnosis.胆道疾病Diseaseofbiliarytract胆石症、胆囊炎可引起右下胸痛，也可出现类似心绞痛样发作（胆心综合症）。但胆道疾病的疼痛多在高脂饮食后发生，疼痛常自胃脘部放射至右季肋及右肩，部分患者伴有黄疸及发热。Biliarycolicisusuallyfeltintherightupperquadrant,heartstroke.Theirappearancesarecommon(gallbladder-heartsyndrome).Theyhappensafterhighfatcongestion.Thepaincanradiatearoundthecostalmarginintothebackorcanspreadtotheregionofthescapula.Jaundiceandfeveroftenoccursinsomecases.值得注意的是胆道疾病与冠心病均是常见病，不少患者两者兼有，并可因胆绞痛而诱发心绞痛。Itshouldbementionedthatdiseaseofbiliarytractandcoronaryarterydiseasearecommon,Weshouldn’tignoretheblendingaffection,biliarycolicprovokeheartstrokewhichleadtothisaffection.心脏神经官能症Cardiacneurosis食管疾病Diseaseofesophagus急性胸膜炎AcutePleurisy多由感染所致，其中以结核性最为常见。体征。膈胸膜炎可引起下胸疼痛，常向肩部、心前区或腹部放射，可伴有腹壁紧张及压痛而被误诊为腹部疾患。危重症指征severecase凡病人表现面色苍白、出汗、紫绀、呼吸困难及生命指征异常，不论其为何种病因，均属危及状态，需立即给氧、心电监护、即刻开放静脉.Ifsymptomsaremanifestedinitiallybypallor,coldsweat,cyanosis,dyspneaandlowerconsciousness;thepatientsneedoxygentherapy,ECGmonitorthenproductvenouschannelimmediately.wheneverthecauseofadisease.急性腹痛

Acuteabdominalpain急性腹痛早识别早诊断的意义

SignicanceofEarlyRecognitiononAcuteAbdominalPain急性腹痛常规的诊断流程ConventionalDiagnosisProcessofAbdominalPain迅速、细致的询问病史、详细的体格检查（重视病人的生命体征BP、HR）Meticulousbodycheckanddetailedmedicalhistory(PayattentiontoBPandHR)选择作一些辅助检查Choiseonauxiliarycheck综合全面的材料分析Comprehensiveanalysisofthematerial动态观察病情变化，及时捕捉新的信息Observationonnewsignsofdisease起病情况有无先驱症状Symptoms内科急腹症多先有发热、呕吐后出现腹痛Abdominalpainfromhighfeverorvomitinmedicineemergency外科急腹症则多先有腹痛，继之发热Highfeverfromabdorminalpaininsurgicalemergency腹痛部位LocationofAbdorminalPain腹痛起始和最明显的部位,病变所在部位Thresholdofabdorminalpainandlocationoflesions有无转移痛,放射痛Transferpainandradiotherapy阑尾炎----转移性右下腹痛Appendicitis网膜\回肠---中上腹/脐周Omentum\Ileum胆道病变----右肩背部放射Lesionofbiliary胰腺炎----左腰部放射Pancreaticinflamation肾绞痛—会阴放射Kidneyache睾丸阴囊痛---放射至下腹部、腰部Testicularache腹痛的性质NatureofAbdorminalPain腹膜炎呈持续性锐痛空腔脏器梗阻或扩张为阵发性绞痛脏器扭转或破裂强烈的绞痛或持续性痛血管梗阻疼痛剧烈、持续中毒与代谢障碍腹痛剧烈而无明确定位腹痛的特点CharactersofAbdorminalPain持续性腹痛多反映腹内炎症和出血Abdorminalinflamationandbleeding阵发性腹痛多为空腔器官梗阻或痉挛Obstructionor