【医学课件】急性胸痛的原因与治疗.ppt

EmergencyMedicineandTechniqueDr.FengQi-ming(MD,PhD封启明)TheEmergencyDepartment,the6thpeopleshospitalofShanghai,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Whatarequalifiedemergencyphysicianneeds1.Richinelementaryknowledgeofmedicine(丰富的医学基础知识)2.Havingrichclinicalexperience(丰富的临床经验)3.Mastertheprincipalsofdecision-makinginemergencymedicine(正确的急诊临床思维)4.Skilledtechniquesforemergency(娴熟的急救技术)Trachealintubation气管插管,Venipuncture深静脉穿刺，Cardiopulmonaryresuscitation心肺复苏5.Emergencyphysiciandiathesis(良好的心理素质)6.Theabilitytodealtwithaccidentappropriately(镇静处理突发事件)AcuteChest Pain急性胸痛急性胸痛Decision-makingonAcuteChestpainatEarlyStage早期识别高危胸痛Recognizethedangerousofacutechestpain,especiallywiththoselife-threatening识别胸痛的危险程度识别胸痛的危险程度,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: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-cardiogenicpain:aorticdissection,pulmonaryembolismandtensionpneumothorax高危非心源性疼痛：主动脉夹层、肺栓高危非心源性疼痛：主动脉夹层、肺栓塞、张力性气胸塞、张力性气胸DiagnosisonAcuteChestPain急性胸痛诊断思路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（EKG、胸片、酶、胸片、酶学等）学等）chest pain division(CardiogenicandNoncardiogenic)区分胸痛系心源性或非心源性区分胸痛系心源性或非心源性Juddgement the risk degree 判断危险度判断危险度characteristicsofchestpain有助于胸痛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,tightness,sharp,pleuritic,burningDuration,aggravation and alleviation of pain疼痛的时疼痛的时间及影响因素、缓解因素间及影响因素、缓解因素,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 location of chest pain胸痛的部位胸痛的部位AnginaPectoris andacutemyocardialinfarction are usually retrosternal.mostpatientsdonotlocalizethepaintoanysmallarea.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 frequently.心绞痛与急性心肌梗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。肩和左上臂内侧。Thepainofesophagealdisease,mediastinalhernia and mediastinal tumer is also aretrosternal.食食管管疾疾患患、隔隔疝疝、纵纵隔隔肿肿瘤瘤的疼痛也位于胸骨后。的疼痛也位于胸骨后。spontaneous pneumothorax,acute pleuritisandpulmonaryembolismet.aloftenunilateralandpleuritic.自自发发性性气气胸胸、急急性性胸膜炎、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。Quality of Chest Pain胸痛的性质Intercostal neuralgia causes paroxysmal burningpainorprickingpain.肋肋间间神神经经痛痛呈呈阵阵发发性性的的灼灼痛或刺痛。痛或刺痛。Myosalgiaoftenoccurswithachingpain.肌肌痛痛则则常呈酸痛；常呈酸痛；Ostalgiaoccurswithachingpainorboringpain骨骨痛呈酸痛或锥痛；痛呈酸痛或锥痛；Esophagitis and diaphragmatocele often occurs withburningpainorheatburn食食管管炎炎、膈膈疝疝常常呈呈灼痛或灼热感；灼痛或灼热感；Quality of Chest Pain胸痛的性质Angina Pectoris or myocardial infarction isusually described as a heaviness,pressure,orsqueezing心心绞绞痛痛或或心心肌肌梗梗死死常常呈呈压压榨榨样样痛痛并并常常伴有压迫感或窒息感。伴有压迫感或窒息感。Borningpainiscausedbytheerosionofaneurysmofaortawhenitcorrodeschestpain主主动动脉脉瘤瘤侵侵蚀胸壁时呈锥痛。蚀胸壁时呈锥痛。The chest suffocation can be diagnosed byprimarilylungcancerormediastinalmass原原发发性性肺癌、纵隔肿瘤可有胸部闷痛。肺癌、纵隔肿瘤可有胸部闷痛。Associated features影响胸痛的因素AnginaPectorisisoftenindusedbytension.It can be released by taking nitroglycerintablets.Myocardial infarction can beindentified with continuing pain which isnot to be released by taking nitroglycerintablets.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Associated features影响胸痛的因素NeuromusculoskeletalConditions:Directpressureonthechondrosternalandcostochondraljunctionsmay reproduce the pain from these and othermusculoskeletal syndromes.It is intensified bythoracicactivity;Esophageal diseases is often exacerbated byswallowingfood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胸胸痛痛常常伴伴咳咳嗽嗽：气管、支气管、胸膜疾病所致。Dysphagia:diseases of esophageal andmediastinum胸胸痛痛常常伴伴吞吞咽咽困困难难：食管、纵隔疾病所致的Hemoptysis:tuberculosis,pulmonaryembolismandprimarylungcancer.胸胸痛痛常常伴伴有有咯咯血血：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加重重：胸胸椎椎病变病变Simultaneousphenomenonofchestpain胸痛的伴随症状Hypertention and/or history of coronaryheart disease:angina pectoris,myocardialinfarction胸痛常伴有高血压和胸痛常伴有高血压和(或或)冠心病史冠心病史：心绞痛、心肌梗死Dyspnea:pneumonia,pneumothorax,pleurisy,pulmonaryembolismandhyperventilationsyndrome,etc.胸胸痛痛常常伴伴有有呼呼吸吸困困难难：肺炎、气胸、胸膜炎、肺栓塞、过度换气综合征等Abatementposition:cardiopericarditis:sitting up and leaningforward;esophageal hiatal hernia:erectposition胸胸痛痛常常伴伴有有特特定定体体位位缓缓解解：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:serummyocardiummakertreadmillexerciseUCGnuclearcardiology(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。Characters of chest pain in emergency急诊常见疾病的胸痛特点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。Most patients with angina pectoris are identfeid asretrosternalchestdiscomfortratherthanasfrankpain.Theformer is usually described as a pressure,heaviness,squeezing,burning,or choking sensation.Anginal painmaylocateprimarilyintheepigastrium,back,neck,jaw,orshoulders.Typical locations for radiation of pain are atarms,shoulders,and neck.Few presents scares on thebrinkofdeathandisforcedtoquitthework.Symptomsandsigns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。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ST段压低和T波改变。TheSTsegmentisusuallydepressedandT-wavechangedduringangina in EKG.心肌酶学无改变NegativechangesinCardiacmarkerCardiacmarker急性心肌梗死急性心肌梗死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,theyaremoreseverer and long-lasting.It can last fromseveralhourstoseveraldayswhichcannotbe alleviated with rest or by takingnitroglycerin.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。Sometimes it is accompanied with fever,nausea,vomiting,paleness,difficultyinbreathing,arrhythmia,lowerbloodpressureandheartfailure.心电图和酶学检查有相应的特异性演变。Positive result in Cardiac marker and ECGexamination急性下壁心肌梗死急性下壁心肌梗死Acuteinferiormyocardialinfarction主动脉夹层主动脉夹层aorticdissection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病史。压和动脉粥样硬化病史。Common in middle-aged patients with hypertension and artherosclerosis.widenedmediastinumCardiovascularmagneticresonance(CMR)ofatype-Aaorticdissection.突发性撕裂样或刀割样胸痛，向胸前及背部放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、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。心梗的高峰早。止痛药常无效。Almostallpatientswithacutedissectionspresentwithseverechestpain,sharp,stabbing,tearing,or ripping pain althoughsomepatientswithchronicdissectionsareidentifiedwithoutassociatedsymptoms.Unlikethepainofischemicheartdisease,symptomsofaorticdissectiontendtoreachpeakseverityimmediately,oftencausingthepatienttocollapsefromitsintensity.It can radiates to the abdomen,limb,thr arm and the neck.Analgeticaisinvalid.诊断:diagnosis：X线见上纵隔或主动脉影增宽。线见上纵隔或主动脉影增宽。X-ray:wideninsuperiormediastinumoraortaUCG 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aorticangiography:Leadto acurate diagnosis肺栓塞PulmonaryEmbolism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脱落进入肺循环，堵塞肺动脉或其分支者称肺栓肺循环，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。组织缺氧坏死者称肺梗死。常有诱因：心脏病、职业、长期卧床、常有诱因：心脏病、职业、长期卧床、新近手术或外伤新近手术或外伤Common incentives:heart disease,occupational,bedridden,recent surgery or trauma肺总动脉的一支堵塞，可胸痛、昏厥、肺总动脉的一支堵塞，可胸痛、昏厥、休克而猝死。休克而猝死。仅肺动脉一分支堵塞，则症状轻重随血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，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、咯随呼吸加剧，同时伴有发热、咳嗽、咯血，白细胞增高与转氨酶血，白细胞增高与转氨酶GOT升高。检升高。检查病变部位有浊音，并可听到胸膜摩擦查病变部位有浊音，并可听到胸膜摩擦音。音。诊断D二聚体初步筛选二聚体初步筛选preliminaryscreening:D-dimerECG;SIQ3T3少见少见，V1-ST-T改变改变ECG:V1-4 wave and ST-T change,血气分析血气分析bloodgasanalysisX线摄片见梗死部位呈楔形致密影，底边线摄片见梗死部位呈楔形致密影，底边近胸膜，尖端向肺门，亦可为圆形或多近胸膜，尖端向肺门，亦可为圆形或多发性小片状影。发性小片状影。选择性肺动脉造影和放射性核素肺扫描选择性肺动脉造影和放射性核素肺扫描可确诊。可确诊。Final diagnostic examination.selective arteriographyofpulmonaryarteriesandradioactivenuclidescan.Thank Thank you you！