上海交通大學醫(yī)學院教案課程名稱 ：急診醫(yī)學第2次課2007年2月28日教師姓名封啟明職稱主任醫(yī)師教研室內(nèi)科教研室教學時數(shù)2授課題目急診醫(yī)學總論、胸痛、腹痛、發(fā)熱的診斷思路、急救處理教學對象六院臨床醫(yī)學五、七年制02級授課地點401教室教學方式雙語授課本課的重點、難點：重點：如何做一名合格急診醫(yī)師，合格急診科醫(yī)生有哪些要求；急性胸痛的危險分類；如何早期識別高危胸痛，胸痛的鑒別診斷思路。腹痛的綜合全面分析；腹痛的病因?qū)W鑒別方法。發(fā)熱的診斷思路，明確診斷方法。難點：早期識別高危胸痛；腹痛的綜合全面分析；發(fā)熱的診斷思路，明確診斷方法。本次課應用的教具：英語講課，雙語多媒體。主要教學內(nèi)容：（可另附頁）急診醫(yī)學簡介非創(chuàng)傷性急診（內(nèi)科、外科、兒科）創(chuàng)傷災難醫(yī)學院前急救合格急診醫(yī)師的要求WhatarequalifiedemergencyphysicianneedsRichinelementaryknowledgeofmedicine(豐富的醫(yī)學基礎知識)Havingrichclinicalexperience(豐富的臨床經(jīng)驗)Mastertheprincipalsofdecision-makinginemergencymedicine(正確的急診臨床思維)Skilledtechniquesforemergency(嫻熟的急救技術)Trachealintubation氣管插管,Venipuncture深靜脈穿刺，Cardiopulmonaryresuscitation心肺復蘇Emergencyphysiciandiathesis(良好的心理素質(zhì))Theabilitytodealtwithaccidentappropriately(鎮(zhèn)靜處理突發(fā)事件)Decision-makinginemergencymedicine(確定診斷)THEUSEOFCOGNITIVESHORTCUTSAcuteChestpain

急性胸痛Decision-makingonAcuteChestpainatEarlyStage

早期識別高危胸痛Recognizethedangerousofacutechestpain,especiallywiththoselife-threatening識別胸痛的危險程度,特別是威脅生命的胸痛Establishpainmanagementcentertoofferacomprehensiverangeofservicesforpatientswithtreatmentonacutechestpain.國外建立疼痛中心建立一系列胸痛診療程序High-riskChestPain

急診常見的高危胸痛

Cardiogenicpain:AcuteCoronarySyndrome（UAP、AMI)高危心源性疼痛：急性冠脈綜合征Non-cardiogenicpain:aorticdissection,pulmonaryembolismandtensionpneumothorax高危非心源性疼痛：主動脈夾層、肺栓塞、張力性氣胸DiagnosisonAcuteChestPain

急性胸痛診斷思路Medicalhistory,physicalexamination,laboratoryexaminationandspecialexaminationandtests(EKG、ChestX-ray、enzymology)病史、體格檢查、輔助檢查（EKG、胸片、酶學等）chestpaindivision(CardiogenicandNoncardiogenic)區(qū)分胸痛系心源性或非心源性Juddgementtheriskdegree判斷危險度characteristicsofchestpain

有助于胸痛的診斷和鑒別診斷的特點Locationofpain疼痛的部位，retrosternal,substernalQuality疼痛的性質(zhì),pressure,tightness,sharp,pleuritic,burningDuration,aggravationandalleviationofpain疼痛的時間及影響因素、緩解因素,exertion,cold,psychologicstress,nitroglycerinSimultaneoussymptomsofpain疼痛的伴隨癥狀Previousmedicalhistory即往史locationofchestpain胸痛的部位AnginaPectorisandacutemyocardialinfarctionareusuallyretrosternal.mostpatientsdonotlocalizethepaintoanysmallarea.Theyaretypicallydescribedastightness,pressure,orsqueezing.Painmayradiatetothejaw,neck,arms,back,andepigastria.Theleftarmisaffectedmorefrequently.心絞痛與急性心肌梗死的疼痛常位于胸骨后或心前區(qū)，且放射到左肩和左上臂內(nèi)側(cè)。Thepainofesophagealdisease,mediastinalherniaandmediastinaltumerisalsoaretrosternal.食管疾患、隔疝、縱隔腫瘤的疼痛也位于胸骨后。spontaneouspneumothorax,acutepleuritisandpulmonaryembolismet.aloftenunilateralandpleuritic.自發(fā)性氣胸、急性胸膜炎、肺栓塞等常呈患側(cè)的劇烈胸痛。QualityofChestPain

胸痛的性質(zhì)Intercostalneuralgiacausesparoxysmalburningpainorprickingpain.肋間神經(jīng)痛呈陣發(fā)性的灼痛或刺痛。Myosalgiaoftenoccurswithachingpain.肌痛則常呈酸痛；Ostalgiaoccurswithachingpainorboringpain骨痛呈酸痛或錐痛；Esophagitisanddiaphragmatoceleoftenoccurswithburningpainorheatburn食管炎、膈疝常呈灼痛或灼熱感；AnginaPectorisormyocardialinfarctionisusuallydescribedasaheaviness,pressure,orsqueezing心絞痛或心肌梗死常呈壓榨樣痛并常伴有壓迫感或窒息感。Borningpainiscausedbytheerosionofaneurysmofaortawhenitcorrodeschestpain主動脈瘤侵蝕胸壁時呈錐痛。Thechestsuffocationcanbediagnosedbyprimarilylungcancerormediastinalmass原發(fā)性肺癌、縱隔腫瘤可有胸部悶痛。Associatedfeatures

影響胸痛的因素AnginaPectorisisoftenindusedbytension.Itcanbereleasedbytakingnitroglycerintablets.Myocardialinfarctioncanbeindentifiedwithcontinuingpainwhichisnottobereleasedbytakingnitroglycerintablets.心絞痛常于用力或精神緊張時誘發(fā)，呈陣發(fā)性，含服硝酸甘油片迅速緩解；心肌梗死常呈持續(xù)性劇痛，雖含服硝酸甘油片仍不緩解Cardiacneurosisisoftenthereasonofchestpain.Itcanberelievedbymovement.心臟神經(jīng)官能癥所致胸痛則常因運動反而好轉(zhuǎn)Thechestpainofpleurisy,pneumothorax,andpericarditiscanoftenbeexacerbatedbycoughordeepbreathing胸膜炎、自發(fā)性氣胸、心包炎的胸痛常因咳嗽或深呼吸而加劇NeuromusculoskeletalConditions:Directpressureonthechondrosternalandcostochondraljunctionsmayreproducethepainfromtheseandothermusculoskeletalsyndromes.Itisintensifiedbythoracicactivity;Esophagealdiseasesisoftenexacerbatedbyswallowingfood胸壁疾病所致的胸痛常于局部壓迫或胸廓活動時加??；食管疾病的胸痛常于吞咽食物時發(fā)作或加劇Simultaneousphenomenonofchestpain胸痛的伴隨癥狀Cough:trachea,bronchiandpleuraldiseases胸痛常伴咳嗽：氣管、支氣管、胸膜疾病所致。Dysphagia:diseasesofesophagealandmediastinum胸痛常伴吞咽困難：食管、縱隔疾病所致的Hemoptysis:tuberculosis,pulmonaryembolismandprimarylungcancer.胸痛常伴有咯血：肺結(jié)核、肺栓塞、原發(fā)性肺癌。Sneeze:brustwirbledisease胸痛常伴有深吸氣或打噴嚏加重：胸椎病變Hypertentionand/orhistoryofcoronaryheartdisease:anginapectoris,myocardialinfarction胸痛常伴有高血壓和(或)冠心病史：心絞痛、心肌梗死Dyspnea:pneumonia,pneumothorax,pleurisy,pulmonaryembolismandhyperventilationsyndrome,etc.胸痛常伴有呼吸困難：肺炎、氣胸、胸膜炎、肺栓塞、過度換氣綜合征等Abatementposition:cardiopericarditis:sittingupandleaningforward;esophagealhiatalhernia:erectposition胸痛常伴有特定體位緩解：心包炎－坐位及前傾位；食管裂孔疝－立位Onsetsuddenly:thoracicorganruptureisconcluedbythesymptomsofrapidseverechestpain.suchandissectionofaorta,aerothorax,andmediastinalemphysemaetc.胸痛伴起病急劇，胸痛迅速達高峰，往往提示胸腔臟器破裂，如主動脈夾層、氣胸、縱隔氣腫等Haemodynamics:fatalsymptomsareappearedashypotension/venousengorgementsuchaspericardialtamponade,acutemyocardialinfarction，severepulmonaryembolism,dissectionofaorta胸痛伴血流動力學異常－低血壓／及靜脈怒張則提示致命性胸痛（心包填塞、急性心肌梗塞、巨大肺栓塞、主動脈夾層）EvaluationCardiogenicChestPain心源性胸痛的急診評價方法Historyandphysicalexamination病史、查體12Leads-ECG(DynamicObservation)-myocardialischemia(30%)increaseST12導ECG(動態(tài)觀察)---心肌缺血(30%)ST抬高ChestpainwithouttypicalECGchange:serummyocardiummaker\treadmillexercise\UCG\nuclearcardiology(Non-abnormal50%AMIduringthediagnoseof20%AMI)–dynamicoberservation對ECG無明顯變化的胸痛-血清標志物檢查\運動平板\UCG\核素檢查(50%AMI的ECG無異常---觀察期間20%AMI)--動態(tài)觀察—易誤診EvaluationonCardiogenicChestPain心源性胸痛的急診評價方法Cardiacmarkertesting(TNT、TNI、CPK-MB、GOT、LDH)血清標志物檢測(TNT、TNI、心肌酶譜)CTNTforecaststheacutemyocardialischemiaCTNT是急性心肌缺血獨立危險預報因子Radionuclide：myocardialischemiaaftersixhours核素心肌缺血或梗死6小時后Identifiedasnon-cardiacchestpainifECGdoesnotchangethroughobservation若胸痛經(jīng)動態(tài)觀察ECG等無變化，考慮非心源性胸痛。Charactersofchestpaininemergency

急診常見疾病的胸痛特點心絞痛AnginaPectoris疼痛部位在胸骨上,中段，少數(shù)在心前區(qū)或劍突下，放射于左胸、左背、左肩、左上臂前內(nèi)側(cè)直達無名指及小指；亦可放射到頸、咽、下頜及乳突。疼痛性質(zhì)為緊縮壓榨感，悶脹窒息感、刺痛、銳痛、灼痛甚至刀割樣疼痛，偶有瀕死樣恐懼，迫使患者立即停止活動。Mostpatientswithanginapectorisareidentfeidasretrosternalchestdiscomfortratherthanasfrankpain.Theformerisusuallydescribedasapressure,heaviness,squeezing,burning,orchokingsensation.Anginalpainmaylocateprimarilyintheepigastrium,back,neck,jaw,orshoulders.Typicallocationsforradiationofpainareatarms,shoulders,andneck.Fewpresentsscaresonthebrinkofdeathandisforcedtoquitthework.疼痛持續(xù)時間約1—5分鐘，休息或含服硝酸甘油后1–3分鐘內(nèi)可緩解癥狀。Itlastsforapproximately1-5minutesandisrelievedbyrestorbynitroglycerinafter1-3minutes.疼痛常因用力、勞累、飽食、情緒激動而誘發(fā)Anginaisprecipitatedbyexertion,diet,exposuretocold,oremotionalstress.發(fā)作時心電圖檢查可見S–T段壓低和T波改變。TheSTsegmentisusuallydepressedandT-wavechangedduringanginainEKG.心肌酶學無改變NegativechangesinCardiacmarker急性心肌梗死

Acutemyocardialinfarction胸痛的性質(zhì)和部位與心絞痛相似，但較劇烈而持久，持續(xù)時間達數(shù)小時至數(shù)日，休息或含服硝酸甘油不能緩解。Natureandlocationofchestpainaresimilartothatofangina.However,theyaremoresevererandlong-lasting.Itcanlastfromseveralhourstoseveraldayswhichcannotbealleviatedwithrestorbytakingnitroglycerin.常伴有發(fā)熱、惡心、嘔吐、面色蒼白、呼吸困難、心律不齊、血壓降低、心力衰竭等。Sometimesitisaccompaniedwithfever,nausea,vomiting,paleness,difficultyinbreathing,arrhythmia,lowerbloodpressureandheartfailure.心電圖和酶學檢查有相應的特異性演變。PositiveresultinCardiacmarkerandECGexamination主動脈夾層aorticdissection本病多見于40歲以上的男性，多有高血壓和動脈粥樣硬化病史。Commoninmiddle-agedpatientswithhypertensionandartherosclerosis.突發(fā)性撕裂樣或刀割樣胸痛，向胸前及背部放射，隨夾層血腫波及范圍可延至腹部、下肢、臂及頸部，極為劇烈，疼痛的高峰一般較急性心梗的高峰早。止痛藥常無效。Almostallpatientswithacutedissectionspresentwithseverechestpain,sharp,stabbing,tearing,orrippingpainalthoughsomepatientswithchronicdissectionsareidentifiedwithoutassociatedsymptoms.Unlikethepainofischemicheartdisease,symptomsofaorticdissectiontendtoreachpeakseverityimmediately,oftencausingthepatienttocollapsefromitsintensity.Itcanradiatestotheabdomen,limb,thrarmandtheneck.Analgeticaisinvalid.診斷diagnosis：X線見上縱隔或主動脈影增寬。X-ray:wideninsuperiormediastinumoraortaUCGCT、核磁（MRI)主動脈造影診斷的準確率９５％aorticangiography:Leadto９５％acuratediagnosis肺栓塞

PulmonaryEmbolism體循環(huán)靜脈或右心內(nèi)血栓栓子脫落進入肺循環(huán)，堵塞肺動脈或其分支者稱肺栓塞；由于肺栓塞或肺血栓形成，引起肺組織缺氧壞死者稱肺梗死。常有誘因：心臟病、職業(yè)、長期臥床、新近手術或外傷Commonincentives:heartdisease,occupational,bedridden,recentsurgeryortrauma肺總動脈的一支堵塞，可胸痛、昏厥、休克而猝死。僅肺動脈一分支堵塞，則癥狀輕重隨血管堵塞的大小而不同，主要表現(xiàn)為突發(fā)性胸痛、呼吸困難與紫紺。疼痛可為刺痛、絞痛，部位在胸骨后，向肩部放射，隨呼吸加劇，同時伴有發(fā)熱、咳嗽、咯血，白細胞增高與轉(zhuǎn)氨酶GOT升高。檢查病變部位有濁音，并可聽到胸膜摩擦音。診斷D二聚體初步篩選preliminaryscreening:D-dimerECG;SIQ3T3少見，V1-４ST-T改變ECG:V1-4waveandST-Tchange,血氣分析bloodgasanalysisX線攝片見梗死部位呈楔形致密影，底邊近胸膜，尖端向肺門，亦可為圓形或多發(fā)性小片狀影。選擇性肺動脈造影和放射性核素肺掃描可確診。Finaldiagnosticexamination.selectivearteriographyofpulmonaryarteriesandradioactivenuclidescan.自發(fā)性氣胸spontaneouspneumothora胸痛的特點是：胸痛驟然發(fā)生；胸痛位于患側(cè)腋下、鎖骨下等處，有時向同側(cè)肩、背或上腹部放射；疼痛隨深呼吸而加劇，常伴氣促、Chestpainisunderthearmpit,subclavianandotherplaces.Itsometimesspreadstotheipsilateralshoulder,backorupperabdominalradiation;Withdeepbreathandintensifiedpain,itisoftenaccompaniedbyshortnessofbreath.干咳和進行性呼吸困難，嚴重者可發(fā)紺和休克，但無全身中毒癥狀。Chestpainisreferredtotheshouldersorinfraclaviculaandisalsoradiatedtoarmoftheinvolvedsideandabdominalregion.Painwillbeaggravatedbydeepbreathing,tachypnea,nonproductivecoughandadvanceddyspnea.Cyanoseandshockwerefoundinseriouscaseswhensomeisoccurredwithsystematictoxicsymptom胸部x線檢查可確診。DefinitediagnosiscanbeidentifiedfromChestX-rayappearance主動脈瓣病AorticValvularDisease.主動脈瓣狹窄和(或)關閉不全均可引起類似心絞痛樣發(fā)作。Attactionofaorticvalvularstenosisoraorticincompetenceresembletheheartstrok主動脈瓣狹窄患者于輕度體力活動時即可誘發(fā)疼痛，服用硝酸甘油可使癥狀加重，偶可引起昏厥。Patientswithaorticvalvularstenosissufferfromchestpainwhichappearatminersress.However,symptomsareaggravatedbyNitroglycerintreatmentandafewleadstofaint.主動脈瓣關閉不全者常于睡眠中發(fā)作胸痛，持續(xù)數(shù)分鐘至1小時以上。發(fā)作時多伴收縮壓升高、竇性心動過速及呼吸加快等。心臟聽診發(fā)現(xiàn)主動脈瓣區(qū)有收縮期和(或)舒張期雜音。Chestpainaccuredwhenpatientsareinsleep,whichappearsinaorticincompetence.Itpersistsfromafewminutesto1hourorover.Advacedsystolicpressure,sinustachycardiaandtachypneaarefoundinattackphase.SM/DMinaorticvalveareaisobtainedbycardiacauscultation超聲心動圖有助于診斷。Ultrasoniccardiogram(UCG)ishelpfultoestablishdiagnosis.膽道疾病Diseaseofbiliarytract膽石癥、膽囊炎可引起右下胸痛，也可出現(xiàn)類似心絞痛樣發(fā)作（膽心綜合癥）。但膽道疾病的疼痛多在高脂飲食后發(fā)生，疼痛常自胃脘部放射至右季肋及右肩，部分患者伴有黃疸及發(fā)熱。Biliarycolicisusuallyfeltintherightupperquadrant,heartstroke.Theirappearancesarecommon(gallbladder-heartsyndrome).Theyhappensafterhighfatcongestion.Thepaincanradiatearoundthecostalmarginintothebackorcanspreadtotheregionofthescapula.Jaundiceandfeveroftenoccursinsomecases.值得注意的是膽道疾病與冠心病均是常見病，不少患者兩者兼有，并可因膽絞痛而誘發(fā)心絞痛。Itshouldbementionedthatdiseaseofbiliarytractandcoronaryarterydiseasearecommon,Weshouldn’tignoretheblendingaffection,biliarycolicprovokeheartstrokewhichleadtothisaffection.心臟神經(jīng)官能癥Cardiacneurosis食管疾病Diseaseofesophagus急性胸膜炎AcutePleurisy多由感染所致，其中以結(jié)核性最為常見。體征。膈胸膜炎可引起下胸疼痛，常向肩部、心前區(qū)或腹部放射，可伴有腹壁緊張及壓痛而被誤診為腹部疾患。危重癥指征severecase凡病人表現(xiàn)面色蒼白、出汗、紫紺、呼吸困難及生命指征異常，不論其為何種病因，均屬危及狀態(tài)，需立即給氧、心電監(jiān)護、即刻開放靜脈.Ifsymptomsaremanifestedinitiallybypallor,coldsweat,cyanosis,dyspneaandlowerconsciousness;thepatientsneedoxygentherapy,ECGmonitorthenproductvenouschannelimmediately.wheneverthecauseofadisease.急性腹痛

Acuteabdominalpain急性腹痛早識別早診斷的意義

SignicanceofEarlyRecognitiononAcuteAbdominalPain急性腹痛常規(guī)的診斷流程ConventionalDiagnosisProcessofAbdominalPain迅速、細致的詢問病史、詳細的體格檢查（重視病人的生命體征BP、HR）Meticulousbodycheckanddetailedmedicalhistory(PayattentiontoBPandHR)選擇作一些輔助檢查Choiseonauxiliarycheck綜合全面的材料分析Comprehensiveanalysisofthematerial動態(tài)觀察病情變化，及時捕捉新的信息Observationonnewsignsofdisease起病情況有無先驅(qū)癥狀Symptoms內(nèi)科急腹癥多先有發(fā)熱、嘔吐后出現(xiàn)腹痛Abdominalpainfromhighfeverorvomitinmedicineemergency外科急腹癥則多先有腹痛，繼之發(fā)熱Highfeverfromabdorminalpaininsurgicalemergency腹痛部位LocationofAbdorminalPain腹痛起始和最明顯的部位,病變所在部位Thresholdofabdorminalpainandlocationoflesions有無轉(zhuǎn)移痛,放射痛Transferpainandradiotherapy闌尾炎----轉(zhuǎn)移性右下腹痛Appendicitis網(wǎng)膜\回腸---中上腹/臍周Omentum\Ileum膽道病變----右肩背部放射Lesionofbiliary胰腺炎----左腰部放射Pancreaticinflamation腎絞痛—會陰放射Kidneyache睪丸陰囊痛---放射至下腹部、腰部Testicularache腹痛的性質(zhì)NatureofAbdorminalPain腹膜炎呈持續(xù)性銳痛空腔臟器梗阻或擴張為陣發(fā)性絞痛臟器扭轉(zhuǎn)或破裂強烈的絞痛或持續(xù)性痛血管梗阻疼痛劇烈、持續(xù)中毒與代謝障礙腹痛劇烈而無明確定位腹痛的特點CharactersofAbdorminalPain持續(xù)性腹痛多反映腹內(nèi)炎癥和出血Abdorminalinflamationandbleeding陣發(fā)性腹痛多為空腔器官梗阻或痙攣Obstructionor