1、.,1,Emergency Medicine and Technique,Dr. Feng Qi-ming (MD, PhD 封啟明) The Emergency Department, the 6th peoples hospital of Shanghai, Shanghai jiaotong University,.,2,Emergency Medicine and Technique Differential diagnosis 癥狀鑒別診斷 Chest pain 胸痛 Abdominal pain 腹痛 Fever 發(fā)熱,.,3,The introduction of emergen

2、cy medicine急診醫(yī)學(xué)簡介,Non-trauma 非創(chuàng)傷性急診（內(nèi)科、外科、 兒科 ） trauma 創(chuàng)傷 Disaster medicine 災(zāi)難醫(yī)學(xué) first aid 院前急救,.,4,.,5,.,6,.,7,.,8,What are qualified emergency physician needs,Rich in elementary knowledge of medicine (豐富的醫(yī)學(xué)基礎(chǔ)知識(shí)) Having rich clinical experience (豐富的臨床經(jīng)驗(yàn)) Master the principals of decision-making in

3、emergency medicine (正確的急診臨床思維),.,9,Skilled techniques for emergency(嫻熟的急救技術(shù)) Tracheal intubation氣管插管, Venipuncture 深靜脈穿刺，Cardiopulmonary resuscitation心肺復(fù)蘇 Emergency physician diathesis(良好的心理素質(zhì)) The ability to dealt with accident appropriately(鎮(zhèn)靜處理突發(fā)事件),.,10,Acute Chest Pain急性胸痛,.,11,Decision-making

4、on Acute Chest pain at Early Stage早期識(shí)別高危胸痛,Recognize the dangerous of acute chest pain, especially with those life-threatening 識(shí)別胸痛的危險(xiǎn)程度,特別是威脅生命的胸痛 Establish pain management center to offer a comprehensive range of services for patients with treatment on acute chest pain. 國外建立疼痛中心建立一系列胸痛診療程序,.,12,Hi

5、gh-risk Chest Pain急診常見的高危胸痛,Cardiogenic pain:Acute Coronary Syndrome （UAP、AMI) 高危心源性疼痛：急性冠脈綜合征 Non-cardiogenic pain:aortic dissection, pulmonary embolism and tension pneumothorax 高危非心源性疼痛：主動(dòng)脈夾層、肺栓塞、張力性氣胸,.,13,.,14,Diagnosis on Acute Chest Pain急性胸痛診斷思路,Medical history, physical examination , laborato

6、ry examination and special examination and tests (EKG、Chest X-ray、enzymology) 病史、體格檢查、輔助檢查（EKG、胸片、酶學(xué)等） chest pain division (Cardiogenic and Non cardiogenic)區(qū)分胸痛系心源性或非心源性 Juddgement the risk degree 判斷危險(xiǎn)度,.,15,characteristics of chest pain有助于胸痛的診斷和鑒別診斷的特點(diǎn),Location of pain疼痛的部位，retrosternal, substernal

7、 Quality 疼痛的性質(zhì), pressure, tightness, sharp,pleuritic,burning Duration, aggravation and alleviation of pain疼痛的時(shí)間及影響因素、緩解因素, exertion, cold, psychologic stress, nitroglycerin Simultaneous symptoms of pain疼痛的伴隨癥狀 Previous medical history 即往史,.,16,location of chest pain胸痛的部位,Angina Pectoris and acute my

8、ocardial 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 frequently.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

9、放射到左肩和左上臂內(nèi)側(cè)。,.,17,The pain of esophageal disease, mediastinal hernia and mediastinal tumer is also a retrosternal .食管疾患、隔疝、縱隔腫瘤的疼痛也位于胸骨后。 spontaneous pneumothorax, acute pleuritis and pulmonary embolism et.al often unilateral and pleuritic.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。,.,18,Quality of Chest Pain胸痛的性質(zhì),I

10、ntercostal neuralgia causes paroxysmal burning pain or pricking pain. 肋間神經(jīng)痛呈陣發(fā)性的灼痛或刺痛。 Myosalgia often occurs with aching pain.肌痛則常呈酸痛； Ostalgia occurs with aching pain or boring pain骨痛呈酸痛或錐痛； Esophagitis and diaphragmatocele often occurs with burning pain or heatburn食管炎、膈疝常呈灼痛或灼熱感；,.,19,Quality of

11、Chest Pain胸痛的性質(zhì),Angina Pectoris or myocardial infarction is usually described as a heaviness, pressure, or squeezing 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。 Borning pain is caused by the erosion of aneurysm of aorta when it corrodes chest pain 主動(dòng)脈瘤侵蝕胸壁時(shí)呈錐痛。 The chest suffocation can be diagnosed by primarily lun

12、g cancer or mediastinal mass 原發(fā)性肺癌、縱隔腫瘤可有胸部悶痛。,.,20,Associated features影響胸痛的因素,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 nitroglycerin tablets.心絞

13、痛常于用力或精神緊張時(shí)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,.,21,Cardiac neurosis is often the reason of chest pain. It can be relieved by movement.心臟神經(jīng)官能癥所致胸痛則常因運(yùn)動(dòng)反而好轉(zhuǎn) The chest pain of pleurisy, pneumothorax, and pericarditis can often be exacerbated by cough or deep breathing 胸膜炎、自發(fā)性氣胸、心包炎的胸痛常因咳嗽或深呼吸

14、而加劇,.,22,Associated features影響胸痛的因素,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; Esophageal diseases is often exacerbated by swallowing

15、 food 胸壁疾病所致的胸痛常于局部壓迫或胸廓活動(dòng)時(shí)加劇；食管疾病的胸痛常于吞咽食物時(shí)發(fā)作或加劇,.,23,Simultaneous phenomenon of chest pain胸痛的伴隨癥狀,Cough: trachea, bronchi and pleural diseases 胸痛常伴咳嗽：氣管、支氣管、胸膜疾病所致。 Dysphagia: diseases of esophageal and mediastinum 胸痛常伴吞咽困難：食管、縱隔疾病所致的,.,24,Hemoptysis: tuberculosis, pulmonary embolism and primary l

16、ung cancer. 胸痛常伴有咯血：肺結(jié)核、肺栓塞、原發(fā)性肺癌。 Sneeze: brustwirble disease 胸痛常伴有深吸氣或打噴嚏加重：胸椎病變,.,25,Simultaneous phenomenon of chest pain 胸痛的伴隨癥狀,Hypertention and/or history of coronary heart disease: angina pectoris, myocardial infarction 胸痛常伴有高血壓和 (或) 冠心病史：心絞痛、心肌梗死,.,26,Dyspnea: pneumonia, pneumothorax, pleur

17、isy, pulmonary embolism and hyperventilation syndrome, 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 Abatement position: cardiopericarditis:sitting up and leaning forward; esophageal hiatal hernia: erect position 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,.,27,Simultaneous phenomenon of chest pain胸痛的伴隨癥狀,Onset suddenly:

18、 thoracic organ rupture is conclued by the symptoms of rapid severe chest pain.such an dissection of aorta, aerothorax,and mediastinal emphysema etc. 胸痛伴起病急劇，胸痛迅速達(dá)高峰，往往提示胸腔臟器破裂，如主動(dòng)脈夾層、氣胸、縱隔氣腫等,.,28,Haemodynamics: fatal symptoms are appeared as hypotension/venous engorgement such as pericardial tampo

19、nade, acute myocardial infarction，severe pulmonary embolism , dissection of aorta 胸痛伴血流動(dòng)力學(xué)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(dòng)脈夾層）,.,29,Evaluation Cardiogenic Chest Pain心源性胸痛的急診評(píng)價(jià)方法,History and physical examination 病史、查體 12 Leads-ECG (Dynamic Observation)- myocardial ischemia (30%) increase ST 12

20、導(dǎo) ECG(動(dòng)態(tài)觀察)-心肌缺血(30%)ST抬高,.,30,Chest 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 對(duì)ECG無明顯變化的胸痛-血清標(biāo)志物檢查運(yùn)動(dòng)平板UCG核素檢查(50%AMI的ECG無異常-觀察期間20%AMI)-動(dòng)態(tài)觀察易誤診,.,31,Evaluation on Cardi

21、ogenic Chest Pain心源性胸痛的急診評(píng)價(jià)方法,Cardiac marker testing (TNT、TNI、CPK-MB、 GOT、 LDH) 血清標(biāo)志物檢測(cè)(TNT、TNI、心肌酶譜) CTNT forecasts the acute myocardial ischemia CTNT是急性心肌缺血獨(dú)立危險(xiǎn)預(yù)報(bào)因子,.,32,.,33,Radionuclide ：myocardial ischemia after six hours 核素心肌缺血或梗死6小時(shí)后 Identified as non-cardiac chest pain if ECG does not change

22、 through observation 若胸痛經(jīng)動(dòng)態(tài)觀察ECG等無變化，考慮非心源性胸痛。,.,34,.,35,Characters of chest pain in emergency急診常見疾病的胸痛特點(diǎn),.,36,心絞痛Angina Pectoris,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(dá)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(dòng)。Most patients with angina pectoris are identfeid as r

23、etrosternal 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 epigastrium, back, neck, jaw, or shoulders. Typical locations for radiation of pain are at arms, should

24、ers, and neck. Few presents scares on the brink of death and is forced to quit the work.,.,37,Symptoms and signs,.,38,疼痛持續(xù)時(shí)間約15分鐘，休息或含服硝酸甘油后13分鐘內(nèi)可緩解癥狀。 It lasts for approximately 1-5 minutes and is relieved by rest or by nitroglycerin after 1-3 minutes. 疼痛常因用力、勞累、飽食、情緒激動(dòng)而誘發(fā) Angina is precipitated by

25、 exertion, diet, exposure to cold, or emotional stress. 發(fā)作時(shí)心電圖檢查可見ST段壓低和T波改變。 The ST segment is usually depressed and T-wave changed during angina in EKG. 心肌酶學(xué)無改變 Negative changes in Cardiac marker,Cardiac marker,.,39,急性心肌梗死Acute myocardial infarction,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(shí)間達(dá)數(shù)小時(shí)至數(shù)日，休息或含服硝酸甘油不能緩解

26、。 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 several days which can not be alleviated with rest or by taking nitroglycerin.,.,40,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。 Sometimes it is accompanied

27、 with fever, nausea, vomiting, paleness, difficulty in breathing, arrhythmia, lower blood pressure and heart failure. 心電圖和酶學(xué)檢查有相應(yīng)的特異性演變。 Positive result in Cardiac marker and ECG examination,.,41,急性下壁心肌梗死Acute inferior myocardial infarction,.,42,主動(dòng)脈夾層 aortic dissection,本病多見于40歲以上的男性，多有高血壓和動(dòng)脈粥樣硬化病史。

28、Common in middle-aged patients with hypertension and artherosclerosis.,.,43,widened mediastinum,.,44,Cardiovascular magnetic resonance (CMR) of a type-A aortic dissection.,.,45,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。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 dissection tend to reach peak severity immediately