【醫(yī)學(xué)課件】急性胸痛的原因與治療

EmergencyMedicineandTechniqueDr.FengQi-ming(MD,PhD封啟明)TheEmergencyDepartment,the6thpeoples’hospitalofShanghai,ShanghaijiaotongUniversityEmergencyMedicineandTechniqueDifferentialdiagnosis癥狀鑒別診斷Chestpain胸痛Abdominalpain腹痛Fever發(fā)熱Theintroductionofemergencymedicine

急診醫(yī)學(xué)簡(jiǎn)介Non-trauma非創(chuàng)傷性急診（內(nèi)科、外科、兒科）trauma創(chuàng)傷Disastermedicine災(zāi)難醫(yī)學(xué)firstaid院前急救WhatarequalifiedemergencyphysicianneedsRichinelementaryknowledgeofmedicine(豐富的醫(yī)學(xué)基礎(chǔ)知識(shí))Havingrichclinicalexperience(豐富的臨床經(jīng)驗(yàn))Mastertheprincipalsofdecision-makinginemergencymedicine(正確的急診臨床思維)Skilledtechniquesforemergency(嫻熟的急救技術(shù))Trachealintubation氣管插管,Venipuncture

深靜脈穿刺，Cardiopulmonaryresuscitation心肺復(fù)蘇Emergencyphysiciandiathesis(良好的心理素質(zhì))Theabilitytodealtwithaccidentappropriately(鎮(zhèn)靜處理突發(fā)事件)

AcuteChestPain

急性胸痛

Decision-makingonAcuteChestpainatEarlyStage

早期識(shí)別高危胸痛Recognizethedangerousofacutechestpain,

especiallywiththoselife-threatening識(shí)別胸痛的危險(xiǎn)程度,特別是威脅生命的胸痛Establishpainmanagementcentertoofferacomprehensiverangeofservicesforpatientswithtreatmentonacutechestpain.國(guó)外建立疼痛中心建立一系列胸痛診療程序High-riskChestPain

急診常見(jiàn)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(dòng)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(xué)等）chestpaindivision(CardiogenicandNoncardiogenic)區(qū)分胸痛系心源性或非心源性Juddgementtheriskdegree判斷危險(xiǎn)度

characteristicsofchestpain

有助于胸痛的診斷和鑒別診斷的特點(diǎn)Locationofpain疼痛的部位，retrosternal,substernalQuality疼痛的性質(zhì),pressure,tightness,sharp,pleuritic,burningDuration,aggravationandalleviationofpain疼痛的時(shí)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AnginaPectoris

andacutemyocardialinfarctionareusuallyretrosternal.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,mediastinalherniaandmediastinal

tumerisalsoaretrosternal.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；QualityofChestPain

胸痛的性質(zhì)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(dòng)脈瘤侵蝕胸壁時(shí)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(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Cardiacneurosisisoftenthereasonofchestpain.Itcanberelievedbymovement.心臟神經(jīng)官能癥所致胸痛則常因運(yùn)動(dòng)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Associatedfeatures

影響胸痛的因素NeuromusculoskeletalConditions:Directpressureonthechondrosternalandcostochondraljunctionsmayreproducethepainfromtheseandothermusculoskeletalsyndromes.Itisintensifiedbythoracicactivity;Esophagealdiseasesisoftenexacerbatedbyswallowingfood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

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

Simultaneousphenomenonofchestpain胸痛的伴隨癥狀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(guò)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

Simultaneousphenomenonofchestpain胸痛的伴隨癥狀Onsetsuddenly:thoracicorganruptureisconcluedbythesymptomsofrapidseverechestpain.suchandissectionofaorta,aerothorax,andmediastinalemphysemaetc.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Haemodynamics:fatalsymptomsareappearedashypotension/venousengorgementsuchaspericardialtamponade,acutemyocardialinfarction，severepulmonaryembolism,dissectionofaorta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）

EvaluationCardiogenicChestPain心源性胸痛的急診評(píng)價(jià)方法Historyandphysicalexamination病史、查體12Leads-ECG(DynamicObservation)-myocardialischemia(30%)increaseST12導(dǎo)ECG(動(dòng)態(tài)觀察)---心肌缺血(30%)ST抬高ChestpainwithouttypicalECGchange:serummyocardiummaker\treadmillexercise\UCG\nuclearcardiology(Non-abnormal50%AMIduringthediagnoseof20%AMI)–dynamicoberservation對(duì)ECG無(wú)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(wú)異常---觀察期間20%AMI)--動(dòng)態(tài)觀察—易誤診

EvaluationonCardiogenicChestPain心源性胸痛的急診評(píng)價(jià)方法Cardiacmarkertesting(TNT、TNI、CPK-MB、GOT、LDH)血清標(biāo)志物檢測(cè)(TNT、TNI、心肌酶譜)CTNTforecaststheacutemyocardialischemiaCTNT是急性心肌缺血獨(dú)立危險(xiǎn)預(yù)報(bào)因子Radionuclide：myocardialischemiaaftersixhours核素心肌缺血或梗死6小時(shí)后Identifiedasnon-cardiacchestpainifECGdoesnotchangethroughobservation若胸痛經(jīng)動(dòng)態(tài)觀察ECG等無(wú)變化，考慮非心源性胸痛。

Charactersofchestpaininemergency

急診常見(jiàn)疾病的胸痛特點(diǎn)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(dá)無(wú)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)。Mostpatientswithanginapectorisareidentfeidasretrosternalchestdiscomfortratherthanasfrankpain.Theformerisusuallydescribedasapressure,heaviness,squeezing,burning,orchokingsensation.Anginalpainmaylocateprimarilyintheepigastrium,back,neck,jaw,orshoulders.Typicallocationsforradiationofpainareatarms,shoulders,andneck.Fewpresentsscaresonthebrinkofdeathandisforcedtoquitthework.Symptomsandsigns疼痛持續(xù)時(shí)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(dòng)而誘發(fā)Anginaisprecipitatedbyexertion,diet,exposuretocold,oremotionalstress.發(fā)作時(shí)心電圖檢查可見(jiàn)S–T段壓低和T波改變。TheSTsegmentisusuallydepressedandT-wavechangedduringanginainEKG.心肌酶學(xué)無(wú)改變NegativechangesinCardiacmarkerCardiacmarker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(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。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(xué)檢查有相應(yīng)的特異性演變。PositiveresultinCardiacmarkerandECGexamination

急性下壁心肌梗死

Acuteinferiormyocardialinfarction

主動(dòng)脈夾層

aorticdissection

本病多見(jiàn)于40歲以上的男性，多有高血壓和動(dòng)脈粥樣硬化病史。Commoninmiddle-agedpatientswithhypertensionandartherosclerosis.widenedmediastinumCardiovascularmagneticresonance(CMR)ofatype-Aaorticdissection.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(wú)效。Almostallpatientswithacutedissectionspresentwithseverechestpain,sharp,stabbing,tearing,orrippingpainalthoughsomepatientswithchronicdissectionsareidentifiedwithoutassociatedsymptoms.Unlikethepainofischemicheartdisease,symptomsofaorticdissectiontendtoreachpeakseverityimmediately,oftencausingthepatienttocollapsefromitsintensity.Itcanradiatestotheabdomen,limb,thrarmandtheneck.Analgeticaisinvalid.診斷:

diagnosis：X線見(jiàn)上縱隔或主動(dòng)脈影增寬。X-ray:wideninsuperiormediastinumoraortaUCGCT、核磁（MRI)主動(dòng)脈造影診斷的準(zhǔn)確率９５％aorticangiography:Leadto

９５％acuratediagnosis肺栓塞

PulmonaryE