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1、EmergencyMedicineandTechniqueDr.FengQi-ming(MD,PhD封启明(qmng)TheEmergencyDepartment,the6thpeopleshospitalofShanghai,ShanghaijiaotongUniversity第一页，共四十五页。EmergencyMedicineandTechniqueDifferentialdiagnosis症状(zhngzhung)鉴别诊断Chestpain胸痛Abdominalpain腹痛Fever发热第二页，共四十五页。Theintroductionofemergencymedicine急诊(jzh
2、n)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(yxu)firstaid院前急救第三页，共四十五页。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(lnchun)思维)第四页，共四十五页。4
3、.Skilledtechniquesforemergency(娴熟的急救技术(jsh)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)第五页，共四十五页。AcuteChest Pain急性急性(jxng)胸痛胸痛第六页，共四十五页。Decision-makingonAcuteChestpainatEarlyStage
4、早期(zoq)识别高危胸痛Recognizethedangerousofacutechestpain,especiallywiththoselife-threatening识别胸痛识别胸痛(xin tn)的危险程度的危险程度,特别是威胁生命的胸特别是威胁生命的胸痛痛(xin tn)Establishpainmanagementcentertoofferacomprehensiverangeofservicesforpatientswithtreatmentonacutechestpain.国外建立疼痛中心建立一系列胸痛诊疗程序第七页，共四十五页。High-riskChestPain急诊常见的高
5、危(owi)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：主动脉夹层高危非心源性疼痛：主动脉夹层(jicng)、肺栓塞、张力性气胸肺栓塞、张力性气胸第八页，共四十五页。DiagnosisonAcuteChestPain急性胸痛(xintn)诊断思路Medical history,physical examinati
6、on,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)区分胸痛区分胸痛(xin tn)系心源性或非心源性系心源性或非心源性Juddgement the risk degree 判断危险度判断危险度第九页，共四十五页。characteristicsofchestpain有助于胸痛(xintn)
7、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疼痛的时间及疼痛的时间及影响因素影响因素(yn s)、缓解因素、缓解因素(yn s),exertion,cold,psychologic stress,nitroglycerinSimultaneous symptoms of pain疼痛的伴随症状疼痛的伴随症状P
8、revious medical history 即往史即往史第十页，共四十五页。location of chest pain胸痛胸痛(xin tn)(xin tn)的部的部位位AnginaPectoris andacutemyocardialinfarction are usually retrosternal.mostpatientsdonotlocalizethepaintoanysmallarea.They are typically described as tightness,pressure,or squeezing.Pain may radiate to the jaw,neck
9、,arms,back,and epigastria.The left arm is affected more frequently.心绞痛与急性心绞痛与急性心肌梗死心肌梗死(xn j n s)的疼痛常位于胸骨后或心前区，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。且放射到左肩和左上臂内侧。第十一页，共四十五页。Thepainofesophagealdisease,mediastinalhernia and mediastinal tumer is also aretrosternal.食食管管疾疾患患、隔隔疝疝、纵纵隔隔(zngg)肿瘤的疼痛也位于胸骨后。肿瘤的疼痛也位于胸骨后。s
10、pontaneous 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。第十二页，共四十五页。Quality of Chest Pain胸痛(xin tn)的性质Intercostal neuralgia causes paroxysmal burning pain orprickingpain.肋肋间间神神经经痛痛呈呈阵阵发发性性的的灼灼痛痛或或刺刺痛痛(c tn)。Myosalg
11、iaoftenoccurswithachingpain.肌肌痛痛则则常常呈呈酸酸痛；痛；Ostalgiaoccurswithachingpainorboringpain骨骨痛痛呈酸痛或锥痛；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灼痛或灼热感；痛或灼热感；第十三页，共四十五页。Quality of Chest Pain胸痛(xin tn)的性质Angina Pectoris or myocardial infarction is usuallyde
12、scribedasaheaviness,pressure,orsqueezing心心绞绞痛痛或或心心肌肌梗梗死死(xn j n s)常常呈呈压压榨榨样样痛痛并并常常伴伴有有压压迫迫感感或或窒息感。窒息感。Borningpainiscausedbytheerosionofaneurysmofaortawhenitcorrodeschestpain主主动动脉脉瘤瘤侵侵蚀蚀胸胸壁时呈锥痛。壁时呈锥痛。The chest suffocation can be diagnosed by primarilylungcancerormediastinalmass原原发发性性肺肺癌癌、纵纵隔隔肿肿瘤可有胸部闷
13、痛。瘤可有胸部闷痛。第十四页，共四十五页。Associated features影响胸痛(xin tn)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(xns)缓解；
14、心肌梗死常呈持续性剧痛，虽含服硝酸甘油片仍不缓解第十五页，共四十五页。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(ksu)或深呼吸而加剧第十六页，共四十五页。Associated features影响(yngxing)胸痛的因素Neur
15、omusculoskeletal Conditions:Direct pressure onthe chondrosternal and costochondral junctions mayreproducethepainfromtheseandothermusculoskeletalsyndromes.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(shgun)疾病的胸痛常于吞咽食物时发作或加剧第十七页，共四十五页
16、。Simultaneousphenomenonofchestpain胸痛(xin tn)的伴随症状Cough:trachea,bronchiandpleuraldiseases胸胸痛痛常常伴伴咳咳嗽嗽(k su)：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、纵隔疾病所致的第十八页，共四十五页。Hemoptysis:tuberculosis,pulmonaryembolismandprimarylungcancer.胸胸痛痛(xin tn)常常伴伴有有咯咯血：肺结核、肺栓塞、原发
17、性肺癌。Sneeze:brustwirbledisease胸痛常伴有深吸气或打喷嚏嚏加加重重：胸胸椎椎病病变变第十九页，共四十五页。Simultaneousphenomenonofchestpain胸痛的伴随(bn su)症状Hypertention and/or history of coronaryheart disease:angina pectoris,myocardialinfarction胸痛胸痛(xin tn)常伴有高血压和常伴有高血压和(或或)冠心病冠心病史史：心绞痛、心肌梗死第二十页，共四十五页。Dyspnea:pneumonia,pneumothorax,pleurisy,
18、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(zuwi)及前倾位；食管裂孔疝立位第二十一页，共四十五页。Simultaneousphenomenonofchestpain胸痛的伴随(bn su)症状
19、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(pli)，如主动脉夹层、气胸、纵隔气肿等第二十二页，共四十五页。Haemodynamics:fatalsymptomsareappearedashypotension/venousengorgementsuchaspericardialtampon
20、ade,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(tsh)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）第二十三页，共四十五页。EvaluationCardiogenicChestPain心源性胸痛的急诊评价(pngji)方法Historyandphysicalexamination病史、查体12Leads-ECG(DynamicObservation)-myocardialischemia(30%)increaseST12导
21、ECG(动态观察(gunch)-心肌缺血(30%)ST抬高第二十四页，共四十五页。ChestpainwithouttypicalECGchange:serummyocardiummakertreadmillexerciseUCGnuclearcardiology(Non-abnormal50%AMIduringthediagnoseof20%AMI)dynamicoberservation对ECG无明显变化的胸痛(xintn)-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)-动态观察易误诊第二十五页，共四十五页。EvaluationonCardioge
22、nicChestPain心源性胸痛的急诊评价(pngji)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(ybo)因子第二十六页，共四十五页。Radionuclide：myocardialischemiaaftersixhours核素心肌缺血或梗死6小时(xiosh)后Identifiedasnon-cardiacchestpainifECGdoesnotchangethroughobservat
23、ion若胸痛经动态观察ECG等无变化，考虑非心源性胸痛。第二十七页，共四十五页。Characters of chest pain in emergency急诊常见疾病的胸痛急诊常见疾病的胸痛(xin tn)(xin tn)特点特点第二十八页，共四十五页。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(fngsh)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(fngsh)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
24、 pectoris are identfeid asretrosternalchestdiscomfortratherthanasfrankpain.Theformer is usually described as a pressure,heaviness,squeezing,burning,orchokingsensation.Anginalpainmaylocate primarily in the epigastrium,back,neck,jaw,orshoulders.Typicallocationsforradiationofpainareatarms,shoulders,and
25、 neck.Few presents scares on the brink ofdeathandisforcedtoquitthework.第二十九页，共四十五页。Symptomsandsigns第三十页，共四十五页。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(zhngzhung)。Itlastsforapproximately1-5minutesandisrelievedbyrestorbynitroglycerinafter1-3minutes.疼痛常因用力、劳累、饱食、情绪激动而诱发Anginaisprecipitatedbyexertion,diet,expos
26、uretocold,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第三十一页，共四十五页。急性急性(jxng)心肌梗死心肌梗死Acutemyocardialinfarction胸痛的性质和部位与心绞痛相似，但较剧烈而持久(chji)，持续时间达数小时至数日，休息或含服硝酸甘油不能缓解。Natureandlocationofchestp
27、ainaresimilartothatofangina.However,theyaremoreseverer and long-lasting.It can last fromseveralhourstoseveraldayswhichcannotbe alleviated with rest or by takingnitroglycerin.第三十二页，共四十五页。常伴有发热、恶心、呕吐(ut)、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,difficul
28、tyinbreathing,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第三十三页，共四十五页。急性急性(jxng)下壁心肌梗死下壁心肌梗死Acuteinferiormyocardialinfarction第三十四页，共四十五页。主动脉夹层主动脉夹层(jicng)(jicng)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压和动脉粥样硬化(y
29、nghu)病史。病史。Common in middle-aged patients with hypertension and artherosclerosis.第三十五页，共四十五页。widenedmediastinum第三十六页，共四十五页。Cardiovascularmagneticresonance(CMR)ofatype-Aaorticdissection.第三十七页，共四十五页。突发性撕裂样或刀割样胸痛突发性撕裂样或刀割样胸痛(xin tn)，向胸前及背，向胸前及背部放射，随夹层血肿波及范围可延至腹部、下肢、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
30、一般较急性心臂及颈部，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。梗的高峰早。止痛药常无效。Almostallpatientswithacutedissectionspresentwithseverechestpain,sharp,stabbing,tearing,or ripping pain althoughsomepatientswithchronicdissectionsareidentifiedwithoutassociatedsymptoms.Unlikethepainofischemicheartdisease,symptomsofaorticdissectiont
31、endtoreachpeakseverityimmediately,oftencausingthepatienttocollapsefromitsintensity.It can radiates to the abdomen,limb,thr arm and the neck.Analgeticaisinvalid.第三十八页，共四十五页。诊断(zhndun):diagnosis：X线见上纵隔线见上纵隔(zngg)或主动脉影增宽。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
32、断的准确率aorticangiography:Leadto acurate diagnosis第三十九页，共四十五页。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、职业常有诱因：心脏病、职业(zhy)、长期卧床、长期卧床、新近手术或外伤新近手术或外伤Common incentives:heart disease,occupationa
33、l,bedridden,recent surgery or trauma第四十页，共四十五页。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，主要管堵塞的大小而不同，主要(zhyo)表现为突表现为突发性胸痛、呼吸困难与紫绀。疼痛可为发性胸痛、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、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咯血，白细胞增高与转氨酶GOT升高。升
34、高。检查病变部位有浊音，并可听到胸膜摩检查病变部位有浊音，并可听到胸膜摩擦音。擦音。第四十一页，共四十五页。诊断(zhndun)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(gibin)ECG:V1-4 wave and ST-T change,血气分析血气分析bloodgasanalysis第四十二页，共四十五页。X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
35、射性核素肺扫描选择性肺动脉造影和放射性核素肺扫描(somio)可确诊。可确诊。Final diagnostic examination.selective arteriographyofpulmonaryarteriesandradioactivenuclidescan.第四十三页，共四十五页。Thank Thank you you！第四十四页，共四十五页。内容(nirng)总结Emergency Medicine and Technique。12导 ECG(动态观察)-心肌缺血(30%)ST抬高。疼痛(tngtng)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。SIQ3T3少见，V1-ST-T改变第四十五页，共四十五页。