急性腹胸痛[4].ppt

Emergency Medicine and Technique Dr.Feng Qi-ming(MD,PhD 封启明)The Emergency Department,the 6th peoples hospital of Shanghai,Shanghai jiaotong University Emergency Medicine and Technique Differential diagnosis 症状鉴别诊断 Chest pain 胸痛 Abdominal pain 腹痛 Fever 发热 The introduction of emergency medicine 急诊医学简介 Non-trauma 非创伤性急诊（内科、外科、儿科）trauma 创伤 Disaster medicine 灾难医学 first aid 院前急救 What are qualified emergency physician needs 1.Rich in elementary knowledge of medicine(丰富的医学基础知识)2.Having rich clinical experience(丰富的临床经验)3.Master the principals of decision-making in emergency medicine(正确的急诊临床思维)4.Skilled techniques for emergency(娴熟的急救技术)Tracheal intubation气管插管,Venipuncture 深静脉穿刺，Cardiopulmonary resuscitation心肺复苏 5.Emergency physician diathesis(良好的心理素质)6.The ability to dealt with accident appropriately(镇静处理突发事件)Acute Chest Pain 急性胸痛急性胸痛 Decision-making on Acute Chest pain at Early Stage 早期识别高危胸痛 Recognize the dangerous of acute chest pain,especially with those life-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 Establish pain management center to offer a comprehensive range of services for patients with treatment on acute chest pain.国外建立疼痛中心建立一系列胸痛诊疗程序 High-risk Chest Pain 急诊常见的高危胸痛 Cardiogenic pain: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-cardiogenic pain:aortic dissection,pulmonary embolism and tension pneumothorax 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 Diagnosis on Acute Chest Pain 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(Cardiogenic and Non cardiogenic)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 characteristics of chest pain 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,substernal Quality 疼痛的性质疼痛的性质,pressure,tightness,sharp,pleuritic,burning Duration,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,nitroglycerin Simultaneous 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 Angina Pectoris and acute myocardial 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。The pain of esophageal disease,mediastinal hernia and mediastinal tumer is also a retrosternal.食管疾患食管疾患、隔疝隔疝、纵隔肿瘤纵隔肿瘤的疼痛也位于胸骨后的疼痛也位于胸骨后。spontaneous pneumothorax,acute pleuritis and pulmonary embolism et.al often unilateral and pleuritic.自发性气胸自发性气胸、急性急性胸膜炎胸膜炎、肺栓塞等常呈患侧的剧烈胸痛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 burning pain or pricking pain.肋间神经痛呈阵发性的灼肋间神经痛呈阵发性的灼痛或刺痛痛或刺痛。Myosalgia often occurs with aching pain.肌痛则肌痛则常呈酸痛；常呈酸痛；Ostalgia occurs with aching pain or boring pain骨骨痛呈酸痛或锥痛；痛呈酸痛或锥痛；Esophagitis and diaphragmatocele often occurs with burning pain or heatburn食管炎食管炎、膈疝常呈膈疝常呈灼痛或灼热感；灼痛或灼热感；Quality of Chest Pain 胸痛的性质 Angina Pectoris or myocardial infarction is usually described as a heaviness,pressure,or squeezing 心绞痛或心肌梗死常呈压榨样痛并常心绞痛或心肌梗死常呈压榨样痛并常伴有压迫感或窒息感伴有压迫感或窒息感。Borning pain is caused by the erosion of aneurysm of aorta when it corrodes chest pain 主动脉瘤侵主动脉瘤侵蚀胸壁时呈锥痛蚀胸壁时呈锥痛。The chest suffocation can be diagnosed by primarily lung cancer or mediastinal mass 原发性原发性肺癌肺癌、纵隔肿瘤可有胸部闷痛纵隔肿瘤可有胸部闷痛。Associated features 影响胸痛的因素 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 Cardiac neurosis is often the reason of chest pain.It can be relieved by movement.心脏神经官能症所致胸痛则常因运动反而好转 The chest pain of pleurisy,pneumothorax,and pericarditis can often be exacerbated by cough or deep breathing 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 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 food 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 Simultaneous phenomenon of chest pain胸痛的伴随症状 Cough:trachea,bronchi and pleural diseases 胸痛常伴咳嗽：胸痛常伴咳嗽：气管、支气管、胸膜疾病所致。Dysphagia:diseases of esophageal and mediastinum 胸痛常伴吞咽困难胸痛常伴吞咽困难：食管、纵隔疾病所致的 Hemoptysis:tuberculosis,pulmonary embolism and primary lung cancer.胸痛常伴有咯血胸痛常伴有咯血：肺结核、肺栓塞、原发性肺癌。Sneeze:brustwirble disease 胸痛常伴有深吸气或打喷嚏加重：加重：胸椎胸椎病变病变 Simultaneous phenomenon of chest pain 胸痛的伴随症状 Hypertention and/or history of coronary heart disease:angina pectoris,myocardial infarction 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,pulmonary embolism and