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EmergencyMedicineandTechniqueDr.FengQi-ming(MD,PhD封启明)TheEmergencyDepartment,the6thpeoples’hospitalofShanghai,ShanghaijiaotongUniversityEmergenc

yMedicineandTechniqueDifferentialdiagnosis症状鉴别诊断①Chestpain胸痛②Abdominalpain腹痛③Fever发热Theintroductionofeme

rgencymedicine急诊医学简介Non-trauma非创伤性急诊（内科、外科、儿科）trauma创伤Disastermedicine灾难医学firstaid院前急救Whatarequalifiedemergencyp

hysicianneeds1.Richinelementaryknowledgeofmedicine(丰富的医学基础知识)2.Havingrichclinicalexperience(丰富的临床经验)3.Mast

ertheprincipalsofdecision-makinginemergencymedicine(正确的急诊临床思维)4.Skilledtechniquesforemergency(娴熟的急救技术)Trachealintubati

on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.The

abilitytodealtwithaccidentappropriately(镇静处理突发事件)AcuteChestPain急性胸痛Decision-makingonAcuteChestpainatEarlyStage早期识别高危胸痛Recognizethedanger

ousofacutechestpain,especiallywiththoselife-threatening识别胸痛的危险程度,特别是威胁生命的胸痛Establishpainmanagementcentertoofferacomprehensiverangeofservice

sforpatientswithtreatmentonacutechestpain.国外建立疼痛中心建立一系列胸痛诊疗程序High-riskChestPain急诊常见的高危胸痛Cardiogenicpain:AcuteCoronarySyndrome（UAP、AMI)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、肺栓塞、张力性气胸DiagnosisonAcuteChestPain

急性胸痛诊断思路Medicalhistory,physicalexamination,laboratoryexaminationandspecialexaminationandtests(EKG、ChestX-ray、enzymology)病史、体格检查、辅助检查（EKG、胸片、酶

学等）chestpaindivision(CardiogenicandNoncardiogenic)区分胸痛系心源性或非心源性Juddgementtheriskdegree判断危险度characteri

sticsofchestpain有助于胸痛的诊断和鉴别诊断的特点Locationofpain疼痛的部位，retrosternal,substernalQuality疼痛的性质,pressure,tightness,sharp,pleuritic,burningDuration,aggr

avationandalleviationofpain疼痛的时间及影响因素、缓解因素,exertion,cold,psychologicstress,nitroglycerinSimultaneoussymptomsofpain疼痛的伴随症状Previousmedical

history即往史locationofchestpain胸痛的部位AnginaPectorisandacutemyocardialinfarctionareusuallyretrosternal.mostpatientsdonotlocalizethepaintoanysmallarea.Th

eyaretypicallydescribedastightness,pressure,orsqueezing.Painmayradiatetothejaw,neck,arms,back,andepigastria.Theleftarmisaffectedmorefr

equently.心绞痛与急性心肌梗死的疼痛常位于胸骨后或心前区，且放射到左肩和左上臂内侧。Thepainofesophagealdisease,mediastinalherniaandmediastinaltumerisalsoaretrosternal.食管疾患、隔疝、纵隔肿瘤的疼痛也位

于胸骨后。spontaneouspneumothorax,acutepleuritisandpulmonaryembolismet.aloftenunilateralandpleuritic.自发性气胸、急性胸膜炎、肺栓塞等常呈患侧的剧烈胸痛。QualityofChestPain胸痛的

性质Intercostalneuralgiacausesparoxysmalburningpainorprickingpain.肋间神经痛呈阵发性的灼痛或刺痛。Myosalgiaoftenoccurswithachingpa

in.肌痛则常呈酸痛；Ostalgiaoccurswithachingpainorboringpain骨痛呈酸痛或锥痛；Esophagitisanddiaphragmatoceleoftenoccurswithbu

rningpainorheatburn食管炎、膈疝常呈灼痛或灼热感；QualityofChestPain胸痛的性质AnginaPectorisormyocardialinfarctionisusuallydesc

ribedasaheaviness,pressure,orsqueezing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。Borningpainiscausedbytheerosionofaneurysmofaortawhenitcorrodeschestpain主动脉

瘤侵蚀胸壁时呈锥痛。Thechestsuffocationcanbediagnosedbyprimarilylungcancerormediastinalmass原发性肺癌、纵隔肿瘤可有胸部闷痛。Associatedfeatures影

响胸痛的因素AnginaPectorisisoftenindusedbytension.Itcanbereleasedbytakingnitroglycerintablets.Myocardialinfarctioncanbeinde

ntifiedwithcontinuingpainwhichisnottobereleasedbytakingnitroglycerintablets.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Cardiacne

urosisisoftenthereasonofchestpain.Itcanberelievedbymovement.心脏神经官能症所致胸痛则常因运动反而好转Thechestpainofpleurisy,pneumothorax,and

pericarditiscanoftenbeexacerbatedbycoughordeepbreathing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Associatedfeatures影响胸痛的因素NeuromusculoskeletalConditions:Di

rectpressureonthechondrosternalandcostochondraljunctionsmayreproducethepainfromtheseandothermusculoskeletalsyndromes.Itisintensifiedbythor

acicactivity;Esophagealdiseasesisoftenexacerbatedbyswallowingfood胸壁疾病所致的胸痛常于局部压迫或胸廓活动时加剧；食管疾病的胸痛常于吞咽食物时发作或加剧Sim

ultaneousphenomenonofchestpain胸痛的伴随症状Cough:trachea,bronchiandpleuraldiseases胸痛常伴咳嗽：气管、支气管、胸膜疾病所致。Dysphagia:diseasesofesophagealan

dmediastinum胸痛常伴吞咽困难：食管、纵隔疾病所致的Hemoptysis:tuberculosis,pulmonaryembolismandprimarylungcancer.胸痛常伴有咯血：肺结核、肺栓塞、原发性肺癌

。Sneeze:brustwirbledisease胸痛常伴有深吸气或打喷嚏加重：胸椎病变Simultaneousphenomenonofchestpain胸痛的伴随症状Hypertentionand/orhistoryofcoronaryhe

artdisease:anginapectoris,myocardialinfarction胸痛常伴有高血压和(或)冠心病史：心绞痛、心肌梗死Dyspnea:pneumonia,pneumothorax,pleurisy,pulmonaryembolismandhyp

erventilationsyndrome,etc.胸痛常伴有呼吸困难：肺炎、气胸、胸膜炎、肺栓塞、过度换气综合征等Abatementposition:cardiopericarditis:sittingupandleanin

gforward;esophagealhiatalhernia:erectposition胸痛常伴有特定体位缓解：心包炎－坐位及前倾位；食管裂孔疝－立位Simultaneousphenomenonofche

stpain胸痛的伴随症状Onsetsuddenly:thoracicorganruptureisconcluedbythesymptomsofrapidseverechestpain.suchandissectionofaorta,aerothorax,andmediastinal

emphysemaetc.胸痛伴起病急剧，胸痛迅速达高峰，往往提示胸腔脏器破裂，如主动脉夹层、气胸、纵隔气肿等Haemodynamics:fatalsymptomsareappearedashypotension/venousengorgementsuchaspericardial

tamponade,acutemyocardialinfarction，severepulmonaryembolism,dissectionofaorta胸痛伴血流动力学异常－低血压／及静脉怒张则提示致命性胸痛（心包填塞、急性心肌梗

塞、巨大肺栓塞、主动脉夹层）EvaluationCardiogenicChestPain心源性胸痛的急诊评价方法Historyandphysicalexamination病史、查体12Leads-ECG(DynamicObservation)-myocardialisch

emia(30%)increaseST12导ECG(动态观察)---心肌缺血(30%)ST抬高ChestpainwithouttypicalECGchange:serummyocardiummaker\tre

admillexercise\UCG\nuclearcardiology(Non-abnormal50%AMIduringthediagnoseof20%AMI)–dynamicoberservation对ECG无明显变化的胸痛-

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EvaluationonCardiogenicChestPain心源性胸痛的急诊评价方法Cardiacmarkertesting(TNT、TNI、CPK-MB、GO

T、LDH)血清标志物检测(TNT、TNI、心肌酶谱)CTNTforecaststheacutemyocardialischemiaCTNT是急性心肌缺血独立危险预报因子Radionuclide：myocardialischemiaaftersixhours核

素心肌缺血或梗死6小时后Identifiedasnon-cardiacchestpainifECGdoesnotchangethroughobservation若胸痛经动态观察ECG等无变化，考虑非心源性胸痛。Chara

ctersofchestpaininemergency急诊常见疾病的胸痛特点心绞痛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。Mostpatientswithanginapectorisareidentfeidasretrosternalchestdiscomfortratherthana

sfrankpain.Theformerisusuallydescribedasapressure,heaviness,squeezing,burning,orchokingsensation.Anginalpainmaylocate

primarilyintheepigastrium,back,neck,jaw,orshoulders.Typicallocationsforradiationofpainareatarms,shoul

ders,andneck.Fewpresentsscaresonthebrinkofdeathandisforcedtoquitthework.Symptomsandsigns疼痛持续时间约1—5分钟，休息或含服硝酸甘油后1–3分钟内可缓解症状。Itlastsforapproximately1-

5minutesandisrelievedbyrestorbynitroglycerinafter1-3minutes.疼痛常因用力、劳累、饱食、情绪激动而诱发Anginaisprecipitatedbyexertion,diet,exposuretocold,oremotional

stress.发作时心电图检查可见S–T段压低和T波改变。TheSTsegmentisusuallydepressedandT-wavechangedduringanginainEKG.心肌酶学无

改变NegativechangesinCardiacmarkerCardiacmarker急性心肌梗死Acutemyocardialinfarction胸痛的性质和部位与心绞痛相似，但较剧烈而持久，持续时间达数小时至数日，休

息或含服硝酸甘油不能缓解。Natureandlocationofchestpainaresimilartothatofangina.However,theyaremoresevererandlong-last

ing.Itcanlastfromseveralhourstoseveraldayswhichcannotbealleviatedwithrestorbytakingnitroglycerin.常伴有发热、恶心、呕吐、面色苍白、呼吸困难、心律不齐、血压降低、

心力衰竭等。Sometimesitisaccompaniedwithfever,nausea,vomiting,paleness,difficultyinbreathing,arrhythmia,lowerbloodpressureandheartfailure.心电图和酶学检查有相应的特

异性演变。PositiveresultinCardiacmarkerandECGexamination急性下壁心肌梗死Acuteinferiormyocardialinfarction主动脉夹层aorticd

issection本病多见于40岁以上的男性，多有高血压和动脉粥样硬化病史。Commoninmiddle-agedpatientswithhypertensionandartherosclerosis.widenedmediastinumCardiovascularmagneticresonan

ce(CMR)ofatype-Aaorticdissection.突发性撕裂样或刀割样胸痛，向胸前及背部放射，随夹层血肿波及范围可延至腹部、下肢、臂及颈部，极为剧烈，疼痛的高峰一般较急性心梗的高峰早。止痛药常无效。Almostallpatientswithacutedis

sectionspresentwithseverechestpain,sharp,stabbing,tearing,orrippingpainalthoughsomepatientswithchronicdiss

ectionsareidentifiedwithoutassociatedsymptoms.Unlikethepainofischemicheartdisease,symptomsofaorticdissectiontendtoreachpeakseverityimmediately,often

causingthepatienttocollapsefromitsintensity.Itcanradiatestotheabdomen,limb,thrarmandtheneck.Analgetic

aisinvalid.诊断:diagnosis：X线见上纵隔或主动脉影增宽。X-ray:wideninsuperiormediastinumoraortaUCGCT、核磁（MRI)主动脉造影诊断的准确率９５％aor

ticangiography:Leadto９５％acuratediagnosis肺栓塞PulmonaryEmbolism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。常有诱因：心脏病、职业、长期卧床、新近手术或外伤Commonincentives:heartdisease,occupational,bedridden,recentsurgeryortrauma肺总动

脉的一支堵塞，可胸痛、昏厥、休克而猝死。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，主要表现为突发性胸痛、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GOT升高。检查病变部位有浊音，并可

听到胸膜摩擦音。诊断D二聚体初步筛选preliminaryscreening:D-dimerECG;SIQ3T3少见，V1-４ST-T改变ECG:V1-4waveandST-Tchange,血气分析bloodgasanalysis提问与解

答环节QuestionsAndAnswers谢谢聆听·学习就是为了达到一定目的而努力去干,是为一个目标去战胜各种困难的过程,这个过程会充满压力、痛苦和挫折LearningIsToAchieveACertainGoalAndWorkHard,IsAProcessToOvercomeVario

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