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 Rich in elementary knowledge of medicine (丰富的医学基础知识) Having rich clinical experience (丰富的临床经验) Master the principals of decision-making in emergency medicine (正确的急诊临床思维)

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 Emergency physician diathesis(良好的心理素质) The ability to dealt with accident appropriately(镇静处理突发事件)

Acute Chest Pain 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,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 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（EKG、胸片、酶学等） chest pain division (Cardiogenic and Non cardiogenic)区分胸痛系心源性或非心源性 Juddgement the risk degree 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，retrosternal, substernal Quality 疼痛的性质, pressure, tightness, sharp,pleuritic,burning Duration, aggravation and alleviation of pain疼痛的时间及影响因素、缓解因素, exertion, cold, psychologic stress, nitroglycerin Simultaneous symptoms of pain疼痛的伴随症状 Previous medical history 即往史

location of chest pain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。

The pain of esophageal disease, mediastinal hernia and mediastinal tumer is also a retrosternal .食管疾患、隔疝、纵隔肿瘤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、急性胸膜炎、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痛或刺痛。 Myosalgia often occurs with aching pain.肌痛则常呈酸痛； Ostalgia occurs with aching pain or boring pain骨痛呈酸痛或锥痛； Esophagitis and diaphragmatocele often occurs with burning pain or heatburn食管炎、膈疝常呈灼痛或灼热感；

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 主动脉瘤侵蚀胸壁时呈锥痛。 The chest suffocation can be diagnosed by primarily lung cancer or mediastinal mass 原发性肺癌、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 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：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：食管、纵隔疾病所致的

Hemoptysis: tuberculosis, pulmonary embolism and primary lung cancer. 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：胸椎病变

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 (或) 冠心病史：心绞痛、心肌梗死

Dyspnea: pneumonia, pneumothorax, pleurisy, pulmonary embolism and hyperventilation syndrome, 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 Abatement position: cardiopericarditis:sitting up and leaning forward; esophageal hiatal hernia: erect position 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

Simultaneous phenomenon of chest pain胸痛的伴随症状 Onset suddenly: 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: fatal symptoms are appeared as hypotension/venous engorgement such as pericardial tamponade, acute myocardial infarction，severe pulmonary embolism , dissection of aorta 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）

Evaluation Cardiogenic Chest Pain心源性胸痛的急诊评价方法 History and physical examination 病史、查体 12 Leads-ECG (Dynamic Observation)- myocardial ischemia (30%) increase ST 12导 ECG(动态观察)---心肌缺血(30%)ST抬高

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 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

Evaluation on Cardiogenic Chest Pain心源性胸痛的急诊评价方法 Cardiac marker testing (TNT、TNI、CPK-MB、 GOT、 LDH) 血清标志物检测(TNT、TNI、心肌酶谱) CTNT forecasts the acute myocardial ischemia CTNT是急性心肌缺血独立危险预报因子

Radionuclide ：myocardial ischemia after six hours 核素心肌缺血或梗死6小时后 Identified as non-cardiac chest pain if ECG does not change through observation 若胸痛经动态观察ECG等无变化，考虑非心源性胸痛。

Characters of chest pain in emergency 急诊常见疾病的胸痛特点

心绞痛 Angina Pectoris 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。Most patients with angina pectoris are identfeid as retrosternal 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, shoulders, and neck. Few presents scares on the brink of death and is forced to quit the work.

Symptoms and signs

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。 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、劳累、饱食、情绪激动而诱发 Angina is precipitated by exertion, diet, exposure to cold, or emotional stress. 发作时心电图检查可见S–T段压低和T波改变。 The ST segment is usually depressed and T-wave changed during angina in EKG. 心肌酶学无改变 Negative changes in Cardiac marker Cardiac marker

急性心肌梗死 Acute myocardial infarction 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。 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.

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。 Sometimes it is accompanied with fever, nausea, vomiting, paleness, difficulty in breathing, arrhythmia, lower blood pressure and heart failure. 心电图和酶学检查有相应的特异性演变。 Positive result in Cardiac marker and ECG examination

急性下壁心肌梗死 Acute inferior myocardial infarction

主动脉夹层 aortic dissection 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。 Common in middle-aged patients with hypertension and artherosclerosis.

widened mediastinum

Cardiovascular magnetic resonance (CMR) of a type-A aortic dissection.

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。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, often causing the patient to collapse from its intensity. It can radiates to the abdomen, limb, thr arm and the neck. Analgetica is invalid.

诊断: diagnosis： X线见上纵隔或主动脉影增宽。 X-ray:widen in superior mediastinum or aorta UCG CT、核磁（MRI) 主动脉造影　诊断的准确率９５％ aortic angiography: Lead to ９５％ acurate diagnosis

肺栓塞 Pulmonary Embolism 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 Common incentives : heart disease, occupational, bedridden, recent surgery or trauma

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 preliminary screening:D-dimer ECG;SIQ3T3少见，V1-４ ST-T改变 ECG:V1-4 wave and ST-T change, 血气分析blood gas analysis

X线摄片见梗死部位呈楔形致密影，底边近胸膜，尖端向肺门，亦可为圆形或多发性小片状影。 选择性肺动脉造影和放射性核素肺扫描可确诊。Final diagnostic examination.selective arteriography of pulmonary arteries and radioactive nuclide scan.

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