胸痛（讲义）-杨震坤.ppt

心包炎：EKG 急性心包炎 急性心肌缺血 J-ST 广泛抬高，弓背向下 局限,弓背向上 PR 压低 无改变 Q 无改变 常有相应改变 T J点回落后弥漫倒置 高尖/对称 与ST改变特异性相关 心包炎 急性心包炎 Diffuse ST segment elevation 肺栓塞 症状 气短 90% 胸痛 40%-70% 咯血 10%-30% 晕厥 13%, 低血压, 猝死 (典型的呼吸困难, 胸痛, 咯血仅占28%) 危险因素 缺乏活动,手术,创伤,肥胖,妊娠,CHF等,大多数来源于下肢深静脉血栓 形成 辅助检查 CXR,ECG(经典20%),血气分析, D-Dimer(PE30%,Miss10%), ECHO, CTPA, V/Q scan 肺栓塞：诊断 EKG S1Q3T3 仅占PE患者的 6% 肺栓塞 肺栓塞 超声心动图 肺动脉内血栓(少见) 右室扩大 右室壁运动减低 室间隔运动异常 三尖瓣反流 肺动脉扩大 肺动脉高压 下腔静脉吸气内径无变化 肺栓塞 肺栓塞 肺栓塞 肺栓塞: the V/Q Scan 正常通气 异常灌注 肺栓塞 可疑高危肺栓塞诊断流程图 注：*如果患者病情危重，只能进行床旁检查，不考虑行急诊CT。#经食道超声心电图对存在右心负荷过重的PE（经螺旋CT确诊）患者，肺动脉内血栓的检出率明显增加；床旁CUS检出DVT有助于决策。 可疑非高危肺栓塞诊断流程图 注：*肺栓塞的抗凝治疗。+段以上肺动脉血栓CT可以做出诊断。≠如果单层螺旋CT不支持PE诊断，需要进行下肢CUS检查，以便安全除外PE。#如果临床高可能性的患者多排螺旋CT是阴性，在停止抗凝治疗之前应进一步检查。 气胸 肺炎累及胸膜 肺部疾病 张力性气胸 右下叶肺炎 带状疱疹 颈、胸椎关节退行病 肋软骨炎 骨骼和神经系统疾病 胸痛的危险分层和分组 1-2小时回家 UA/NSTEMI， 短期留观 STEMI 主动脉夹层 肺栓塞 心包填塞 ? Thank you for your patience! Thank you for your patience! * GERD=Gastroesophogeal reflux disease * * those with typical sx only 24% had MI and 30% had unstable angina Burning or indigestion 23% MI and 21% had angina sharp and stabing 5% had MI and 17% had unstable angina Beware of GI cocktail Can mimic renal colic, inf. sx nausea,vomiting, abd pain, hypotension Diabettics present with atypical symtpoms * * those with typical sx only 24% had MI and 30% had unstable angina Burning or indigestion 23% MI and 21% had angina sharp and stabing 5% had MI and 17% had unstable angina Beware of GI cocktail Can mimic renal colic, inf. sx nausea,vomiting, abd pain, hypotension Diabettics present with atypical symtpoms * proximal dissection may involve RCA pulmonary apical cap from blood dissection RX-beta blocker-rate of rise Nipride Surgery * those with typical sx only 24% had MI and 30% had unstable angina Burning or indigestion 23% MI and 21% had angina sharp and stabing 5% had MI and 17% had uns