With acute chest pain in emergency department chest pain is often faced with the problem. There are indications of the chief complaint of acute chest pain patients in emergency medical patients accounted for 5% to 20% in tertiary hospitals is accounted for 20% to 30% . With the lifestyle changes and population aging treatment in the emergency department chest pain patients by a gradual increase in volume. any physical, chemical, mechanical and biological stimuli, such as mechanical pressure, chemical irritants, trauma, inflammation, tumor stimulation sensory fibers of heart and great vessels, trachea, bronchi and esophagus vagal sensory fibers and the phrenic nerve afferent fibers, etc., can cause chest pain sensation. In addition, the mechanism of referred pain, visceral afferent impulses may also lead to corresponding parts of the body surface of pain. ischemia lactic acid and other substances on local afferent nerve stimulation can cause jaw, neck, left shoulder, left arm pain. thorax, including chest wall layers (skin, muscle, intercostal nerve, rib, sternum, thoracic spine until parietal pleura), heart, aorta, pulmonary artery, trachea, esophagus, mediastinum, and lung disease or injury can cause chest pain. it is more a result of symptoms of chest pain.
different clinical manifestations of acute chest pain, the ever-changing condition, There is also risk of a large difference. there is a retrospective study found that in the final diagnosis of acute coronary syndrome in patients with acute chest pain 15608, there are 2992 people in the emergency department was diagnosed with non-cardiac chest pain. Another studies indicate that nearly 3% were diagnosed in the emergency room for non-cardiac chest pain patients home within 30 days after the occurrence of a malignant cardiac event. but some good prognosis if misdiagnosed as chest pain and serious cardiovascular events, will increase the patient's concerns and psychological burden, lead to unnecessary medical expenses and even bodily trauma. Therefore, given rapid identification of patients with acute chest pain diagnosis, while giving its accurate assessment of risk and make timely and proper disposal, is the emergency One of the great challenges facing doctors.
common idea of differential diagnosis of acute chest pain is from the perspective of the cause, will be divided into cardiac chest pain and non-cardiac chest pain. then occur according to the etiology of chest pain and anatomical pathology, the differential diagnosis. However, not all are fatal cardiac chest pain or chest pain in the emergency disposal stages prompted serious consequences of poor prognosis, such as tuberculous pericarditis; the same time, some non-cardiac chest pain patients in critical condition or may occur at any life-threatening, such as tension pneumothorax. In addition, a variety of reasons can lead to acute non-cardiac chest pain, emergency room doctors often need to arrange for the patient a series of related inspection, then the differential diagnosis of the results of these checks. But the reality is that, due to the limited space environment and emergency medical resources, emergency physicians are often faced with many diseases, easy to reflect the emergency After emergency medical treatment is the basic working principle. in this context, the ER doctors from the perspective of severity of illness diagnosis and to initiate emergency treatment. The more severe the disease, its prognosis becomes time dependent, it should be For a limited time to complete goal-oriented treatment.
patients with acute chest pain treatment should be attention to two principles: first, to quickly eliminate the most dangerous and urgent diseases, such as acute myocardial infarction, aortic dissection , pulmonary embolism, tension pneumothorax, etc.; Second, the diagnosis is not routine in hospital patients should be observed evolution of the disease, prevent the occurrence of sudden death after discharge of these serious cardiac events. the specific processes are as follows:
(1) First of all determine the severity of unstable vital signs of patients, should immediately begin to stabilize the vital signs of the treatment; also began further processing;
(2) of the patients vital signs were stable, the first access to medical history and symptoms;
(3) targeted supplementary examination;
(4) After the above process can begin immediately clear cause of the patients the cause of the targeted therapy, such as acute myocardial infarction by coronary reperfusion therapy as soon as possible, on pneumothorax in patients with acute ventilation or drainage, etc. as soon as possible;
(5) can not clear the cause of patients hospitalized for observation for some time, 6 hours is generally recommended.
one emergency medical admissions
access After attending patients with chest pain, should first assess the patient's vital signs: consciousness, heart rate, respiration, blood pressure (not including body temperature, because the temperature measurement will take some time), the assessment process should be as short. If it is found in patients with unstable vital signs ( For example, confusion) or a rapid deterioration of vital signs (such as severe hypotension), patients should be immediately sent to the recovery, the preparation or implementation of cardiopulmonary resuscitation. this time, no matter what the cause chest pain caused by the first ABCDE cardiopulmonary resuscitation should be in accordance with the procedures (see relevant sections), and stable vital signs of patients, treatment of life-threatening pathological condition. If the patient is relatively stable vital signs, diagnosis and treatment steps can be the next step.
Second, the history of
on the vital signs were stable patients, the first for history and symptoms. Zonglun in this book, we have introduced the emergency diagnosis of fact is based on probability, pain accounted for 19%, while only 16% of cardiac pain. occur in young people and chest pain in menopausal women, functional chest pain, a considerable proportion of the common determined to neurosis, hyperventilation syndrome. In fact, women before menopause, without the risk factors (such as family history, hypertension, dyslipidemia and diabetes) are rare coronary heart disease. But in the over 60 population, the proportion of cardiac chest pain is much higher than 50%. Therefore, understanding the patient's age, gender, and social psychological factors, smoking, diabetes, hyperlipidemia, left ventricular hypertrophy, hypertension and other medical history and family history of patients with chest pain for the assessment of the cause is essential. At the same time, some of these basic patients with chest pain assessment data is an important basis for risk stratification.
general, the main features of chest pain described by five aspects, namely, pain location and radiation parts of the nature of pain, pain, time, predisposing factors, mitigating factors and associated symptoms These characteristics are often implicit in the diagnosis and differential diagnosis of a clue, these characteristics of patients with acute chest pain admissions doctors need to focus on the content of inquiry, a considerable part of the chest pain patients rely solely on the detailed history can be essential to diagnosis:
1
site and radiation parts of chest pain in the chest, often prompted angina, acute myocardial infarction, aortic dissection, esophageal disease, and mediastinal diseases; to precordial chest pain as the main site of pain is seen in angina pectoris, acute pericarditis, left intercostal neuritis, cartilage inflammation, herpes zoster; chest pain in the side are often occurs in acute pleurisy, pulmonary embolism, intercostal muscle inflammation; liver or subphrenic lesions can be expressed as the right side of chest pain; limited to the apex or the left chest below the nipple for the heart neurosis and other multi-functional due to chest pain, it can be splenic flexure syndrome.
the same position with chest pain, radiation site is also an important clue to the cause of chest pain prompted. radiotherapy to the neck, jaw, left arm ulnar cardiac chest pain is often the typical symptoms of ischemic chest pain, also can be seen in acute pericarditis. chest pain radiating to the back can be found in aortic dissection acute myocardial infarction. radiotherapy to the right shoulder and right chest pain often prompts may or subphrenic biliary lesions.
2
considerable part of the nature of disease, pain, chest pain caused by the nature of the pain that has certain characteristics, such as heart ischemic chest pain. When a patient to his chest discomfort described as oppressive, crushing resistance, up a sense of nausea or chest pain, the most typical situation is tight in the chest by the patient make a fist to describe his discomfort. The sharp knife cut, the pain often support pericarditis, pleurisy and pulmonary embolism. aortic dissection occurs more performance for the sudden tearing pain, with a strong characteristic. showed needle-like or electric shock-like moment of pain can be found in functional chest pain, intercostal neuritis, herpes zoster, esophageal hiatal hernia. chest wall pain is often positioning clear, and chest pain caused by lesions of internal organs can not be more clearly position.
3 pain pain lasting
the time limit on the differential diagnosis of chest pain has a strong value, especially for non-ischemic chest pain and myocardial ischemia the identification of chest pain. only a brief moment or less than 15 seconds of chest pain, chest pain, myocardial ischemia is not supported, but more likely to musculoskeletal neuropathic pain, hiatal hernia pain or functional pain. for 2 to 10 minutes of chest pain , and more for the stability of the chest pain, and for 10 to 30 minutes are much more unstable angina. even more than 30 minutes to a few hours of chest pain can be acute myocardial infarction, pericarditis, aortic dissection, herpes zoster, bone pain, the pain of these diseases of long duration and difficult to alleviate in the short period of time.
4 and mitigating factors
induced ischemic chest pain, particularly angina pectoris, or more emotion evoked by the labor, and rest or sublingual nitroglycerin, due to reduced demand for cardiac oxygen consumption, chest pain can be relieved. Most of angina after sublingual nitroglycerin within 3-5 minutes can significantly relieve that, more than 15 minutes without relief may be a myocardial infarction or ischemic chest pain. esophageal spasm in consuming more than chest pain induced by cold liquid, and sometimes free to attack, after sublingual nitroglycerin partial remission, but a slower onset than angina. In addition to esophageal spasm chest pain caused by, other non-ischemic chest pain with nitroglycerin can not be mitigated. pleurisy caused by acute chest pain often related to respiratory and chest movement, deep breathing can be induced by the increase, can reduce breath-hold. musculoskeletal chest pain and nerve often touch or movement in the chest aggravated. and more with functional chest pain related to depression, chest pain, hyperventilation induced by breathing too fast. Mallory-Weiss syndrome is often after vomiting. Thus, to understand the incentive chest pain and mitigation factors contribute to the analysis of the possible causes.
5
symptoms associated with chest pain caused by different causes have different associated symptoms. chest pain associated with pale skin, sweating, blood pressure or shock can be seen in acute myocardial infarction, the main artery dissection, aortic sinus aneurysm rupture or acute pulmonary embolism. hemoptysis with chest pain suggestive of pulmonary embolism, lung cancer and other respiratory diseases. chest pain with fever seen in lobar pneumonia, acute pleuritis, acute pericarditis and other acute infectious diseases . When the chest pain was accompanied by breathing difficulties, severe disease often involving the heart and lung function prompts, such as acute myocardial infarction, pulmonary embolism, lobar pneumonia, pneumothorax, mediastinal emphysema and other conditions. dysphagia associated with chest pain the presence of esophageal diseases prompted. And when the chest pain patients with significant anxiety, depression, sighing symptoms of cardiac neurosis should think of the possibility of chest pain and other functions.
Third, physical examination
in emergency conditions, for patients with acute chest pain, generally can not conduct a comprehensive, systematic physical examination, because in most cases the disease does not allow sufficient time for doctors to do so. And was regrettable that the heart symptoms of chest pain patients in the few specific changes, so not much help on the differential diagnosis. It is therefore important to have specific, targeted manner based on the patient's medical history and personal characteristics of the clinical thinking of some key physical examination.
examination of patients with acute chest pain and general principles: easy things first, give priority to life-threatening gastrointestinal emergency in the investigation, in adherence to the possibility of large-derived. However, there may be other reasons? speculate on the probability from the onset, the possibility of a large cardiovascular origin. However, there may be other reasons? clothes if we open the patient to see along the rib Traveling the blister space, it is highly suspected diagnosis of chest pain caused by herpes zoster. Although the incidence of the disease is not high, but the differential diagnosis of simple to just do an ECG to develop simultaneously, carefully check the skin of patients, can quickly give patients a preliminary condition assessment. Therefore, a relatively stable vital signs of patients under the premise of a similar process is simple and clear conclusion to the first examination carried out.
65 years old male patient, at home, stand up when the sudden squatting toilet chest pain and breathing difficulties 1h, is looking cyanosis, orthopnea. past smoking, hypertension, chronic obstructive pulmonary disease, history of diabetes. Our focus is on the or Any patients with severe chest pain, should first touch the limbs of the arterial pulse. Although the normal limb arterial pulse can not be other than the disease, but if the blood pressure in patients with limb asymmetry not even touched, and the past are very different, the next treatment should be directed to a high degree of suspected aortic dissection. In addition, sometimes the Ministry of aortic arch dissection on sternal fossa in the abnormal pulse; jugular vein filling or distention seen in cardiac tamponade.
for patients with chest pain, chest examination is naturally the focus. but because of the heart chest pain of the pneumothorax may be suspected if (caused by large unilateral breath sounds reduced survival of patients with pulmonary embolism rarely reach the emergency room, so the probability of the angle from the onset, and less considered). If you find wet rales lungs clouds, the direction and treatment be emphasized (mm myocardial infarction heart failure).
chest pain in patients with abdominal signs also need attention, attention should be without tenderness, especially the xiphoid, the gallbladder area site. Do not forget to check whether the swelling of the lower limbs, whether deep vein thrombosis based.
four auxiliary examination
with social development and technological advancement, emergency physicians can use the secondary inspection means more and more. but not all in the emergency conditions are applied. How to choose trade-offs, is the medical admissions have to be solved. For patients with acute chest pain should be based on patient history, physical examination results initial, targeted to carry out additional tests. in the choice of other auxiliary examination, paying particular attention to a few principles: 1, effective, safe and simple to complete secondary inspection, 2, note that the unity of sensitivity and specificity, 3, pay attention to the risks and benefits of unification. auxiliary inspection arrangements, but also pay attention to co-ordinate learning arrangements. acute chest pain clinic Unlike other emergency condition, a strong time-dependent. the use of different secondary examination time waiting for results, a supplementary examination under reasonable arrangement can effectively reduce the waiting time of patients diagnosed, for example, waiting for the return of blood biochemistry results time, can do several EKG.
for acute myocardial infarction, coronary angiography is no doubt the ECG because of its non-invasive, repeatable, simple and advantages as acute chest pain of choice for secondary inspection. emergency department chest pain patients should strive for 10 min to complete clinical examination, tracings of 18-lead ECG (normal 12-lead plus V7 ~ V9, V3R ~ V5R) and analyzed. electrocardiogram is the emergency room doctors suspected acute chest pain caused by acute myocardial ischemia time High, ST segment depression (g1mV) and the ST segment remained unchanged. on risk stratification of suspected ACS patients has important significance. Although the emergency room doctors often can not be sure whether a myocardial infarction in patients with Q wave myocardial infarction development, or non-Q wave myocardial infarction, but the initial evaluation and treatment can be based on whether the ST-segment elevation, ST segment depression and T wave changes to the decision.
history of support if the diagnosis of myocardial ischemia is approximately 29% of chest pain patients with ST> 1 mV; 22%> 2 mV.15% of patients with chest pain and 1 mV> ST> 0 with acute myocardial ischemia. its sensitivity = 77%, specificity = 97%; and has the value of the diagnosis . But it should be noted: ECG error rate of about 1 - 10%; in particular the rate of change of different operators = 14% (ST> 2 mV), the error is mainly due to the placement of ECG leads, followed by position patients. about 70% of acute inferior wall myocardial ischemia, 30% of the existence of acute myocardial ischemia mirror phenomenon. its specificity 93%, sensitivity 69%. If there is no inter-ventricular conduction problem, there more value. image intensity and poor prognosis, in V1, V2, V3 has great value.
patients with ST-segment elevation is not to necessarily mean myocardial ischemia (such as Brugada syndrome or acute cardiac inflammation). On the contrary, ST segment did not change does not mean there is no myocardial injury. In fact, 50% AMI patients in the emergency room, the ECG may be normal. And, no ECG changes in non-ST segment elevation myocardial infarction does not exist. In addition to ST changes, but also should be noted that the height of R wave, as represented in the contraction of the main electrical vector sum of the myocardial cells. For patients with persistent chest pain, repeated ECG and compared the change is more than one single ECG meaningful. particularly with old myocardial infarction or bundle branch block with previous patients.
studies have reported that, for acute myocardial ischemia, emergency bedside ultrasound is more sensitive than the ECG and specificity can be found in wall and observe the stages of movement disorders in the treatment of vascular re-opened. Although bedside ultrasound also has a non-invasive, repeatable characteristics, but in practice, even in Europe, America and other developed countries, with the emergency conditions of emergency echocardiography Branch and rare, and in cardiac ultrasound results influenced by the operator, it is difficult to become a unified standard. So bedside echocardiography diagnosis of acute myocardial ischemia is currently only stay in the research stage. However, if the patient's history, signs suggest there may be cardiac tamponade, or artificial heart valve implantation in patients with severe chest pain with cardiac murmurs, then it should create the conditions for cardiac ultrasound.
not every patient needs to do chest radiography. If history symptoms typical dynamic ECG changes, acute myocardial infarction can be established at this time need to quickly open the side of the weakening or disappearance of breath sounds, chest radiography (chest CT or chest X-ray) is the content must be completed. On the other hand, in most hospitals, patients need to leave the emergency room for radiography, be sure to check out a full assessment of the risk . If there is no performance of acute pneumothorax, in general, thoracic and abdominal imaging studies (X ray, ultrasound) suggested on the blood test results return will come next. This condition can have a more comprehensive understanding of imaging will be done targeted.
in arranging blood tests, they should be combined with patient history and clinical presentation focused. should pay special attention to the choice of the sensitivity and specificity. such as lactate dehydrogenase (LDH) increase in myocardial infarction, However, LDH increased in a considerable number of diseases caused by chest pain also exists, therefore, patients with chest pain can not be excluded either LDH diagnostic testing can not confirm the diagnosis, but the diagnosis of a indicators to carry out as little as possible in the emergency department, patients in the treatment process to reduce unnecessary medical expenses.
in the revised WHO diagnostic guidelines in acute myocardial infarction, myocardial importance of biochemical markers is greatly increased. myocardial biochemical The corresponding interpretation of markers of acute myocardial infarction in this chapter will detail cases. This paper focuses on the perspective of chest pain from the reception to introduce the biochemical markers of myocardial note.
Although CK-MB is a specific marker of myocardial thing, but there may be normal 5U / L of MB, can be 5% of the total CK. In striated muscle damage caused by the chest pain (intercostal muscle damage) when, CK significantly increased, CK-MB will follow increased but the proportion is still less than 5% -8%. Therefore, the detection of CK-MB should be simultaneous detection of CK, the proportion of their key observations. In some adenocarcinomas, will appear CK CK-MB greater than the phenomenon, which mainly two enzymes with different detection methods, interfere with tumor secreted proteins.
troponin T or I was recently used in clinical cardiac markers. Some studies have shown elevated troponin value than the clinical and ECG greater value; specificity and sensitivity are better than creatine kinase (CK). However, in patients with acute chest pain, if patients have a history of kidney or renal insufficiency performance (no urine, oliguria or urinary protein) , should also check renal function. as TNT or TNI by renal excretion, renal clearance rate decreased in the case, TNT will rise, but definitely does not mean myocardial injury. repeatedly review TNT has a certain significance. but this often requires After several hours in order to have results. Moreover, even if the patient had no history of renal, and if patients need treatment by emergency intervention, and emergency interventions need to use contrast agent, understanding renal function, renal injury to avoid contrast medium is important. Therefore, in the next diagnosis of suspected acute cardiovascular disease, acute chest pain, and should check kidney function.
auxiliary examination in the arrangements, they should consider whether the patient's condition changes due to additional tests and to try to ensure that patients in stable condition in the inspection process. If the inspection process or to check their own risks to patients, must be fully informed of their families, to obtain cooperation and understanding. emergency room doctors should be aware, the arrangements for inspection or examination of certainty exclude checks. If it is excluded from checking whether a safer alternative to other ways? For example, after attending patients with chest pain to ECG found SIQIIITIII, not excluding pulmonary embolism. what additional tests should be scheduled the next step? Because D-dimer negative predictive value 99%, although the pulmonary artery increased CT can clearly confirm the existence of pulmonary embolism, but the balance safety, efficiency and cost and other factors, should be first choice when the serum D-dimer testing.
check if the line is a certainty to be checked, such as aortic dissection rapid development, the condition may suddenly deteriorate, and even leads to death, but if not to enhance the CT scan, no clear dissection type, it can not surgery. meals are enhanced CT scan before, need to prepare, control blood pressure, heart rate, talk to the family, signed, ready to recover the drugs. But from another perspective, if the general condition of patients can not tolerate surgery, or family members will not surgery, it is necessary to reassess the risks should be enhanced CT. At this time, we should pay attention to the unity of the risks and benefits.
certainty, although some check check, but if it can be diagnosed with the disease, not in need of emergency treatment, generally do not need to do a similar check in the emergency department. For example, drop test of esophageal acid pH monitoring or esophageal 24 hours can be diagnosed reflux esophagitis induced chest pain. But if the patient history and signs of making admissions of doctors feel the need to do this inspection, emergency medical treatment program is the best first remission symptoms, then you dispose of Gastroenterology clinics to save the limited medical resources.
not clear cause of patients hospitalized for observation for some time, is generally recommended 6-8 hours. During this period, in addition to symptomatic treatment, should be reviewed at least 1 ECG and cardiac markers. because of acute myocardial infarction (2-4 hours) of myocardial markers can be expressed as normal, ECG also need to observe the dynamic changes of multiple comparison. In addition, the past of old lesions may ECG interference on the formation of .8 hours later, still not a clear diagnosis of the patient, should be based on thorough examination of existing clinical data, such as angiography or enhanced CT scan. For patients with unclear diagnosis should always observe the changes in vital signs , looking for signs of sudden disease progression. Even after remission, also asked the patient before going home chest pain patients, and so once again.
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