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胸痛之處理

Hu Mei Hua2010-07-07

P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com

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Epidemiology

• Many causes of chest pain in children are benign and self-limited.

• 0.2~0.6% of patients visits to pediatric outpatient clinics or PER.

• Peak incidence 12~14 y/o




Emergency responses to acute chest pain

• Acute myocarditis, tension pneumothorax, aortic dissection may result in sudden death.

• Any patient with recent onset chest pain who may be potentially unstable ( history, appearance, vital signs)




Stabilization in the ER setting

• Supplemental oxygen • IV access • Cardiac monitoring• ECG• Blood sample for cardiac enzymes• CXR




Priorities in chest pain evaluation

• Exclude potentially life-threatening conditions

• Identify specific cause of symptoms• Begin treatment acute myocarditis quickly• A diagnostic pattern will frequently emerge,

based on risk factors, description of pain associated symptoms.




Conclusion

• Treatment for chest pain should be directed at the underlying cause whenever possible.

• Most cases of musculoskelectal and nonorganic pain can be treated with reassurance, analgesia, rest and relaxation technique.




胸腔急症~氣胸

1.氣胸( Pneumothorax):是氣體在胸腔內引起肺萎陷。若引起縱隔偏移及壓迫到對側的肺稱之為高張性氣胸 (tension pneumothorax)，常因使用的人工呼吸器壓力過大而引起，或是肺氣腫的水泡、肺囊腫破裂而造成。




診斷 : i.理學檢查: 患側的呼吸音減弱，心音偏向對側。有時頸部有捻髮音(crepitus)。

ii.胸部X光: 患側呈現高透光性，而且沒有支氣管的顯影。旁邊或甚至對側的肺葉萎陷。縱隔及心臟向對側偏移。

治療 : 無症狀或僅有輕微的呼吸窘迫，可在病房作嚴密的看護，這種單純性氣胸有三分之二在五至七天內自癒而無須手術。若有嚴重的呼吸困難及高張性氣胸，則應立即採取行動。以靜脈注射用之套管針，由前胸第二肋間或腋窩中線第五或第六肋間插入，接上水下引流瓶，先解除呼吸困難。然後再改用胸管插入，等肺完全擴張沒漏氣後24-48小時再拔除。

手術(肺氣泡切除術、肋膜沾粘術)




Spontaneous Pneumothorax-Clinical investigation

• Signs and symptoms– Sudden onset chest pain– Shortness of breathing– Cough

• Diagnosis– CXR– Auscultation

• Differential diagnosis– Skin fold– Giant bulla




圖 A




Y= 4.2+ ( 4.7x ( A+B+C))

AJR 1995;165:1127-1130




ØEarly complicationProlonged air leakage >7~10 daysNon re-expansion of the lungBilateralityHemothoraxTensionComplete pneumothorax

ØPotential hazardOccupational hazardAbsence of medical facilities in isolated areasAssociated single bullaPsychological

ØSecond EpisodeIpsilateral recurrenceContralateral recurrence after a first pneumothorax

Surgical indication for primary spontaneous pneumothorax




Treatment Options for Pneumothorax

• Observation

• Needle aspiration

• Percutaneous catheter to drainage• Tube thoracostomy• Tube thoracostomy with instillation of pleural

irritant

• Video-assisted thoracoscopic surgery• Thoracotomy




Recurrence of Primary Spontaneous Pneumothorax

• Therapy Recurrence (%)– Expectant 30– Aspiration 20-50– Chest tube drainage 20-30– Pleurodesis (tetracycline) 25– Pleurodesis (talc) 7– Surgery 2




Needle Needle ThoracostomyThoracostomy, , DiscussionDiscussion

§§ ProcedureProcedure1.1. Use a large bore needle w/ catheter ( 14~18 gauge)Use a large bore needle w/ catheter ( 14~18 gauge)2.2. Identify 2Identify 2ndnd intercostalintercostal space at space at midclavicularmidclavicular line (1line (1--

2 cm lateral to the 2 cm lateral to the sternalsternal angle). angle). 3.3. Prepare area with Prepare area with BetadineBetadine4.4. Insert needle directly superior to the 3rd rib. This Insert needle directly superior to the 3rd rib. This

prevents injury to neurovascular bundle located on prevents injury to neurovascular bundle located on the inferior aspect of each rib. the inferior aspect of each rib.

5.5. Insert needle perpendicular to the chest wall, Insert needle perpendicular to the chest wall, approximately 3approximately 3--6 cm in depth6 cm in depth

6.6. Stop advancement of needle upon hearing opening Stop advancement of needle upon hearing opening hiss/pressure release of pleural space.hiss/pressure release of pleural space.

7.7. Remove needle; leave catheter in placeRemove needle; leave catheter in place




What next?What next?§§ Tube Tube ThoracostomyThoracostomy

1.1. Identify and prepare the area w/ Identify and prepare the area w/ BetadineBetadine at ICS 4 or 5 along the midat ICS 4 or 5 along the mid--axillaryaxillary or anterior or anterior axillaryaxillary lineline

2.2. Anesthetize the area (subcutaneous tissue, Anesthetize the area (subcutaneous tissue, intercostalintercostal muscles) with muscles) with LidocaineLidocaine. Some physicians use . Some physicians use opioidopioid analgesia or a combination of analgesia or a combination of an an opioidopioid + + BenzoBenzo..

3.3. Make a 2 cm incisionMake a 2 cm incision4.4. Insert a large blunt clamp over superior aspect of rib (preventiInsert a large blunt clamp over superior aspect of rib (preventi ng ng

damage to the neurovascular bundle that lies on the inferior bordamage to the neurovascular bundle that lies on the inferior bor der of der of the rib). Apply gentle pressure until the parietal pleura is piethe rib). Apply gentle pressure until the parietal pleura is pie rced.rced.

5.5. Open clamp to establish a tract for the chest tube.Open clamp to establish a tract for the chest tube.6. Bluntly dissect w/ finger.7.7. Clamp proximal end of tube tangentially w/ Clamp. Insert tube ovClamp proximal end of tube tangentially w/ Clamp. Insert tube ov er er

superior aspect of rib into pleural space.superior aspect of rib into pleural space.8.8. Insert the chest tube past the last hole. Note the last hole disInsert the chest tube past the last hole. Note the last hole dis rupts the rupts the

continuity of the continuity of the radiopaqueradiopaque lineline——this facilitates radiographic this facilitates radiographic placement confirmation. Suture chest tube w/ Silk sutures.placement confirmation. Suture chest tube w/ Silk sutures.




Myocarditis




INTRODUCTION• In 1837, the term myocarditis was first

introduced as inflammation or degeneration of the heart by postmortem

• 心肌炎簡單的說就是心臟肌肉或傳導系統發炎，它可以是因為一些藥物、毒物或是自體免疫疾病所引發。

• Studies suggest that myocarditis is a major cause of sudden(20%), unexpected death in adults less than 40 years of age




CAUSATION最常見的原因還是感染所致，包含•細菌感染 (腦膜炎球菌、鏈球菌、黴漿菌、沙門氏菌、結核菌等)，•真菌感染、•寄生蟲感染及•病毒感染(如腸病毒中的克沙其病毒(Coxsackie)及伊科勒病毒(Echovirus)、腺病毒(adenovirus)、流行性感冒病毒、腮腺炎病毒等)，•其中又以病毒感染最多。




American Journal of Emergency Medicine (2009) 27, 942–947




Pathophysiology

• Triphasic disease process

Phase I: Viral Infection and Replication

Phase 2: Autoimmunity and injury

Phase 3: Dilated Cardiomyopathy




Clinical Findings• Symptoms and Signs

- 心肌炎臨床表現千變萬化，可從輕微的胸口不舒服、肚子痛、呼吸急促、臉色蒼白冒冷汗、心律不整 (包括異常加快或減慢)、頭暈、疲倦、到突發性昏倒、多重器官衰竭甚至猝死。

• Patients(59%) frequently present days to weeks after an acute febrile illness, particularly a flu-like syndrome

• Chest discomfort(35%) is a common symptom and is typically pericardial in nature

• Cardiac symptoms may result from systolic or diastolic left ventricular dysfunction or from tachyarrhythmias or bradyarrhythmias (dyspnea, fatigue, decreased exercise tolerance, palpitations )




Clinical Findings• Physical Examination

-Tachycardia, hypotension, fever and tachycardiamay be disproportionate to the degree of fever

• -Bradycardia is seen rarely, and a narrow pulse pressure is occasionally detected

• -Murmurs of mitral or tricuspid regurgitation are common , S3 and S4 gallops may also be heard.

• -Distended neck veins, pulmonary rales, wheezes,gallops, and peripheral edema may be detected




Diagnostic Studies• CXR:心臟擴大、肺水腫• EKG-The most common abnormality is sinus tachycardia.

- may show ventricular arrhythmias or heart block, or it may mimic the findings in acute myocardial infarction or pericarditis.

•心電圖上可有心律過速或過慢甚或傳導中斷、心肌缺氧、心律不整或傳導異常等變化。

•心肌酵素可能升高。

•心臟超音波檢查顯示心臟擴大、心室功能不良，有時併發心包膜積水和瓣膜關閉不全




Diagnostic Studies• Myocardial imaging

-Gallium-67 imaging-> active inflammation of the myocardium

and pericardium -Indium-111 monoclonal antimyosin

antibody imaging-> detecting myocyte injury in patients

•-Contrast media-enhanced MRI

->detecting myocardial inflammation




Diagnostic Studies• Cardiac catheterization

-elevated left ventricular end-diastolic pressure, a depressed cardiac output, and increased ventricular volumes

• -Coronary angiogram typically demonstrates normal coronary arteries.




Diagnostic Studies• Endomyocardial biopsy

- gold standard for the diagnosis of myocarditis

-Dallas criteria(an inflammatory infiltrate of themyocardium +injury to the adjacentmyocytes)

-borderline myocarditis is made when the infiltrate is not accompanied by myocyte injury




Normal Myocardium




Borderline Myocarditis




Active Myocarditis




Triphasic disease process.




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