急诊经皮冠状动脉介入治疗ST段抬高心肌梗死的护理

目的研究ST段抬高心肌梗死急诊经皮冠状动脉介入治疗(急诊PCI)的护理要点。方法43例ST段抬高急性心肌梗死行急诊PCI术,观察胸痛、血压、心率、心律失常、再灌注心律失常、出血并发症,密切配合医生做好术前准备,术中监护和术后护理。结果25例术中出现再灌注心律失常,3例出现穿刺部位血肿,所有43例顺利出院。结论快速的术前准备,术中密切监测症状、心电图和血流动力学改变,术后及时发现并发症,做好心理护理与健康指导,有助于手术的安全和成功率。     

Managing recurrent nonischemic chest pain in the emergency department

Many patients who seek emergency evaluation for recurrent chest pain have had negative cardiac evaluations, sometimes including normal coronary angiograms. Despite reassurance, many of these patients return to emergency departments with complaints of chest pain. Studies have shown that one third to one half of these patients suffer from panic disorder characterized by attacks of intense fear accompanied by chest pain or discomfort, nausea, and shortness of breath. If panic disorder is identified, it can be successfully treated. This article explores the causes of recurrent nonischemic chest pain and offers treatment recommendations.     

Practical approach to the diagnosis of unexplained chest pain

Chest pain is a frequent medical problem causing concern for both patients and physicians. A multidisciplinary meeting recently developed algorithms for evaluating these patients in the two most common scenarios for the presentation of chest pain: (1) new onset of chest pain in the primary care setting, and (2) recurrent chest pain in the the referral setting. In both situations, the primary care physician, rather than specialists, should direct the evaluation and treatment of patients with chest pain and normal coronary angiograms.     

Beyond the Twelve-Lead Electrocardiogram: Diagnostic Tests in the Evaluation for Suspected Acute Myocardial Infarction in the Emergency Department,Part II

On a daily basis the emergency physician is faced with the difficult task of determining whether or not a patient with acute chest pain is sustaining an acute myocardial infarction. In most cases this is not a straightforward decision. Although observation units are being used more often for chest pain evaluations, many emergency physicians currently admit such patients to an intensive care setting. Because fewer than one-third of emergency department chest pain patients actually suffer an acute myocardial infarction, expensive resources are, in retrospect, used unnecessarily. Conversely, patients who are infarcting, and are inadvertently discharged home from the emergency department, have a worse prognosis than those admitted. This two-part series reviews the newer modalities available that may help the emergency physician arrive at a more accurate diagnosis. This article, Part II, will review the use of biochemical assays of cardiac proteins and discuss the Chest Pain Observation Unit.     

Mitral valve prolapse

Mitral valve prolapse is a common mitral valve disorder manifested clinically as a midsystolic click and/or a late systolic murmur (the click-murmur syndrome) and pathologically as billowing or prolapsing mitral leaflets (the floppy valve syndrome). Not only is it one of the two most common congenital heart diseases and the most common valve disorder diagnosed in the United States, but it is also prevalent throughout the world. Mitral valve prolapse may be associated with a variety of other conditions or diseases. Diagnosis of mitral valve prolapse should be made on clinical grounds and, if necessary, supported by echocardiography. The majority of patients with mitral valve prolapse suffer no serious sequelae. However, major complications such as disabling angina-like chest pains, progressive mitral regurgitation, infective endocarditis, thromboembolism, serious arrhythmias, and sudden death may occur. Unless these serious complications occur, most of the patients with mitral valve prolapse need no treatment other than reassurance, including those with atypical chest pain or palpitation unconfirmed by objective data. Therapy with a beta-blocker for disabling chest pain and/or arrhythmias and antiplatelet therapy for cerebral embolic events may be indicated. In occasional patients with significant mitral regurgitation surgery may be necessary.     

Unexplained chest pain and breathlessness

Complaints of chest pain and breathlessness are common in both primary care and medical outpatient settings. A subgroup of these patients who find their way into tertiary care settings and subsequently are found to have no relevant organic pathology are at risk of continuing morbidity. One possible reason for this is that diagnostic strategies often focus on establishing an organic cause of pain and ignore psychosocial factors. In this article I have attempted to describe not only the prevalence but also the clinical characteristics of patients with medically unexplained cardiorespiratory symptoms. A method of establishing a positive diagnosis of noncardiac chest pain has also been outlined. This is based on an interactive and overlapping model that takes into account not only a number of psychological and social factors but also current physical and cardiac risk factors. It is important for nonpsychiatric physicians to diagnose noncardiac pain at an earlier stage in the evolution of the disorder. This would have major beneficial effects for patients, including (1) fewer unnecessary investigations; (2) less distress and functional disability; (3) reduced cost to the hospital; and (4) fewer iatrogenic complications.     

Beyond the twelve-lead electrocardiogram: Diagnostic tests in the evaluation for suspected acute myocardial infarction in the emergency department, part I

On a daily basis the emergency physician is faced with the difficult task of determining whether or not a patient with acute chest pain is sustaining an acute myocardial infarction. In most cases, this is not a straightforward decision. Although observation units are being used more often for chest pain evaluations, many emergency physicians currently admit such patients to an intensive care setting. Because fewer than one-third of emergency department chest pain patients actually suffer an acute myocardial infarction, expensive resources are, in retrospect, used unnecessarily. Conversely, patients who are infarcting, and are inadvertently discharged home from the emergency department, have a worse prognosis than those admitted. This two-part series reviews the newer modalities available that may help the emergency physician arrive at a more accurate diagnosis. The current article, Part I, examines the use of myocardial imaging, computer assisted diagnostic protocols, and newer uses of the electrocardiogram. Part II reviews the use of biochemical assays of cardiac proteins and the Chest Pain Observation Unit.     

无胸痛急性冠脉综合征32例临床分析

目的 分析32例无胸痛急性冠脉综合征(ACS)病人，强化对无胸痛ACS的认识，提高早期诊断率，为早期强化治疗奠定基础。方法 将275例病人按是否有典型胸痛分为无痛组(32例)、有痛组(243例)；从年龄、心血管病危险因素、血脂、入院时主要症状及主要并发症、ACS的临床诊断分类、确诊时间、治疗情况、死亡率等方面，比较分析两组病人的临床资料。结果 无痛组女性病人明显增加；ACS发生率随着年龄增长而增高；伴有糖尿病、高血压及心衰者更易发生无胸痛ACS；无胸痛ACS缺乏典型心前区疼痛，常伴有心律失常、心衰、心源性休克、脑血管病等并发症；无痛组病人早期确诊率明显低于有痛组。结论 无胸痛ACS无典型症状，容易误诊及延误治疗，进而对预后产生不良影响。     

青少年巨大胸壁原始神经外胚层肿瘤患者的护理

报告了3例青少年巨大胸壁原始神经外胚层肿瘤患者的护理经验。本组均进行了胸壁巨大肿瘤切除及胸壁重建或改形手术。护理要点:术前评估患者的情况,提高患者的治疗依从性,加强胸壁巨大肿瘤部位的皮肤护理;术后加强对胸腔出血、心律失常、反常呼吸、疼痛等的观察及护理,并做好系统的功能训练。通过及时、有效的护理干预,有效促进了患者康复。     

Identifying chest pain emergencies in the primary care setting

The majority of patients presenting to a primary care physician with acute chest pain will have non-life-threatening etiologies. Nevertheless, catastrophic cause of chest pain such as ACS, AD, PE, esophageal perforation, and pericarditis must be considered in the differential diagnosis. Often, these deadly conditions have atypical clinical presentations that must be recognized. Furthermore, the physical examination can be deceptively benign in patients harboring a catastrophic etiology of chest pain. By identifying these atypical presentations, recognizing the utility of the physical examination, and understanding of the limitations of traditional diagnostic imaging, primary care physicians can effectively diagnose patients who have life-threatening cause of acute chest pain.     

Chest pain

The purpose of this article has been to review the multiple causes of chest pain. Because acute chest pain can be the only presenting symptom of a potentially life-threatening illness, it is important that the physician identify these patients rapidly and arrange appropriate hospital care. Likewise, it is also important that the physician recognize the less severe causes of chest pain so that the patient can be appropriately reassured in the office or sent for evaluation of the cause of this pain. Although nearly every patient with acute chest pain views this pain as an emergency, the majority of patients with this type of pain presenting to a physician's office can be evaluated and reassured using only basic office skills.     

Psychiatric aspects of chest pain in the emergency department

We estimate that a third of the patients who present to the ED with chest pain have a current psychiatric disorder and that psychiatric disorders among chest pain patients are associated with a high rate of ED utilization for chest pain evaluations. Physicians in the ED recognize only a small fraction of the psychiatric disorders, so appropriate treatment or referral may be infrequent. The proportion of chest pain patients with CAD who also have a psychiatric disorder may be in the range of 20% to 30%, justifying careful assessment of psychiatric disorders in CAD patients. We conclude that the psychiatric aspects of chest pain are sufficiently prevalent, clinically significant, and a contributor to unnecessarily high utilization of medical services. We call for clinical research to address these questions by outlining three areas of study that will advance our knowledge and care of the patient with chest pain.     

The utility of the presence or absence of chest pain in patients with suspected acute myocardial infarction

In 422 patients admitted from the emergency department (ED) for suspected acute myocardial infarction, the hypothesis that chest pain that persists on arrival in the ED or recurs during the initial ED evaluation is a useful predictor of acute myocardial infarction (AMI) and complications of coronary ischemia was tested. Compared with patients whose chest pain spontaneously ceased before arrival in the ED, patients whose chest pain persisted or recurred during the initial ED evaluation had a 2.3 times greater risk of interventions (P less than .001), a 1.7 times greater risk of complications (P = .045), a 3.8 times greater risk of life-threatening complications (P = .04), and a 2.4 times greater risk of AMI (P = .005). A third group of patients with suspected AMI never experienced chest pain. This group of patients who never experienced chest pain had a three times higher risk of death (P = .02) compared with patients whose chest pain persisted or recurred in the ED, and a 2.1 times greater risk of intervention (P = .01), a 5.2 times greater risk of life-threatening complication (P = .015), and a 7.9 times greater risk of death (P = .025) compared with patients whose chest pain resolved before arrival in the ED. It was concluded that patients with chest pain that resolves spontaneously before arrival to the ED have a better in-hospital prognosis than any other group.     

Hypnotherapy for Functional Gastrointestinal Disorders: A Review

Patients with functional gastrointestinal disorders, such as irritable bowel syndrome, functional dyspepsia, and noncardiac chest pain, can suffer from a range of severe symptoms that often substantially erode quality of life. Unfortunately, these conditions are notoriously difficult to treat, with many patients failing to improve despite being prescribed a wide variety of conventional medications. As a consequence, the potential benefits of hypnotherapy have been explored with evidence that this approach not only relieves symptoms but also appears to restore many of the putative psychological and physiological abnormalities associated with these conditions toward normal. These observations suggest that this form of treatment has considerable potential in aiding the management of functional gastrointestinal disorders and should be integrated into the ongoing medical care that these patients are receiving.     

Complications from the use of thrombolytic agents in patients with cocaine associated chest pain

Previous investigators have noted that patients with cocaine associated chest pain frequently have abnormal electrocardiograms, including ST segment elevation, in the absence of ongoing myocardial ischemia. The effects of these nonischemic ST segment elevations have not been evaluated. We report two patients with cocaine associated chest pain and ST segment elevations who received thrombolytic agents in the absence of myocardial ischemia. Neither patient sustained a myocardial infarction, nor had clinical evidence of reperfusion. The ST segment elevations persisted after resolution of chest pain in both patients, and both of the patients experienced complications of thrombolytic therapy. One patient sustained a hemorrhagic stroke and one had minor oral-pharyngeal bleeding. Given the lack of documented efficacy, concerns about safety, and poor specificity of the electrocardiogram for myocardial ischemia in patients with cocaine associated chest pain, thrombolytic therapy should be used with caution in these patients.     

Chest pain. How serious is it?

The very thought of chest pain often brings terror to patients and health care providers. Chest pain typically invokes a "worst case" scenario of massive myocardial infarction (MI) resulting from cardiovascular disease (CD) and requiring immediate medical attention. However, chest pain is a common complaint suffered by most people at some time in their lives. People complaining of chest pain may be young, middle-aged, or elderly, and they may or may not be under a health care provider's care. Chest pain may be a symptom of a variety of disorders other than CD. Therefore it is helpful to differentiate quickly between the types of chest pain to determine whether immediate assistance is necessary.     

胸腔镜交感神经切断术治疗手汗症患者的护理

笔者报道108例胸腔镜交感神经切断术治疗手汗症患者的护理。认为术前应针对患者心理特点做好心理护理．术后加强病情的观察，及早发现处理并发症：气胸及皮下气肿，代偿性多汗及前胸部疼痛，是患者得到良好恢复的关键。     

36例突发致命性胸痛病人院前急救和转运效果分析

目的探讨突发致命性胸痛病人院前急救及转运效果。方法回顾性分析深圳市急救中心院前急救科2006年1月至2009年1月接收的突发致命性胸痛病人36例的临床资料,并比较同期自行人院的21例同类病人病死率。结果院前急救组病人经专业现场急救处理后,其处理前后呼吸、心率、血压、胸痛程度差异均有统计学意义,院前急救组病死率低于自行入院组。结论突发致命性胸痛病人临床表现复杂,专业的院前急救能及时抢救监护,合理用药,保证安全、快速、有效转送,病情控制较好,有效降低病死率。     

网状钛合金钢板修复胸壁缺损围手术期护理

目的总结应用网状钛合金钢板修复胸壁缺损围手术期护理要点,为临床提供借鉴。方法对应用网状钛合金钢板修复胸壁缺损的14例患者实施系统化术前健康宣教、心理疏导、呼吸道和皮肤准备;术中协助患者摆放手术体位,协助麻醉及复苏;术后密切观察生命体征的同时规范引流管管理,严格执行无菌护理技术,控制切口感染,预防皮下积液、积气、肺不张、肺部感染等并发症的发生,促进皮瓣存活,切口愈合,患者疼痛护理等;做好出院指导和定期随访,及时指导院外自我护理。结果所有患者均顺利完成手术,在科学护理措施保障下,未出现气胸、反常呼吸、切口及肺部感染等严重并发症,2例出现皮下脂肪液化、炎性反应,1例痰液不易咳出,血氧饱和度低于94%,经对症护理后,均明显改善,最终切口均Ⅰ期愈合,顺利出院。随访2年,均未发生排异反应、固定不牢等情况,患者对修复效果满意。结论网状钛合金钢板具有良好的生物相容性,用于修复胸壁缺损效果明显,但术后并发症较多,实施科学有效的围手术期护理可有效降低或预防术后并发症的发生,减轻患者疼痛,促进康复,对提高患者生存质量具有重要意义。