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1、认识主动脉夹层,急诊胸痛诊断,“The Big Five” 胸痛的五大致命病因,Acute coronary syndrome Aortic dissection Pulmonary Embolism Tension Pneumothorax Esophageal Rupture,主动脉起自主动脉环，沿脊柱偏后，上升部称升主动脉，至右无名动脉分支横行至锁骨下动脉，称主动脉弓，此后沿脊柱左侧下行称降主动脉，穿过膈肌进入腹部称腹主动脉，直达左右髂动脉分支。主动脉弓部重要分支的头、颈动脉供应两上肢及颅脑部的血流，以无名动脉和左锁骨下动脉为标志又分为右弓和左弓。降主动脉有多个分支，供应脊髓的血液。腹主
2、动脉是腹腔许多脏器血供的分支主干，如左右肾动脉、肝、脾及肠系膜上动脉等,定 义,主动脉夹层动脉瘤，也有称为主动脉内膜剥离症或壁间动脉瘤，是由于不同原因造成主动脉内膜破裂，在内膜和中外层间有血液通过时的压力导致大血管纵向剥离，形成双腔主动脉（double-barrel），或主动脉瘤样扩张。少数病人可能没有内膜破裂而是中层出血形成夹层。,Aortic Dissection,流行病学特点,多见于男性病人； 多发于5070岁； 40岁以前发病患者多见于以下疾病: Marfans syndrome, congenital heart disease, familial incidence, pregna
3、ncy, Turners syndrome and trauma等； 2/3以上病人有高血压病史。,分 类,DeBakey : Type I: 病变包括升主动脉、主动脉弓和降主动脉 Type II:限制于升主动脉 Type III:限制于降主动脉 Type IIIA: 横膈膜以上； Type IIIB:横膈膜以下。,Aortic Dissection,分 类,Stanford: Type A:包含升主动脉 Type B:不包含升主动脉 Acute: less than 2 weeks Chronic: more than 2 weeks,Aortic Dissection,New Classi
4、fication,Class 1: classical aortic dissection with an intimal flap between true and false lumen Class 2: medial disruption with formation of intramural haematoma/haemorrhage Class 3: discrete/subtle dissection without haematoma, eccentric bulge at tear site,New Classification,Class 4: plaque rupture
5、 leading to aortic ulceration, penetrating aortic atherosclerotic ulcer with surrounding haematoma, usually subadventitial Class 5: iatrogenic and traumatic dissection Classes 1 through 5 represent a subdivision to the Stanford or DeBakey classifications,临床表现,Diagnostic Findings Pain is by far the m
6、ost common presenting complaint(90%) pain is decribed as “tearing, knifelike” usually the pain occurs quite abruptly and is most severe at onset neurologic deficit(20%) syncope(5%),临床表现,Physical Examination pulse deficits and discrepancies in BP between limbs are key diagnostic clues pulse deficits
7、(50%) aortic regurgitation(50%) neurologic findings(20%): 感觉障碍, 偏瘫, 半身麻木, 向患侧凝视,临床表现,Klompas M. JAMA. 2002;287:2262-72.,辅助检查,Routine Lab. Tests: non-specific EKG: 长期高血压损害表现，常合并有心肌梗死表现 心肌酶学、肌钙蛋白等心肌损伤标志物检查。,影像学检查,CXR CT Ultrasound MRI Angiogram,影像学检查,Chest X ray mediastinal widening(75%) “calcium sign
8、” -uncommon but highly specific, 5mm double-density appearance of the aorta a localized bulge along a normally smooth aortic contour,影像学检查,a disparity in the caliber between the descending and ascending aorta obliteration of the aortic knob displacement of the trachea or nasogastric tube to the righ
9、t by the dissection pleural effusions(left),影像学检查,Klompas M. JAMA. 2002;287:2262-72.,影像学检查,超声心动图 transthoracic approach: M-mode & 2-D=low sensitivity and specificity transesophageal = more accuracy and very sensitive, can be done in ER (safer).,影像学检查,Computed Tomography dilatation of the aorta ident
10、ification of an intimal flap differential rates of flow in true and false lumina the clear demonstration of both the true and false lumina,影像学检查,limitations of CT scan: it dose not provide information about the presence of aortic regurgitation no information about the relationship of the dissection
11、to the major arterial branches of the aorta time-consuming and requires the patient to be outside ER,影像学检查,advantages over aortography : （主动脉血管造影） greater contrast resolution and detects small or delayed differences in the opacification（乳浊状） of true and false channels may be able to detect a thrombo
12、sed false lumen despite nonopacification does not require arterial catheterization,影像学检查,Aortography filling of a false channel or channels with or without an intervening intimal flap distortion of the true lumen by either a patent or thrombosed false lumen thickening of the aortic wall by more than
13、 5-6 mm caused by a thrombosed false lumen displaced intimal calcification,影像学检查,disadvantages of aortography: most invasive, most expensive risks of intravenous contrast material inadequate detection of pleural leak,影像学检查,advantages of aortography: accurate for determining the site of the initmal t
14、ear and extent of the dissection easily demonstrated aortic regurgitation the only procedure that demonstrates the extent and location of dissection into aortic side branches,影像学检查,Magnetic Resonance Imaging shows the site of intimal tear, type and extent of dissection, presence of aortic insufficie
15、ncy, and differential flow velocities in the true and false channels and in the aortic side branches advantages: no contrast material, no ionizing radiation, noninvasive,鉴别诊断,Acute myocardial infarction pain is more typically pressurelike but may radiate to the arms or neck pain does not typically m
16、igrate over time CK-MB levels are elevated elevation prominent in ECG,鉴别诊断,Pulmonary embolus pain is generally respirophasic hypoxemia secondary to ventilation/perfusion mismatch Pericarditis（心包炎） pain typically changes with position auscultation may reveal a pericardial friction rub EKG is common d
17、iagnostic(ST-segment）,Case Study,65 yo African American male 3 days of intermittent chest pain Episodes last several hours “Squeezing” pain Radiated to back and left arm Positional,Case Study,+ fevers, chills, weight loss + productive cough + hoarse voice - hemoptysis（咳血）, orthopnea （端坐呼吸） - nausea, vomiting, diarrhea,
