主动脉夹层急诊救治与临床路径探讨

Emergency treatment of aortic dissection and Clinical pathway discussion

目的探讨主动脉夹层（aortic dissection，AD）的临床特点与急诊救治方法及路径。方法采用回顾性分析方法，收集2000年1月至2009年12月中南大学湘雅医院急诊科收治的784例主动脉夹层患者的临床资料等分别进行对比及统计分析，分析其存活率、病死率及有效率。结果首发症状以痛疼为主占77．7％（609／784），原有高血压病史占86．5％（678／784）。确诊至术前784例均行急诊内科救治，存活率81．5％（639／784），病死率18．5％（145／784），无效157例（20．O％），总有效率（83．1％），其中传统治疗有效率（76．4％），三联四程序化治疗有效率（89．8％）（P〈0．05），差异具有统计学意义。在院急诊死亡139例（17．7％）。其中24h内死亡26例（18．4％），48h内死亡47例（33．8％），72h死亡66例（47．2％）。确诊后拒绝治疗92例，其中72h内死亡81例（88．04％），两组病死率相比较，具有统计学意义（P〈0．05）。结论详细病史、体查及CT和MRI主动脉造影检查是诊断主动脉夹层的主要手段，镇痛、镇静、降压是急诊救治的重要方法。急诊早期确诊和有效救治为争取早期手术及进一步治疗赢得了时间，是提高AD生存率的关键。

Objective To investigate the clinical features of aortic dissection （AD） and emergency treatments. Methods Data from 784 patients with aortic dissection were collected in the Department of Emergency from January 2000 through December 2009. A retrospective analysis was carried out to determine the survival rate, mortality rate and treatment efficiency. Results Pain was the most common onset symptom （77.7%, 609/784）. The majority of patients （86.5%） had essential hypertension （678/784）. All the patients with preoperative diagnosis of aortic dissection underwent emergency medical intervention by internists resulting in 81.5% survival rate （639/784） and 18.5% mortality rate （145/784）. There were 157 patients without improvement （20.0%） and the total efficiency rate was （ 83.1% ）. The efficiency rate of conventional treatment was 76.4%, while the efficiency rate of triple four-procedure treatment was 89.8% （P 〈0.05）. Of them, 139 patients （ 17.7% ） died in the hospital. Among them,, 26 patients died within 24 hours （ 18.4% ） and 47 cases died within 48 hours （ 33.8% ） and 66 patients died within 72 hours （47.2%）. There were 92 patients who refused treatments after diagnosis, and among them, 81 patients died within 72 hours （88.04%）. The difference in mortality rate between two groups was significant （P 〈0. 05）. Conclusions The diagnosis of aortic dissection depends on detailed history, physical examination and CT or MRI imaging. Analgesia, sedation and control of blood pressure are essential for emergency treatments. Early diagnosis and effective emergency treatments are the critical strategy for the early surgical intervention and time window for further treatment to improve the survival rate of AD.