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【流行病学】在小儿神经门诊初诊病人中，22%的患儿以头痛为主诉，其中约1/2为小儿偏头痛。 | [
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关于偏头痛的流行病学调查，由于调查的年龄范围、诊断标准及调查方式不同，调查结果往往存在差异。 | [
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偏头痛可见于任何年龄的儿童，特别是青春期前后的女孩。 | [
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小儿偏头痛发病年龄多为6～10岁，平均7.5岁；但6岁以前发病也不少见，文献报告有5个月起病者。 | [
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一般来讲，在6～12岁儿童中，偏头痛的患病率为2%～5%；此后随年龄增加而逐渐增多，14岁左右患病率约为10%；成人患病率为10%～30%。 | [
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在所有儿童中，偏头痛的发病率为3%～7%。 | [
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【病因与发病机制】偏头痛真正的病因与发病机制尚未明确，提出了许多学说，但偏头痛发作时颅内、外血管舒缩障碍已被证实。 | [
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目前认为偏头痛是在遗传素质基础上形成的局部颅内外血管对神经-体液调节机制的阵发性异常反应。 | [
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（一）遗传因素现认为偏头痛与遗传有关，其阳性家族史为50%～80%。 | [
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双亲都患偏头痛的，其子女患偏头痛的约占70%；单亲患偏头痛的，子女的患病机会约50%；单卵双胎共同发生率为50%以上。 | [
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但基底动脉型偏头痛和家族性偏瘫型偏头痛例外，呈常染色体显性遗传。 | [
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家族性偏瘫型偏头痛的致病基因可能定位于19p13.1-1.2。 | [
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Ducros等于1997年将家族性偏瘫型偏头痛的致病基因定位于1q21-23，提示该病具有遗传异质性。 | [
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（二）血管源学说认为偏头痛的先兆症状与颅内血管的收缩有关，随后由于颅内、外血管的扩张，血管周围组织产生血管活性多肽，导致无菌性炎症而诱发头痛。 | [
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20世纪90年代Olsen进一步发展了血管源学说，提出有先兆和没有先兆的偏头痛是血管痉挛程度不同的同一疾病。 | [
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（三）神经源学说认为偏头痛时神经功能变化是首要的，血流量的变化是继发的。 | [
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1.神经递质假说5-HT在偏头痛的发病中具有重要作用，它可使血管壁产生无菌性炎症或通过受体使脑血管收缩导致局部脑血流下降引起头痛。 | [
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β-内啡肽、甲硫脑啡肽、P物质、儿茶酚胺、组织胺、血管活性肽和前列环素等神经递质，亦与偏头痛的发生有关。 | [
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2.扩散性抑制假说是指各种因素刺激大脑皮层后出现的由刺激部位向周围组织呈波浪式扩展的皮层电活动抑制。 | [
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这种抑制以波的形式非常缓慢地通过皮质区，皮层扩散性抑制伴有明显的大脑血流减少（持续2～6个小时）。 | [
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此假说可以充分解释偏头痛发作的神经功能障碍，但不能成功地解释头痛。 | [
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（四）三叉神经血管反射学说是指三叉神经传入纤维末梢释放P物质及其他神经递质，传出神经作用于颅内外血管，引起头痛和血管扩张。 | [
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偏头痛作为一种不稳定的三叉神经-血管反射，伴有疼痛控制通路中的节段性缺陷，使得从三叉神经脊核来的过量冲动发放以及对三叉丘脑束或皮质延髓束来的过量传入冲动发生应答，最终引起脑干与颅内血管发生相互作用。 | [
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（五）其他学说有关偏头痛发病机制尚有低镁学说、高钾诱导血管痉挛学说、自主神经功能紊乱学说及大脑细胞电流紊乱学说等。 | [
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【临床表现】小儿偏头痛的临床表现与成人基本相似，但与成人比较又有许多不同之处，小儿偏头痛发作时的症状不如成人鲜明，但胃肠道症状非常突出。 | [
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（一）有先兆的偏头痛旧称经典型偏头痛，多数患儿先兆先于头痛发作，少数与头痛同时发作，偶尔在头痛后发作，个别病例只有先兆而没有偏头痛发作。 | [
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先兆以视觉症状最常见，如眼前出现不同形状的闪烁暗点、“冒金星”、城垛样闪光、视物模糊不清、偏盲以及黑蒙等，亦可出现视幻觉和视物变形或变色，持续数分钟至数小时。 | [
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头痛发作往往开始于一侧额颞部、眶上或眶后，偶尔出现在顶部或枕部，呈搏动性（跳痛）或胀痛，可扩展到半侧头部或全头部，亦有左右交替发作者。 | [
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头痛时有伴随症状，如恶心、呕吐、腹痛及面色苍白等。 | [
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（二）没有先兆的偏头痛旧称普通型偏头痛，最常见，是青春期前儿童最常见的头痛发作形式。 | [
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常为双侧额或颞部疼痛，大约一半患儿头痛性质为搏动性，头痛程度比经典型偏头痛轻，持续时间0.5～2小时。 | [
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（三）特殊类型的偏头痛1.偏瘫型偏头痛头痛开始或头痛不久出现头痛对侧肢体瘫痪，可伴有瘫痪肢体麻木，持续时间长时可致瘫痪肢体抽搐。 | [
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偏瘫一般较轻，持续数小时至1～2日，重者可达数日，一般均能完全恢复。 | [
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2.基底动脉型偏头痛多见于儿童（女孩多于男孩）或年轻女性。 | [
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先兆症状多持续数分钟或数十分钟，而后出现枕部搏动性疼痛，常伴恶心和呕吐，发作持续数小时。 | [
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"entity": "恶心",
"start_offset": 30,
"end_offset": 32,
"label": "sym"
},
{
"id": 2,
"entity": "呕吐",
"start_offset": 33,
"end_offset": 35,
"label": "sym"
},
{
"id": 3,
"entity": "发作持续数小时",
"start_offset": 36,
"end_offset": 43,
"label": "sym"
}
] |
有时头痛也可先出现或与诸多神经症状同时发生。 | [
{
"id": 0,
"entity": "头痛",
"start_offset": 2,
"end_offset": 4,
"label": "sym"
}
] |
3.眼肌瘫痪型偏头痛多在12岁以前发病，有时见于婴幼儿。 | [
{
"id": 0,
"entity": "眼肌瘫痪型偏头痛",
"start_offset": 2,
"end_offset": 10,
"label": "dis"
}
] |
眼眶部疼痛伴有动眼神经完全性或不全性麻痹，部分病例同时累及滑车和展神经，出现眼球运动障碍。 | [
{
"id": 0,
"entity": "眼眶部疼痛",
"start_offset": 0,
"end_offset": 5,
"label": "sym"
},
{
"id": 1,
"entity": "动眼神经完全性",
"start_offset": 7,
"end_offset": 14,
"label": "sym"
},
{
"id": 2,
"entity": "不全性麻痹",
"start_offset": 15,
"end_offset": 20,
"label": "sym"
},
{
"id": 3,
"entity": "眼球运动障碍",
"start_offset": 38,
"end_offset": 44,
"label": "sym"
}
] |
眼肌瘫痪可在头痛前或后或同时发生，以上眼睑下垂最常见，重者眼外肌全部瘫痪，伴瞳孔散大，眼球固定，光反应消失。 | [
{
"id": 0,
"entity": "眼肌瘫痪",
"start_offset": 0,
"end_offset": 4,
"label": "sym"
},
{
"id": 1,
"entity": "眼外肌全部瘫痪",
"start_offset": 29,
"end_offset": 36,
"label": "sym"
},
{
"id": 2,
"entity": "瞳孔散大",
"start_offset": 38,
"end_offset": 42,
"label": "sym"
},
{
"id": 3,
"entity": "眼球固定",
"start_offset": 43,
"end_offset": 47,
"label": "sym"
},
{
"id": 4,
"entity": "光反应消失",
"start_offset": 48,
"end_offset": 53,
"label": "sym"
}
] |
疼痛可持续数小时，眼肌瘫痪可持续数日至数周。 | [
{
"id": 0,
"entity": "疼痛可持续数小时",
"start_offset": 0,
"end_offset": 8,
"label": "sym"
},
{
"id": 1,
"entity": "眼肌瘫痪可持续数日至数周",
"start_offset": 9,
"end_offset": 21,
"label": "sym"
}
] |
4.可能为偏头痛先驱或与偏头痛有关的周期性综合征即过去所称的偏头痛等位症，是指临床出现短暂性神经功能障碍而当时头痛只是次要症状，甚至不出现头痛的一组综合征。 | [
{
"id": 0,
"entity": "偏头痛",
"start_offset": 30,
"end_offset": 33,
"label": "dis"
},
{
"id": 1,
"entity": "短暂性神经功能障碍",
"start_offset": 43,
"end_offset": 52,
"label": "sym"
}
] |
【诊断】关于偏头痛的诊断，目前还没有一个客观的生物学指标，主要根据临床症状及阳性家族史加以诊断。 | [
{
"id": 0,
"entity": "偏头痛",
"start_offset": 6,
"end_offset": 9,
"label": "dis"
}
] |
至于辅助检查对偏头痛的诊断是不必要的，其价值在于排除非偏头痛疾病。 | [
{
"id": 0,
"entity": "辅助检查",
"start_offset": 2,
"end_offset": 6,
"label": "pro"
},
{
"id": 1,
"entity": "偏头痛",
"start_offset": 7,
"end_offset": 10,
"label": "dis"
},
{
"id": 2,
"entity": "非偏头痛",
"start_offset": 26,
"end_offset": 30,
"label": "dis"
}
] |
2004年IHS制定了没有先兆的偏头痛诊断标准是至少有5次发作符合下列条件：①小儿头痛发作持续1～72小时；②头痛至少具有下列4项中的2项特点：a.单侧头痛，b.搏动性头痛，c.中度或重度头痛，影响日常生活，d.日常体力活动（如上楼梯）时头痛加重；③头痛时至少有下列2项中的1项表现：a.恶心和（或）呕吐，b.畏光及畏声；④病史、体检及各项检查未发现全身或中枢神经系统器质性疾病，如有其他疾病需有证据说明与头痛发作无关。 | [
{
"id": 0,
"entity": "偏头痛",
"start_offset": 16,
"end_offset": 19,
"label": "dis"
},
{
"id": 1,
"entity": "小儿头痛",
"start_offset": 39,
"end_offset": 43,
"label": "dis"
},
{
"id": 2,
"entity": "持续1～72小时",
"start_offset": 45,
"end_offset": 53,
"label": "sym"
},
{
"id": 3,
"entity": "单侧头痛",
"start_offset": 74,
"end_offset": 78,
"label": "sym"
},
{
"id": 4,
"entity": "搏动性头痛",
"start_offset": 81,
"end_offset": 86,
"label": "sym"
},
{
"id": 5,
"entity": "中度或重度头痛",
"start_offset": 89,
"end_offset": 96,
"label": "sym"
},
{
"id": 6,
"entity": "头痛加重",
"start_offset": 119,
"end_offset": 123,
"label": "sym"
},
{
"id": 7,
"entity": "恶心",
"start_offset": 144,
"end_offset": 146,
"label": "sym"
},
{
"id": 8,
"entity": "呕吐",
"start_offset": 150,
"end_offset": 152,
"label": "sym"
},
{
"id": 9,
"entity": "畏光",
"start_offset": 155,
"end_offset": 157,
"label": "sym"
},
{
"id": 10,
"entity": "畏声",
"start_offset": 158,
"end_offset": 160,
"label": "sym"
},
{
"id": 11,
"entity": "中枢神经系统器质性疾病",
"start_offset": 178,
"end_offset": 189,
"label": "dis"
},
{
"id": 12,
"entity": "头痛",
"start_offset": 203,
"end_offset": 205,
"label": "dis"
}
] |
有先兆的偏头痛诊断标准是：a.符合以下b～d特点的发作≥2次。 | [
{
"id": 0,
"entity": "偏头痛",
"start_offset": 4,
"end_offset": 7,
"label": "dis"
}
] |
c.至少符合以下两条：①至少1种先兆症状逐渐发展时间≥5分钟和（或）不同先兆症状接连出现≥5分钟；②先兆症状持续时间5～60分钟；③视觉症状和（或）感觉症状。 | [
{
"id": 0,
"entity": "先兆症状逐渐发展时间≥5分钟",
"start_offset": 16,
"end_offset": 30,
"label": "sym"
},
{
"id": 1,
"entity": "不同先兆症状接连出现≥5分钟",
"start_offset": 34,
"end_offset": 48,
"label": "sym"
},
{
"id": 2,
"entity": "先兆症状持续时间5～60分钟",
"start_offset": 50,
"end_offset": 64,
"label": "sym"
},
{
"id": 3,
"entity": "视觉症状",
"start_offset": 66,
"end_offset": 70,
"label": "sym"
},
{
"id": 4,
"entity": "感觉症状",
"start_offset": 74,
"end_offset": 78,
"label": "sym"
}
] |
此外，病史、体检及各项检查应未发现全身或中枢神经系统器质性疾病，如果有其他疾病需有证据说明与头痛发作无关。 | [
{
"id": 0,
"entity": "中枢神经系统",
"start_offset": 20,
"end_offset": 26,
"label": "bod"
}
] |
HIS制定的偏头痛诊断标准过于繁琐及严格，不便于临床工作时应用。 | [
{
"id": 0,
"entity": "偏头痛",
"start_offset": 6,
"end_offset": 9,
"label": "dis"
}
] |
并且此诊断标准是面对整个人群的，由于小儿偏头痛的症状主诉、发作方式与成人不尽相同（比如小儿的发作时间较短，单侧性和畏声在小儿较少见），故有不少针对儿童的修改性意见。 | [
{
"id": 0,
"entity": "小儿偏头痛",
"start_offset": 18,
"end_offset": 23,
"label": "dis"
},
{
"id": 1,
"entity": "小儿的发作时间较短",
"start_offset": 43,
"end_offset": 52,
"label": "sym"
},
{
"id": 2,
"entity": "单侧性",
"start_offset": 53,
"end_offset": 56,
"label": "sym"
},
{
"id": 3,
"entity": "畏声",
"start_offset": 57,
"end_offset": 59,
"label": "sym"
}
] |
比较认同的有以下几点：①发作头痛时伴有腹痛、恶心或呕吐；②偏侧头痛；③头痛性质呈跳动或搏动性、刺痛性；④经短暂时间后能完全缓解；⑤有视觉、感觉或运动性先兆；⑥在一级亲属中有一个或更多成员有头痛史。 | [
{
"id": 0,
"entity": "腹痛",
"start_offset": 19,
"end_offset": 21,
"label": "sym"
},
{
"id": 1,
"entity": "恶心",
"start_offset": 22,
"end_offset": 24,
"label": "sym"
},
{
"id": 2,
"entity": "呕吐",
"start_offset": 25,
"end_offset": 27,
"label": "sym"
},
{
"id": 3,
"entity": "偏侧头痛",
"start_offset": 29,
"end_offset": 33,
"label": "sym"
},
{
"id": 4,
"entity": "跳动",
"start_offset": 40,
"end_offset": 42,
"label": "sym"
},
{
"id": 5,
"entity": "搏动性",
"start_offset": 43,
"end_offset": 46,
"label": "sym"
},
{
"id": 6,
"entity": "刺痛性",
"start_offset": 47,
"end_offset": 50,
"label": "sym"
},
{
"id": 7,
"entity": "视觉、感觉或运动性先兆",
"start_offset": 66,
"end_offset": 77,
"label": "sym"
}
] |
头痛特征如具有以上几项中之三项以上，则较支持偏头痛的诊断。 | [
{
"id": 0,
"entity": "头痛",
"start_offset": 0,
"end_offset": 2,
"label": "dis"
}
] |
迄今尚无一致公认的偏头痛诊断标准，但以下几点受到普遍的赞同：①反复发作性的头痛，间歇期完全正常，排除其他器质性疾病引起的头痛；②具备以下6条中的3条：a.头痛发作时伴有恶心、呕吐，头痛时或不头痛时有发作性腹痛；b.偏侧头痛；c.搏动性头痛；d.短期休息或睡眠后缓解；e.有视觉异常等先兆；f.有偏头痛家族史。 | [
{
"id": 0,
"entity": "反复发作性的头痛",
"start_offset": 31,
"end_offset": 39,
"label": "sym"
},
{
"id": 1,
"entity": "恶心",
"start_offset": 84,
"end_offset": 86,
"label": "sym"
},
{
"id": 2,
"entity": "呕吐",
"start_offset": 87,
"end_offset": 89,
"label": "sym"
},
{
"id": 3,
"entity": "头痛",
"start_offset": 90,
"end_offset": 92,
"label": "sym"
},
{
"id": 4,
"entity": "发作性腹痛",
"start_offset": 99,
"end_offset": 104,
"label": "sym"
},
{
"id": 5,
"entity": "偏侧头痛",
"start_offset": 107,
"end_offset": 111,
"label": "sym"
},
{
"id": 6,
"entity": "搏动性头痛",
"start_offset": 114,
"end_offset": 119,
"label": "sym"
},
{
"id": 7,
"entity": "短期休息",
"start_offset": 122,
"end_offset": 126,
"label": "pro"
},
{
"id": 8,
"entity": "睡眠后缓解",
"start_offset": 127,
"end_offset": 132,
"label": "pro"
},
{
"id": 9,
"entity": "偏头痛",
"start_offset": 147,
"end_offset": 150,
"label": "dis"
}
] |
这比较符合Prensky提出的小儿偏头痛诊断标准。 | [
{
"id": 0,
"entity": "小儿偏头痛",
"start_offset": 15,
"end_offset": 20,
"label": "dis"
}
] |
伴恶心、呕吐者可用甲氧氯普胺或氯丙嗪；伴眩晕或头晕者可用地芬尼多或东莨菪碱等治疗。 | [
{
"id": 0,
"entity": "恶心",
"start_offset": 1,
"end_offset": 3,
"label": "sym"
},
{
"id": 1,
"entity": "甲氧氯普胺",
"start_offset": 9,
"end_offset": 14,
"label": "dru"
},
{
"id": 2,
"entity": "氯丙嗪",
"start_offset": 15,
"end_offset": 18,
"label": "dru"
},
{
"id": 3,
"entity": "眩晕",
"start_offset": 20,
"end_offset": 22,
"label": "sym"
},
{
"id": 4,
"entity": "地芬尼多",
"start_offset": 28,
"end_offset": 32,
"label": "dru"
},
{
"id": 5,
"entity": "东莨菪碱",
"start_offset": 33,
"end_offset": 37,
"label": "dru"
}
] |
1.解热镇痛剂常用对乙酰氨基酚（paracetamol）每次10～15mg/kg、阿司匹林（aspirin）每次10～15mg/kg、布洛芬（ibuprofen）每次5～10mg/kg以及奈普生（naproxen）每次5～10mg/kg等，在头痛早期服用有效。 | [
{
"id": 0,
"entity": "对乙酰氨基酚",
"start_offset": 9,
"end_offset": 15,
"label": "dru"
},
{
"id": 1,
"entity": "阿司匹林",
"start_offset": 41,
"end_offset": 45,
"label": "dru"
},
{
"id": 2,
"entity": "布洛芬",
"start_offset": 67,
"end_offset": 70,
"label": "dru"
},
{
"id": 3,
"entity": "奈普生",
"start_offset": 94,
"end_offset": 97,
"label": "dru"
}
] |
2.麦角胺制剂如麦角胺及双氢麦角胺等，对颅外动脉有收缩作用。 | [
{
"id": 0,
"entity": "麦角胺制剂",
"start_offset": 2,
"end_offset": 7,
"label": "dru"
},
{
"id": 1,
"entity": "麦角胺",
"start_offset": 8,
"end_offset": 11,
"label": "dru"
},
{
"id": 2,
"entity": "双氢麦角胺",
"start_offset": 12,
"end_offset": 17,
"label": "dru"
}
] |
常用的复方片剂为麦角胺咖啡因（每片含麦角胺1mg和咖啡因100mg），学龄儿童用量每次1片，对终止头痛发作有效。 | [
{
"id": 0,
"entity": "麦角胺咖啡因",
"start_offset": 8,
"end_offset": 14,
"label": "dru"
}
] |
3.曲普坦类药物如舒马曲坦（sumatriptan），是一种选择性5-羟色胺受体激动剂，具有高度选择性地收缩颈动脉作用，为治疗偏头痛急性发作有效而昂贵的药物。 | [
{
"id": 0,
"entity": "舒马曲坦",
"start_offset": 9,
"end_offset": 13,
"label": "dru"
}
] |
（二）预防性治疗偏头痛的预防第一步就是要消除或减少发作的诱发因素，如避免情绪紧张、劳累、睡眠不足、声及光刺激，不进食含奶酪食物等。 | [
{
"id": 0,
"entity": "偏头痛",
"start_offset": 8,
"end_offset": 11,
"label": "dis"
},
{
"id": 1,
"entity": "避免情绪紧张、劳累、睡眠不足",
"start_offset": 34,
"end_offset": 48,
"label": "pro"
},
{
"id": 2,
"entity": "声及光刺激",
"start_offset": 49,
"end_offset": 54,
"label": "pro"
},
{
"id": 3,
"entity": "不进食含奶酪食物",
"start_offset": 55,
"end_offset": 63,
"label": "pro"
}
] |
1.β受体阻断剂常用普萘洛尔（propranolol），剂量为2mg/（kg•d），分3次口服。 | [
{
"id": 0,
"entity": "β受体阻断剂",
"start_offset": 2,
"end_offset": 8,
"label": "dru"
},
{
"id": 1,
"entity": "普萘洛尔",
"start_offset": 10,
"end_offset": 14,
"label": "dru"
}
] |
为防止低血压及心率减慢副作用发生，应从小量0.5～1mg/（kg•d）开始，缓慢加量直至可以耐受。 | [
{
"id": 0,
"entity": "低血压",
"start_offset": 3,
"end_offset": 6,
"label": "dis"
}
] |
2.组胺受体阻断剂常用赛庚啶（cyprohepladine），剂量为0.2～0.4mg/（kg•d），疗程6～12个月或更长。 | [
{
"id": 0,
"entity": "赛庚啶",
"start_offset": 11,
"end_offset": 14,
"label": "dru"
}
] |
3.5-羟色胺受体阻断剂常用苯噻啶（pizolifen），兼有组胺受体拮抗作用。 | [
{
"id": 0,
"entity": "苯噻啶",
"start_offset": 14,
"end_offset": 17,
"label": "dru"
}
] |
4.钙通道阻滞剂常用氟桂利嗪（flunarizine），剂量为每晚睡前服2.5～5mg，一般疗程2～3个月。 | [
{
"id": 0,
"entity": "氟桂利嗪",
"start_offset": 10,
"end_offset": 14,
"label": "dru"
}
] |
5.其他药物丙戊酸（valproicacid），卡马西平（carbamazepine），托吡酯（topiramate），可乐定（clonidine），苯乙肼（phenelzine），阿米替林（amitriptyline）等。 | [
{
"id": 0,
"entity": "丙戊酸",
"start_offset": 6,
"end_offset": 9,
"label": "dru"
},
{
"id": 1,
"entity": "卡马西平",
"start_offset": 24,
"end_offset": 28,
"label": "dru"
},
{
"id": 2,
"entity": "托吡酯",
"start_offset": 44,
"end_offset": 47,
"label": "dru"
},
{
"id": 3,
"entity": "可乐定",
"start_offset": 60,
"end_offset": 63,
"label": "dru"
},
{
"id": 4,
"entity": "苯乙肼",
"start_offset": 75,
"end_offset": 78,
"label": "dru"
},
{
"id": 5,
"entity": "阿米替林",
"start_offset": 91,
"end_offset": 95,
"label": "dru"
}
] |
【预后】偏头痛病程较长，但预后良好。 | [
{
"id": 0,
"entity": "偏头痛",
"start_offset": 4,
"end_offset": 7,
"label": "dis"
}
] |
近年有报道小儿偏头痛发作过程中有时并发脑梗死，被称为偏头痛脑卒中（migrainousstroke），其机制不明，可能与血小板聚集后的微血栓形成有关。 | [
{
"id": 0,
"entity": "小儿偏头痛",
"start_offset": 5,
"end_offset": 10,
"label": "dis"
},
{
"id": 1,
"entity": "脑梗死",
"start_offset": 19,
"end_offset": 22,
"label": "dis"
},
{
"id": 2,
"entity": "偏头痛脑卒",
"start_offset": 26,
"end_offset": 31,
"label": "dis"
},
{
"id": 3,
"entity": "migrainousstroke",
"start_offset": 33,
"end_offset": 49,
"label": "dis"
},
{
"id": 4,
"entity": "血小板",
"start_offset": 60,
"end_offset": 63,
"label": "bod"
}
] |
五、混合性酸碱平衡紊乱当有两种或以上的酸碱紊乱分别同时作用于呼吸或代谢系统称为混合性酸碱平衡紊乱（mixeddisorders）。 | [
{
"id": 0,
"entity": "混合性酸碱平衡紊乱",
"start_offset": 2,
"end_offset": 11,
"label": "dis"
},
{
"id": 1,
"entity": "酸碱紊乱",
"start_offset": 19,
"end_offset": 23,
"label": "dis"
},
{
"id": 2,
"entity": "呼吸或代谢系统",
"start_offset": 30,
"end_offset": 37,
"label": "bod"
},
{
"id": 3,
"entity": "混合性酸碱平衡紊乱",
"start_offset": 39,
"end_offset": 48,
"label": "dis"
},
{
"id": 4,
"entity": "mixeddisorders",
"start_offset": 49,
"end_offset": 63,
"label": "dis"
}
] |
当代偿能力在预计范围之外时，就应考虑存在混合性酸碱平衡紊乱（表2-8）。 | [
{
"id": 0,
"entity": "混合性酸碱平衡紊乱",
"start_offset": 20,
"end_offset": 29,
"label": "dis"
}
] |
例如糖尿病酮症酸中毒病人同时存在肺气肿，呼吸窘迫综合征（respiratorydistresssyndrome，RDS）病人有呼吸性酸中毒与代谢性酸中毒同时存在时。 | [
{
"id": 0,
"entity": "糖尿病酮症酸中毒",
"start_offset": 2,
"end_offset": 10,
"label": "dis"
},
{
"id": 1,
"entity": "肺气肿",
"start_offset": 16,
"end_offset": 19,
"label": "dis"
},
{
"id": 2,
"entity": "呼吸窘迫综合征",
"start_offset": 20,
"end_offset": 27,
"label": "dis"
},
{
"id": 3,
"entity": "respiratorydistresssyndrome",
"start_offset": 28,
"end_offset": 55,
"label": "dis"
},
{
"id": 4,
"entity": "RDS",
"start_offset": 56,
"end_offset": 59,
"label": "dis"
},
{
"id": 5,
"entity": "呼吸性酸中毒",
"start_offset": 63,
"end_offset": 69,
"label": "dis"
},
{
"id": 6,
"entity": "代谢性酸中毒",
"start_offset": 70,
"end_offset": 76,
"label": "dis"
}
] |
呼吸系统本身的疾病存在阻碍了降低PaCO2</sub>的代偿机制，结果使pH下降显著慢性呼吸性酸中毒伴有充血性心力衰竭时，如过度使用利尿剂可出现代谢性碱中毒，此时血浆水平和pH将高于单纯的慢性呼吸性酸中毒。 | [
{
"id": 0,
"entity": "呼吸系统",
"start_offset": 0,
"end_offset": 4,
"label": "bod"
},
{
"id": 1,
"entity": "PaCO2",
"start_offset": 16,
"end_offset": 21,
"label": "ite"
},
{
"id": 2,
"entity": "pH",
"start_offset": 36,
"end_offset": 38,
"label": "ite"
},
{
"id": 3,
"entity": "使pH下降显著",
"start_offset": 35,
"end_offset": 42,
"label": "sym"
},
{
"id": 4,
"entity": "慢性呼吸性酸中毒",
"start_offset": 42,
"end_offset": 50,
"label": "dis"
},
{
"id": 5,
"entity": "充血性心力衰竭",
"start_offset": 52,
"end_offset": 59,
"label": "dis"
},
{
"id": 6,
"entity": "利尿剂",
"start_offset": 66,
"end_offset": 69,
"label": "dru"
},
{
"id": 7,
"entity": "代谢性碱中毒",
"start_offset": 72,
"end_offset": 78,
"label": "dis"
},
{
"id": 8,
"entity": "血浆",
"start_offset": 81,
"end_offset": 83,
"label": "bod"
},
{
"id": 9,
"entity": "pH",
"start_offset": 86,
"end_offset": 88,
"label": "ite"
},
{
"id": 10,
"entity": "慢性呼吸性酸中毒",
"start_offset": 94,
"end_offset": 102,
"label": "dis"
}
] |
肝功能衰竭时可出现代谢性酸中毒与呼吸性碱中毒，此时pH可能变化不大，但血浆和PaCO2</sub>显著降低。 | [
{
"id": 0,
"entity": "肝功能衰竭",
"start_offset": 0,
"end_offset": 5,
"label": "dis"
},
{
"id": 1,
"entity": "代谢性酸中毒",
"start_offset": 9,
"end_offset": 15,
"label": "dis"
},
{
"id": 2,
"entity": "呼吸性碱中毒",
"start_offset": 16,
"end_offset": 22,
"label": "dis"
},
{
"id": 3,
"entity": "pH",
"start_offset": 25,
"end_offset": 27,
"label": "ite"
},
{
"id": 4,
"entity": "PaCO2",
"start_offset": 38,
"end_offset": 43,
"label": "ite"
},
{
"id": 5,
"entity": "pH可能变化不大，但血浆和PaCO2</sub>显著降低",
"start_offset": 25,
"end_offset": 53,
"label": "sym"
}
] |
第三章心血管系统疾病的诊疗技术第一节胸部X线检查过去，胸部X线检查需结合详细病史，体格检查和心电图才能对先心病做出可能的诊断。 | [
{
"id": 0,
"entity": "心血管系统疾病",
"start_offset": 3,
"end_offset": 10,
"label": "dis"
},
{
"id": 1,
"entity": "胸部X线检查",
"start_offset": 18,
"end_offset": 24,
"label": "pro"
},
{
"id": 2,
"entity": "胸部X线检查",
"start_offset": 27,
"end_offset": 33,
"label": "pro"
},
{
"id": 3,
"entity": "体格检查",
"start_offset": 41,
"end_offset": 45,
"label": "pro"
},
{
"id": 4,
"entity": "心电图",
"start_offset": 46,
"end_offset": 49,
"label": "pro"
},
{
"id": 5,
"entity": "先心病",
"start_offset": 52,
"end_offset": 55,
"label": "dis"
}
] |
毫无疑问，如今胸部X线检查的作用愈不如前。 | [
{
"id": 0,
"entity": "胸部X线检查",
"start_offset": 7,
"end_offset": 13,
"label": "pro"
}
] |
超声心动图技术的迅速发展为先心病诊断提供了一条快捷准确的诊断方式，二维超声心动图可显示心内的解剖结构，体循环和肺静脉连接，大血管关系和瓣膜异常，使先心病的诊断较前更加便捷准确。 | [
{
"id": 0,
"entity": "超声心动图",
"start_offset": 0,
"end_offset": 5,
"label": "pro"
},
{
"id": 1,
"entity": "先心病",
"start_offset": 13,
"end_offset": 16,
"label": "dis"
},
{
"id": 2,
"entity": "二维超声心动图",
"start_offset": 33,
"end_offset": 40,
"label": "pro"
},
{
"id": 3,
"entity": "心内",
"start_offset": 43,
"end_offset": 45,
"label": "bod"
},
{
"id": 4,
"entity": "肺静脉",
"start_offset": 55,
"end_offset": 58,
"label": "bod"
},
{
"id": 5,
"entity": "大血管",
"start_offset": 61,
"end_offset": 64,
"label": "bod"
},
{
"id": 6,
"entity": "瓣膜",
"start_offset": 67,
"end_offset": 69,
"label": "bod"
},
{
"id": 7,
"entity": "先心病",
"start_offset": 73,
"end_offset": 76,
"label": "dis"
}
] |
同时由于超声心动图的广泛应用，先心病得以早期发现，年长儿的典型X线表现已不多见。 | [
{
"id": 0,
"entity": "超声心动图",
"start_offset": 4,
"end_offset": 9,
"label": "pro"
},
{
"id": 1,
"entity": "先心病",
"start_offset": 15,
"end_offset": 18,
"label": "dis"
},
{
"id": 2,
"entity": "X线",
"start_offset": 31,
"end_offset": 33,
"label": "pro"
}
] |
尽管非侵入性诊断方法的应用日渐增多，X线作为一种价廉的影像技术，在先心病的筛查方面仍然起着重要的作用。 | [
{
"id": 0,
"entity": "X线",
"start_offset": 18,
"end_offset": 20,
"label": "pro"
},
{
"id": 1,
"entity": "先心病",
"start_offset": 33,
"end_offset": 36,
"label": "dis"
}
] |
而且，胸片X线检查可提供心脏的血流动力学（如左向右分流量、青紫型先心病的肺血流多少）、充血性心力衰竭时心脏扩大的随访及手术后及经导管介入治疗效果等一系列信息。 | [
{
"id": 0,
"entity": "胸片X线检查",
"start_offset": 3,
"end_offset": 9,
"label": "pro"
},
{
"id": 1,
"entity": "心脏",
"start_offset": 12,
"end_offset": 14,
"label": "bod"
},
{
"id": 2,
"entity": "左向右分流量",
"start_offset": 22,
"end_offset": 28,
"label": "ite"
},
{
"id": 3,
"entity": "青紫型先心病",
"start_offset": 29,
"end_offset": 35,
"label": "dis"
},
{
"id": 4,
"entity": "肺血流",
"start_offset": 36,
"end_offset": 39,
"label": "ite"
},
{
"id": 5,
"entity": "充血性心力衰竭",
"start_offset": 43,
"end_offset": 50,
"label": "dis"
},
{
"id": 6,
"entity": "心脏",
"start_offset": 51,
"end_offset": 53,
"label": "bod"
},
{
"id": 7,
"entity": "手术",
"start_offset": 59,
"end_offset": 61,
"label": "pro"
},
{
"id": 8,
"entity": "经导管介入治疗",
"start_offset": 63,
"end_offset": 70,
"label": "pro"
}
] |
（一）胸片分析步骤胸部后前位是常规的摄片位，一般不用加拍侧位片，斜位片目前已少用。 | [
{
"id": 0,
"entity": "胸片",
"start_offset": 3,
"end_offset": 5,
"label": "pro"
},
{
"id": 1,
"entity": "胸部",
"start_offset": 9,
"end_offset": 11,
"label": "bod"
}
] |
摄片时宜取吸气状态，如呼气相摄片可能易误认为有心脏肥大或肺充血。 | [
{
"id": 0,
"entity": "心脏肥大",
"start_offset": 23,
"end_offset": 27,
"label": "sym"
},
{
"id": 1,
"entity": "肺充血",
"start_offset": 28,
"end_offset": 31,
"label": "sym"
}
] |
如果膈肌位于第9、10后肋水平，说明摄片时处于理想的吸气状态。 | [
{
"id": 0,
"entity": "膈肌",
"start_offset": 2,
"end_offset": 4,
"label": "bod"
}
] |
当分析正位片时，应将心脏大小、心缘影与肺血管影结合起来分析，还应注意脊柱和肋骨有无异常，内脏位置，尤其是胃泡及肝脏的位置应与心脏的位置一起分析。 | [
{
"id": 0,
"entity": "心脏",
"start_offset": 10,
"end_offset": 12,
"label": "bod"
},
{
"id": 1,
"entity": "肺血管",
"start_offset": 19,
"end_offset": 22,
"label": "bod"
},
{
"id": 2,
"entity": "脊柱",
"start_offset": 34,
"end_offset": 36,
"label": "bod"
},
{
"id": 3,
"entity": "肋骨",
"start_offset": 37,
"end_offset": 39,
"label": "bod"
},
{
"id": 4,
"entity": "胃泡",
"start_offset": 52,
"end_offset": 54,
"label": "bod"
},
{
"id": 5,
"entity": "肝脏",
"start_offset": 55,
"end_offset": 57,
"label": "bod"
},
{
"id": 6,
"entity": "心脏",
"start_offset": 62,
"end_offset": 64,
"label": "bod"
}
] |
（二）心脏大小判断一般通过正位片观察心脏大小。 | [
{
"id": 0,
"entity": "心脏",
"start_offset": 3,
"end_offset": 5,
"label": "bod"
},
{
"id": 1,
"entity": "心脏",
"start_offset": 18,
"end_offset": 20,
"label": "bod"
}
] |
影响心脏大小的因素很多，吸气相或仰卧位时心影增大，婴儿和幼儿的正常胸腺可能被误诊为心脏增大。 | [
{
"id": 0,
"entity": "心脏",
"start_offset": 2,
"end_offset": 4,
"label": "bod"
},
{
"id": 1,
"entity": "胸腺",
"start_offset": 33,
"end_offset": 35,
"label": "bod"
},
{
"id": 2,
"entity": "心脏增大",
"start_offset": 41,
"end_offset": 45,
"label": "sym"
}
] |
胸腺可向下扩展，占据胸骨后间隙，与心影重叠。 | [
{
"id": 0,
"entity": "胸腺",
"start_offset": 0,
"end_offset": 2,
"label": "bod"
},
{
"id": 1,
"entity": "胸骨",
"start_offset": 10,
"end_offset": 12,
"label": "bod"
}
] |
增大的胸腺如位于上纵隔可形成类似于心上型肺静脉异常连接的“雪人形”心影，二维超声可明确诊断。 | [
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"id": 0,
"entity": "胸腺",
"start_offset": 3,
"end_offset": 5,
"label": "bod"
},
{
"id": 1,
"entity": "上纵隔",
"start_offset": 8,
"end_offset": 11,
"label": "bod"
},
{
"id": 2,
"entity": "心上型肺静脉",
"start_offset": 17,
"end_offset": 23,
"label": "bod"
},
{
"id": 3,
"entity": "二维超声",
"start_offset": 36,
"end_offset": 40,
"label": "pro"
}
] |
心脏大小由心胸比率来定量，心胸比率即心脏最大横径与右膈最高点水平的胸廓内径之比。 | [
{
"id": 0,
"entity": "心脏",
"start_offset": 0,
"end_offset": 2,
"label": "bod"
},
{
"id": 1,
"entity": "心脏",
"start_offset": 18,
"end_offset": 20,
"label": "bod"
},
{
"id": 2,
"entity": "右膈",
"start_offset": 25,
"end_offset": 27,
"label": "bod"
}
] |
如在成人或年长儿心胸比例超过0.5，婴儿超过0.6即为心脏增大。 | [
{
"id": 0,
"entity": "心脏增大",
"start_offset": 27,
"end_offset": 31,
"label": "sym"
}
] |
绝大多数的先心病伴有心脏扩大。 | [
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"id": 0,
"entity": "先心病",
"start_offset": 5,
"end_offset": 8,
"label": "dis"
},
{
"id": 1,
"entity": "心脏扩大",
"start_offset": 10,
"end_offset": 14,
"label": "sym"
}
] |
明确有心脏增大后，仔细分析心缘各段变化可确定扩大的腔室。 | [
{
"id": 0,
"entity": "心脏增大",
"start_offset": 3,
"end_offset": 7,
"label": "sym"
}
] |
（三）心脏外形1.右心房右房增大时，右心缘弧度增大，向右肺野突出，单纯的右房增大不多见，典型征象见于Ebstein畸形，在新生儿期即可出现明显的右房增大（图9-9）。 | [
{
"id": 0,
"entity": "心脏",
"start_offset": 3,
"end_offset": 5,
"label": "bod"
},
{
"id": 1,
"entity": "右心房",
"start_offset": 9,
"end_offset": 12,
"label": "bod"
},
{
"id": 2,
"entity": "右房",
"start_offset": 12,
"end_offset": 14,
"label": "bod"
},
{
"id": 3,
"entity": "右房增大时",
"start_offset": 12,
"end_offset": 17,
"label": "sym"
},
{
"id": 4,
"entity": "右心缘弧度增大",
"start_offset": 18,
"end_offset": 25,
"label": "sym"
},
{
"id": 5,
"entity": "向右肺野突出",
"start_offset": 26,
"end_offset": 32,
"label": "sym"
},
{
"id": 6,
"entity": "右房",
"start_offset": 36,
"end_offset": 38,
"label": "bod"
},
{
"id": 7,
"entity": "右房增大",
"start_offset": 36,
"end_offset": 40,
"label": "sym"
},
{
"id": 8,
"entity": "Ebstein畸形",
"start_offset": 50,
"end_offset": 59,
"label": "dis"
},
{
"id": 9,
"entity": "右房",
"start_offset": 72,
"end_offset": 74,
"label": "bod"
},
{
"id": 10,
"entity": "右房增大",
"start_offset": 72,
"end_offset": 76,
"label": "sym"
}
] |
图9-1Ebstein畸形（正位片）示：右心房扩大可见右心缘膨出，肺血管纹理减少2.右心室右心室在正位片时不构成左下心缘，轻度的右室肥大或扩大，心影变化不明显，如右室继续增大可导致心尖向侧、上移位，当心影扩大不明显而右心室肥厚时，心尖上翘明显，侧位片心脏前缘向胸骨方向扩大。 | [
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"id": 0,
"entity": "Ebstein畸形",
"start_offset": 4,
"end_offset": 13,
"label": "dis"
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{
"id": 1,
"entity": "右心房",
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"label": "bod"
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{
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"entity": "右心房扩大",
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{
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"entity": "右心缘膨出",
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{
"id": 4,
"entity": "肺血管",
"start_offset": 33,
"end_offset": 36,
"label": "bod"
},
{
"id": 5,
"entity": "肺血管纹理减少",
"start_offset": 33,
"end_offset": 40,
"label": "sym"
},
{
"id": 6,
"entity": "右心室",
"start_offset": 42,
"end_offset": 45,
"label": "bod"
},
{
"id": 7,
"entity": "右心室",
"start_offset": 45,
"end_offset": 48,
"label": "bod"
},
{
"id": 8,
"entity": "右室",
"start_offset": 64,
"end_offset": 66,
"label": "bod"
},
{
"id": 9,
"entity": "轻度的右室肥大或扩大",
"start_offset": 61,
"end_offset": 71,
"label": "sym"
},
{
"id": 10,
"entity": "右室",
"start_offset": 81,
"end_offset": 83,
"label": "bod"
},
{
"id": 11,
"entity": "右室继续增大可导致心尖向侧、上移位",
"start_offset": 81,
"end_offset": 98,
"label": "sym"
},
{
"id": 12,
"entity": "右心室肥厚",
"start_offset": 108,
"end_offset": 113,
"label": "sym"
},
{
"id": 13,
"entity": "心尖上翘明显",
"start_offset": 115,
"end_offset": 121,
"label": "sym"
},
{
"id": 14,
"entity": "侧位片心脏前缘向胸骨方向扩大",
"start_offset": 122,
"end_offset": 136,
"label": "sym"
}
] |
3.左心房在正位片，当左房扩大时，显示左心缘位于肺动脉干影下方有一小的膨出，如胶片透光良好，可显示双房影。 | [
{
"id": 0,
"entity": "左心房",
"start_offset": 2,
"end_offset": 5,
"label": "bod"
},
{
"id": 1,
"entity": "左房",
"start_offset": 11,
"end_offset": 13,
"label": "bod"
},
{
"id": 2,
"entity": "左心缘",
"start_offset": 19,
"end_offset": 22,
"label": "bod"
},
{
"id": 3,
"entity": "肺动脉",
"start_offset": 24,
"end_offset": 27,
"label": "bod"
}
] |
左房增大明显时，左主支气管受压上抬，隆凸角度增大，侧位片可见左主支气管移位。 | [
{
"id": 0,
"entity": "左房",
"start_offset": 0,
"end_offset": 2,
"label": "bod"
},
{
"id": 1,
"entity": "左主支气管",
"start_offset": 8,
"end_offset": 13,
"label": "bod"
},
{
"id": 2,
"entity": "左主支气管",
"start_offset": 30,
"end_offset": 35,
"label": "bod"
}
] |
4.左心室当左室扩张时，心尖向侧下方移位，而右室扩大时心尖上翘。 | [
{
"id": 0,
"entity": "左心室",
"start_offset": 2,
"end_offset": 5,
"label": "bod"
},
{
"id": 1,
"entity": "左室",
"start_offset": 6,
"end_offset": 8,
"label": "bod"
},
{
"id": 2,
"entity": "当左室扩张时，心尖向侧下方移位",
"start_offset": 5,
"end_offset": 20,
"label": "sym"
},
{
"id": 3,
"entity": "右室",
"start_offset": 22,
"end_offset": 24,
"label": "bod"
},
{
"id": 4,
"entity": "右室扩大时心尖上翘",
"start_offset": 22,
"end_offset": 31,
"label": "sym"
}
] |
左室肥大时，心影变化不明显。 | [
{
"id": 0,
"entity": "左室",
"start_offset": 0,
"end_offset": 2,
"label": "bod"
}
] |
（四）肺血管评估肺血管状况需要有高质量的胸片及丰富的经验。 | [
{
"id": 0,
"entity": "肺血管",
"start_offset": 3,
"end_offset": 6,
"label": "bod"
},
{
"id": 1,
"entity": "肺血管",
"start_offset": 8,
"end_offset": 11,
"label": "bod"
},
{
"id": 2,
"entity": "胸片",
"start_offset": 20,
"end_offset": 22,
"label": "pro"
}
] |
过度曝光会低估肺血供；在新生儿，如曝光过度尚可能遮盖中等程度左向右分流导致的肺血增多的表现。 | [
{
"id": 0,
"entity": "肺",
"start_offset": 7,
"end_offset": 8,
"label": "bod"
},
{
"id": 1,
"entity": "肺血增多",
"start_offset": 38,
"end_offset": 42,
"label": "sym"
}
] |
由于心脏病变引起的左向右分流造成肺血流增多时，心腔因容纳额外的血液而扩大。 | [
{
"id": 0,
"entity": "心脏病变",
"start_offset": 2,
"end_offset": 6,
"label": "dis"
},
{
"id": 1,
"entity": "肺血流增多",
"start_offset": 16,
"end_offset": 21,
"label": "sym"
},
{
"id": 2,
"entity": "心腔",
"start_offset": 23,
"end_offset": 25,
"label": "bod"
},
{
"id": 3,
"entity": "血液",
"start_offset": 31,
"end_offset": 33,
"label": "bod"
}
] |
在左向右分流先心病，如肺动脉血流量与主动脉血流量之比小于2∶1，肺血管影可正常。 | [
{
"id": 0,
"entity": "左向右分流先心病",
"start_offset": 1,
"end_offset": 9,
"label": "dis"
},
{
"id": 1,
"entity": "肺动脉血流量",
"start_offset": 11,
"end_offset": 17,
"label": "ite"
},
{
"id": 2,
"entity": "主动脉血流量",
"start_offset": 18,
"end_offset": 24,
"label": "ite"
},
{
"id": 3,
"entity": "肺血管影",
"start_offset": 32,
"end_offset": 36,
"label": "pro"
}
] |
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