晕厥 or 猝死?何时心肺复苏?

2018-05-27 周鹏 医学界心血管频道

晕厥的原因复杂,不同原因导致的晕厥,预后差异很大。仔细的病史采集、查体包括卧位和直立位的生命体征,在诊断方面有最佳的“费用-效益比”。总体上,单一的客观辅助检查,对病因的诊断价值都不是很大。

晕厥的原因复杂,不同原因导致的晕厥,预后差异很大。仔细的病史采集、查体包括卧位和直立位的生命体征,在诊断方面有最佳的“费用-效益比”。总体上,单一的客观辅助检查,对病因的诊断价值都不是很大。胸中有剑——在排除心源性和神经源性的原因后,血管迷走性晕厥和占晕厥40%的“原因不明的晕厥”,预后良好。

1.定义

先兆晕厥:头昏眼花先兆症状,但无晕厥。

晕厥:因为脑灌注不足而产生的意识突然丧失症状。

如果需要心肺复苏或复律,诊断为心脏性猝死(SCD)而不是晕厥(预后不一样)。

点评:

晕厥和SCD,大多数情况下都可表现为突然倒地。突然倒地的,究竟是晕厥?还是SCD?需不需要心肺复苏(CPR)?

哈佛大学麻省总医院内科医生简介版的《晕厥》,给了现实的、实际的答案:没有进行CPR就醒过来、站起来的,就是晕厥;需要CPR的,就是SCD或心脏骤停(SCA),两者预后是很不一样的。

何时需要CPR?

看见一个人倒下,根据美国心脏学院和美国心脏协会(ACC/AHA)最新更新的心肺复苏指南,目击者在判断环境是否安全后,若患者无反应、无呼吸或呼吸异常、无抽搐,立即开始CPR。——因为晕厥是短暂的、可逆的,大多数情况下是不会超过20秒钟会自行恢复的,而SCD或SCA,是要命而且如果不及时进行心肺复苏是不可逆的。

看到一个人突然倒下,按照ACC/AHA更新的指南做,是正解。晕厥、SCD和SCA,都是回顾性诊断。

哈佛大学麻省总医院简洁版的《晕厥》,开门见山,单刀直入,对以上问题给出了清晰的概念。同时,下面的有关晕厥的其它问题,这个简洁版的《晕厥》,也给出了文献和循证医学证据,并尽量给出具体数据——这,是中美两国医生培训的差距之一。

2.病  因

(1)神经心源性(Neurocardiogenic)(又称为血管迷走性晕厥,占晕厥原因的25%左右):

交感神经张力增加,左心室收缩增强,触发左心室机械感受器,迷走神经张力增加,血管迷走反射(Bezold-Jarisch反射)亢进,心率下降(心脏抑制)及/或血压下降(血管抑制)。

咳嗽、吞咽、排便或排尿时,迷走神经张力增加因此可以被诱发。

颈动脉窦过敏症(迷走神经对颈动脉窦按压的过度反应)也是相关的疾病。

(2)体位性低血压(Orthostatic hypotension):

利尿剂导致的容积缺失,血管扩张药物(特别是与负性变力变时药联用时)。

自主神经病:原发性即帕金森氏病、MAS/Shy-Drager综合征、Lewy体痴呆、直立位心动过速综合征(POTS,青年人的家族性自主神经异常);继发性即糖尿病、酒精依赖、淀粉样变性和慢性肾脏病(参考文献:NEJM 2008;358:615)。

(3)心血管源性(Cardiovascular): (占晕厥病因的20%,男多于女)

心律失常(占晕厥的15%):由于心律失常经常是短暂的,许多情况下需要做激发试验以明确诊断

心动过缓:病态窦房结综合征、高度房室传导阻滞、负性变时药物和起搏器故障

心动过速:室性心动过速、室上性心动过速(除非合并结构性心脏病或预激综合征)

机械性(占晕厥的5%)

心内膜/瓣膜:主动脉狭窄、二尖瓣狭窄、肺动脉瓣狭窄、人工瓣膜的血栓形成和粘液瘤;

心肌:心梗后的泵功能障碍、肥厚梗阻型心肌病的流出道梗阻(更多引起的是室速)。

心包:心包填塞

血管:肺栓塞、肺动脉高压、主动脉夹层、腹主动脉瘤破裂和锁骨下盗血

(4)神经源性(Neurologic):(占晕厥的10%)锥-基底动脉功能不全、脑动脉夹层、蛛网膜下腔出血、短暂性脑缺血发作/脑血管意外、偏头痛等。

(5)其它意识丧失的原因(但不是晕厥):惊厥/癫痫低血糖、低氧血症、发作性嗜睡病、心因性意识丧失等。

3.检 查(40%的患者,晕厥的病因不能确定)

(1)病史和查体:卧位和直立位的生命体征,有最佳的“费用-效益比”(Archives 2009;169:1299)

①现病史:(目击者提供的信息非常重要):晕厥前患者的活动和体位、姿势非常重要。

诱发因素:A.劳力诱发?提示主动脉瓣狭窄、肥厚梗阻型心肌病和肺动脉高压;B.体位改变?提示直立体位性低血压;C.心情相关的因素?如看见流血、闻到血腥味;D.情绪刺激;E.疲劳;F.长时间站立;G.高热环境;H.恶心呕吐;I咳嗽、排便、排尿和吞咽?提示神经心脏性(血管迷走性晕厥);J.头部位置变动(回头或剃须):提示颈动脉窦敏感;K.上肢运动:锁骨下窃血。

②前驱症状:A.(如发汗、恶心、视力模糊):心源性<5秒,血管迷走性>5秒;B.伴随症状:胸痛、心悸、神经症状、发作后症状、大小便失禁(短暂的脑低灌注,一般小于<10秒,可发生痉挛、惊厥,类似癫痫发作。)

③个人史:A.先前的晕厥,既往的心血管和神经系统疾病。B.如果患者无基础心血管病背景,5%是心源性的、25%是血管迷走性的;如果患者有基础心血管病背景,25%是心源性的,10%是血管迷走性的(参考文献:NEJM 2002;347:878)。

④可作为晕厥诱因的药物:A.血管扩张剂:ɑ-受体阻断剂,硝酸酯类、转换酶抑制剂/血管紧张素受体阻断剂、钙拮抗剂、肼苯哒嗪、吩噻嗪类和抗抑郁药。B.利尿剂、负性变时变力药如β-受体阻断剂、钙拮抗剂。C.QT间期延长、抗心律失常药物的促心律失常作用:1A、1C和III类抗心律失常药物。D.精神科用药:抗精神病药、三环类抗抑郁药、巴比妥类药、苯二氮卓类药物。

⑤家族史:心肌病、心脏性猝死、晕厥(血管迷走性晕厥可有遗传易感性。)

⑥查体:

A.要包括直立位的生命体征(如果与卧位相比,直立位的收缩压降低>20mmHg,舒张压降级>10mmHg或者心率增加10-20次每分钟以上,有重要意义),血压应该测双上肢血压,并对比。

B.心脏方面的查体:心功能不全的全套体征、心室肥厚的全套体征、杂音和肺动脉高压的全套体征。

C.血管查体的重点:脉搏是否对称?颈动脉、椎动脉和锁骨下动脉区域的杂音?如果颈动脉无杂音,单侧颈动脉按压以模拟颈动脉窦过敏综合征:颈动脉窦按压后,如果3秒钟内无心脏收缩和收缩压降低>50mmHg,阳性。

D.神经系统的查体:任何局灶性阳性体征、有无舌咬伤?

(2)心电图

①50%晕厥患者的心电图都有异常,但能确定晕厥原因的心电图改变<10%。

②传导阻滞:窦性心动过缓、窦性停搏/窦性心律失常,房室阻滞、束支传导阻滞/室内传导阻滞。

③心律失常:异位心律、QT间期延长或缩短、预激综合征(WPW)、Brugada综合征、?-波(致心律失常性右心室心肌病)、室上速/室速。

(3)实验室检查

血糖、血红蛋白、妊娠试验(女性,能怀孕的年龄)、D-二聚体?肌钙蛋白(如果没有其它症状和体征,诊断价值小)?

4,其它客观检查(病史、查体和心电图结果)


图:晕厥诊断流程

(1)动态心电图监测(如果怀疑心律失常导致的晕厥):

①24小时动态心电图监测Holter(可连续监测24-48小时):心律失常+症状(4%),无症状但有严重心律失常(13%),有症状但无心律失常(17%)。

②事件记录器:因需要患者启动,所以作用很有限:因为晕厥是突发事件,事件记录器需要患者启动,只有前驱症状明显的患者,才有用。

③体外事件记录器(能连续存储心脏节律,在心律失常事件发生后被激活):适用于估计短期(比如1个月内)内有事件发生的患者(无论有无前驱症状);也可偶联移动-远程心电设备,由专业人员触发事件记录。

④可植入的事件记录器(皮下植入,记录时间可长达1年):适用于晕厥事件每月 < 1次的患者。可诊断55%以上的病例(参考文献:Circ 2001;104:46),适用于晕厥重复发作、但又不频繁又无前驱症状的患者。

(2)超声心动图:

用于排除结构性心脏病(包括肥厚梗阻型心肌病和致心律失常性心肌病)、瓣膜病(主动脉瓣狭窄、二尖瓣狭窄和二尖瓣脱垂等)、粘液瘤、淀粉样变、肺动脉高压或冠状动脉畸形。

(3)运动负荷、CT冠脉造影和导管检查

特别是劳力诱发的晕厥,排除缺血性心脏病或儿茶酚胺诱导的心律失常。

(4)电生理检查

①考虑心动过缓或心动过速是晕厥原因、但又无法肯定的高危患者。

②如果患者有心血管病,50%患者电生理检查有异常(可诱导的室速、传导异常),但其重要性仍然有争议。

③如果心电图异常,3%-20%的患者电生理检查有异常;如果患者心脏正常或心电图正常,<1%的患者电生理检查异常。

(5)倾斜试验

因其敏感性、特异性和可重复性较低,实用性有很大争议。仅用于考虑血管迷走性晕厥但病史又不能肯定的患者。

(6)心脏核磁

如果心电图提示心肌病、超声心动图有右心功能不全或有心脏性猝死的家族史,对诊断致心律失常性心肌病有帮助。

(7)神经科的检查

如果病史和查体支持,应进行脑血管检查、CT、核磁和脑电图检查,但帮助诊断价值有限。

5.晕厥的高危特征

年龄>60岁,冠状动脉疾病、心功能不全/心肌病、瓣膜病或先心病、心律失常背景,心脏性猝死的家族史;

伴心脏原因(缺乏前驱症状、劳力诱发、心脏创伤导致的)的或复发的晕厥;

患者诉胸痛或呼吸困难、心脏、呼吸和神经系统检查有异常生命体征的晕厥;

心电图提示传导异常、心律失常或缺血;

植入起搏器或可植入心脏转复除颤器的患者;

6.治疗

(1)心源性或神经源性晕厥: 治疗基础病因。

(2)血管迷走性晕厥

①氟氢可的松、米多君和选择血清素再摄取抑制剂(SSRI)的疗效有争议(参考文献:Int J Cardiol2013;167:1906; JACC 2016;68:1);

②双异丙吡胺和β-受体阻断剂没有预防得益(参考文献:Circ 2006;113:1164);

有前驱症状、发作前喝450-500毫升水(相当于1.5瓶瓶装水),有争议(参考文献:Circ 2003;108:2660);

③两年> 3次晕厥事件、而且可植入的事件记录器记录到心脏停搏> 3秒,这种情况起搏器植入的得益也存争议(参考文献:Circ 2012;125:2566);

④如果倾斜试验阳性而且没有心律失常,起搏器植入很可能无益(参考文献:EHJ 2014;35:2211)。

(3)体位性低血压、晕厥

液体容量补充(每天早上500毫升水),如果是慢性情况,起床时候一定要慢点,弹力袜、米多君,阿托莫西汀(作用尚存争议,参考文献:HTN 2014;64:1235)、氟氢可的松和增加含钠饮食。

7.预后

对特发性的晕厥,总体复发率为22%,其它情况,复发率是3%;

心源性晕厥:每年20%-40% SCD发生率,中位数存活时间为6年。

原因不能解释的晕厥:死亡率增加1.3倍,但非心源性,心电图正常、无室速、无心衰史和年龄<45岁的原因不能解释的晕厥,复发率低并且1年心脏性猝死的发生率<5%。

血管迷走性晕厥:不增加死亡、心肌梗死卒中风险。

点  评:

晕厥的原因复杂,不同原因导致的晕厥,预后差异很大。

仔细的病史采集、查体包括卧位和直立位的生命体征,在诊断方面有最佳的“费用-效益比”。

总体上,单一的客观辅助检查,对病因的诊断价值都不是很大。

胸中有剑——在排除心源性和神经源性的原因后,血管迷走性晕厥和占晕厥40%的“原因不明的晕厥”,预后良好。

专家简介

周鹏,男,临床医学博士、哲学博士、心血管内科副主任医师,留美博士后、研究员,北京明德国际医院内科主任。

周鹏医生是《西南医科大学学报》特约编委,中华医学会急诊医学分会心肺复苏学组委员,中国抗衰老促进会慢病防控工作委员会专家组常委,美国心脏协会会员,美国生理学会会员,美国心脏骤停基金会义务教员,美国科研协会会员,国际心电学会官方杂志《Journal of Electrocardiology》和欧洲心脏协会官方杂志《Cardiovascular Research》等国际专业期刊的论文评阅人,《Journal of Cardiovascular Disease Research(JCDR)》总编辑、美国华裔心脏协会(CNAHA)学术/教育委员会主席(2012-2018年)、美国华裔心脏协会公共健康教育部部长(2018年-)。从2007年以来,37篇科研摘要被美国心脏协会(AHA)科学年会接受并已发表在美国的《循环》杂志增刊上。

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createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-12-06 sfb591110

    学习了,谢谢分享。

    0

  2. 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createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2019-03-02 aids222
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createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-06-02 荒郊野树

    学习

    0

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createdAvatar=, createdBy=18741984753, createdName=smartxiuxiu, createdTime=Sun May 27 11:24:39 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319016, encodeId=73c4319016c3, content=晕厥原因很多.心缘性往往愈合不好., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzcjoLTEEgkSSQ8pVIiaf4a4INaoMLBV16QEk3dvvBRpicwIwmDGv0jePErJ4aE9ibVBDPtkialQLT9Bs/0, createdBy=04811949400, createdName=邓启付, createdTime=Sun May 27 10:39:09 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319007, encodeId=0d5531900ead, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-05-28 lily1616
  5. 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authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Mon May 28 06:29:17 CST 2018, time=2018-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319069, encodeId=8069319069c7, content=认真学习.不断进步.把经验分享给同好.点赞了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Sun May 27 14:13:31 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319032, encodeId=826a31903218, content=mark, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=18741984753, createdName=smartxiuxiu, createdTime=Sun May 27 11:24:39 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319016, encodeId=73c4319016c3, content=晕厥原因很多.心缘性往往愈合不好., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzcjoLTEEgkSSQ8pVIiaf4a4INaoMLBV16QEk3dvvBRpicwIwmDGv0jePErJ4aE9ibVBDPtkialQLT9Bs/0, createdBy=04811949400, createdName=邓启付, createdTime=Sun May 27 10:39:09 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319007, encodeId=0d5531900ead, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-05-28 lizhou0204
  6. [GetPortalCommentsPageByObjectIdResponse(id=354676, encodeId=3a1a3546e631, content=学习了,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Pw2csslt7CukWiabqiblnQARsVTQlGkb8xg4wNC2SBgoxvlIMpiaibIgUJh5ibtmCCj2hv9e7bzLL0KaNRFXcsLReiaFYDtDdbqWB1/0, createdBy=5fbb1577691, createdName=sfb591110, createdTime=Thu Dec 06 23:06:10 CST 2018, time=2018-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1684499, encodeId=6667168449929, content=<a href='/topic/show?id=dfae5133e1d' target=_blank style='color:#2F92EE;'>#心肺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51337, encryptionId=dfae5133e1d, topicName=心肺)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c8e128082444, 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authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Mon May 28 06:29:17 CST 2018, time=2018-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319069, encodeId=8069319069c7, content=认真学习.不断进步.把经验分享给同好.点赞了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Sun May 27 14:13:31 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319032, encodeId=826a31903218, content=mark, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=18741984753, createdName=smartxiuxiu, createdTime=Sun May 27 11:24:39 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319016, encodeId=73c4319016c3, content=晕厥原因很多.心缘性往往愈合不好., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzcjoLTEEgkSSQ8pVIiaf4a4INaoMLBV16QEk3dvvBRpicwIwmDGv0jePErJ4aE9ibVBDPtkialQLT9Bs/0, createdBy=04811949400, createdName=邓启付, createdTime=Sun May 27 10:39:09 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319007, encodeId=0d5531900ead, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-05-28 yfjms

    学习

    0

  7. 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authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Mon May 28 06:29:17 CST 2018, time=2018-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319069, encodeId=8069319069c7, content=认真学习.不断进步.把经验分享给同好.点赞了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Sun May 27 14:13:31 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319032, encodeId=826a31903218, content=mark, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=18741984753, createdName=smartxiuxiu, createdTime=Sun May 27 11:24:39 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319016, encodeId=73c4319016c3, content=晕厥原因很多.心缘性往往愈合不好., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzcjoLTEEgkSSQ8pVIiaf4a4INaoMLBV16QEk3dvvBRpicwIwmDGv0jePErJ4aE9ibVBDPtkialQLT9Bs/0, createdBy=04811949400, createdName=邓启付, createdTime=Sun May 27 10:39:09 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319007, encodeId=0d5531900ead, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-05-27 lietome2

    认真学习.不断进步.把经验分享给同好.点赞了!

    0

  8. 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createdAvatar=, createdBy=18741984753, createdName=smartxiuxiu, createdTime=Sun May 27 11:24:39 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319016, encodeId=73c4319016c3, content=晕厥原因很多.心缘性往往愈合不好., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzcjoLTEEgkSSQ8pVIiaf4a4INaoMLBV16QEk3dvvBRpicwIwmDGv0jePErJ4aE9ibVBDPtkialQLT9Bs/0, createdBy=04811949400, createdName=邓启付, createdTime=Sun May 27 10:39:09 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319007, encodeId=0d5531900ead, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-05-27 smartxiuxiu

    mark

    0

  9. [GetPortalCommentsPageByObjectIdResponse(id=354676, encodeId=3a1a3546e631, content=学习了,谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Pw2csslt7CukWiabqiblnQARsVTQlGkb8xg4wNC2SBgoxvlIMpiaibIgUJh5ibtmCCj2hv9e7bzLL0KaNRFXcsLReiaFYDtDdbqWB1/0, createdBy=5fbb1577691, createdName=sfb591110, createdTime=Thu Dec 06 23:06:10 CST 2018, time=2018-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1684499, encodeId=6667168449929, content=<a href='/topic/show?id=dfae5133e1d' target=_blank style='color:#2F92EE;'>#心肺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51337, encryptionId=dfae5133e1d, topicName=心肺)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c8e128082444, 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authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Mon May 28 06:29:17 CST 2018, time=2018-05-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319069, encodeId=8069319069c7, content=认真学习.不断进步.把经验分享给同好.点赞了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Sun May 27 14:13:31 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319032, encodeId=826a31903218, content=mark, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=18741984753, createdName=smartxiuxiu, createdTime=Sun May 27 11:24:39 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319016, encodeId=73c4319016c3, content=晕厥原因很多.心缘性往往愈合不好., beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzcjoLTEEgkSSQ8pVIiaf4a4INaoMLBV16QEk3dvvBRpicwIwmDGv0jePErJ4aE9ibVBDPtkialQLT9Bs/0, createdBy=04811949400, createdName=邓启付, createdTime=Sun May 27 10:39:09 CST 2018, time=2018-05-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=319007, encodeId=0d5531900ead, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfDEeydJz0GlP8O0ngrUX6AYCXFic0XDOOAyeQicIqnOd4TrWSwiagJrsFNYuWC1Uc6iavbS1hWt9xtZAhAqLGHqZyl/0, createdBy=42891977006, createdName=1e17414fm02(暂无匿称), createdTime=Sun May 27 09:59:30 CST 2018, time=2018-05-27, status=1, ipAttribution=)]
    2018-05-27 邓启付

    晕厥原因很多.心缘性往往愈合不好.

    0

  10. 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    2018-05-27 1e17414fm02(暂无匿称)

    学习

    0

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