★胸前V字,張牙舞爪,急診唬爛熊是也★

今早一位60歲男性,過去有高血壓病史,並無糖尿病與抽煙.主述做生意時突然覺得胸口抽痛/悶痛至本院急診就診

一開始詢問病史時,病患表示過去並無此狀況,且左手開始麻麻的.當下問診完後,心中認為此病患為急性心肌梗塞的高危險群

病患09:30開始疼痛,09:45至本院急診

上一張在09:50做的.....當時看到有Hyperacute T wave.....內心再次和自己說,"這病人是高危險群AMI".....

病患給了NTG 1# sl st,morphine 3 mg後症狀稍微緩解.....

上一張在10:20分所做看起來T wave更高.....

當時已經和病患的女兒告知,她的父親是高危險群AMI病患,因為症狀典型,隨時都有心律不整可能性,且第一次的CK/CK-MB/TnI應該會是正常的,有可能需要觀察抽到第二次心臟酵素....

後來報告的確正常,此時病患的太太趕來急診,當時病患有點多,我還猶豫了一下要不要先解釋病患狀況,不過心理想了一下,還是解釋一下好了,畢竟懷疑是心肌梗塞,隨時都可能心律不整....

和太太解釋目前胸痛的診斷,與可能會發生的狀況後,我表示要做個心臟超音波看一下心臟收縮能力,於是將病患推到急救室旁的超音波....probe才剛放到胸壁上,病患就ㄚ了一聲,開始cyanosis,air-hunger....

此時趕緊call for help,女兒和太太大叫,趕快救他.....EKG monitor顯示VT/Vf.....電擊了200 j(Biphasic).....回復正常心律.....30秒後,病患意識開始回復....

上一張為DC shock 200j後的心電圖變化.....

給了STEMI的藥物後,轉院做PTCA.....

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今日感想:

1.感謝老天這病人沒有待在家裡,感謝老天讓我還抱持著急診人應有的敏感度

2.感謝老天,我那時有詳細解釋病患的狀況給家屬了解,因為我當時聽到家屬大叫"趕快救他",而不是"怎麼會這樣?!"因為有解釋清楚,家屬了解她老爸正在經歷我解釋病情時所說的心律不整,而不是我們把他老爸搞爛了!!!!

我覺得病情解釋真的很重要,因為往往醫糾就是在沒有詳細解釋與溝通不良下發生的....

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擷取一下ECG in Emergency Medicine and Acute care的一段針對Hyperacute T wave的文章

Hyperacute T Wave
In the ECG evolution of AMI, alteration in T wave morphology or amplitude may be the first sign of coronary occlusion (Fig. 32-4). Experimentally, these hyperacute T waves may form as early as 2 minutes after coronary ligation, but typically present within the first 30 minutes after a clinical event. Even at this early phase, there is only subendocardial ischemia without cell death. The first change to the T wave may be an oblique straightening of the ST segment (Fig. 32-4), followed by a subtle enlargement of the T wave, with diminishing R wave amplitude. The T waves, often bulky and wide, without much upward concavity, are localized to the area of injury. The J point is usually elevated, but may become depressed, with the T wave appearing to have its take-off below the isoelectric line (see Fig. 32-4). The ratio of T wave amplitude to QRS amplitude is a better indicator of AMI than T wave amplitude alone, and that ratio correlates with the duration of coronary occlusion. Reperfusion therapy begun while T waves are hyperacute has been demonstrated to correlate with a clinically better outcome because hyperacute T waves are a marker of early coronary occlusion.

上圖顯示四種hyperacute T wave的圖形