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1 1 急診心電圖案例討論會報告醫師 : 劉傑翹醫師指導醫師 : 方耀德醫師 / 陳文鍾教授

2 2 PATIENT 132 A 41-year-old male presented to ER for chest pain radiation to back for 1 day. (2016/03/17 0:51)

3 CLINICAL PRESENTATION [C. C.] Chest pain radiation to back since 3/16 2pm [P. H.] Hypertension [P. I.] Intermittent chest tightness in recent one week which subsided after rest Persistent chest pain radiation to back since 3/16 2pm despite sublingual NTG usage for 4 times No cold sweating 3

4 CLINICAL PRESENTATION [Vitals] BP: 135/81 mmhg, T/P/R: 36.7/89/16 [P. E.] Chest: symmetric expansion Breath sound: Clear Heart: regular Heart Beat Murmur: no obvious murmur Extremities: no pitting edema 4

5 ECG (2016/03/17 0:57) 5

6 OLD ECG (2011/12/21, baseline) 6

7 What s your interpretation? What s your next step? 7

8 ECG FINDINGS AND DIAGNOSIS Sinus rhythm V1-V3 poor R wave progression T wave inversion (TWI) in avr and avl 8

9 Professor Chen s Comments V1 到 V3 的 poor R wave progression, 這時要想是否有舊的 anteroseptal myocardial infarction. V2 很深,>30mm, 要考慮 LVH 但是病人主訴痛到背後, ACS 很少痛到背後, 應測四肢血壓, 有無 heart murmur, 照 CXR, 優先排除 aortic dissection, 再來考慮 anteroseptal MI 和 LVH. 9

10 LABORATORY STUDIES 10

11 ECG (2016/03/17 02:25) 11

12 ECG (2016/03/17 04:27) 12

13 ECG FINDINGS AND DIAGNOSIS Sinus rhythm TWI in avr,avl and V2-3 STE over V2-V3 STEMI 13

14 Professor Chen s Comments 這種新的 Infarction 發生在舊的 lesion 上, 表現不會那麼 typical, 這種做 emergent cath 是 ok 的. STEMI 和 NTEMI 最主要的不同是, STEMI 的要求是儘早要做 cath; NSTEMI 目前 study 比較小時後做和緊急做預後差不多. 在這邊提醒大家, 有痛到背後的病人, CXR 要看, 摸一下四肢 pulse, 聽一下有無 AR murmur, 在本院的經驗, 100 個 cases 有一個左右是 aortic dissection 造成的 AMI. 問 : 是否符合 Wellen s syndrome? 答 :Typical Wellen 是正常 QRS, 在 V1-3 有 biphasic inverted T wave, 是 critical LAD 的 lesion, 可是這個病人過去有 anteroseptal infarction, 所以我診斷是舊的 anteroseptal myocardial infarction 加上新的 insult. 14

15 COURSE AND TREATMENT Emergent CAG: LM: Patent LAD: proximal total occlusion LCX: Patent RCA: Patent 15

16 FINAL DIAGNOSIS CAD, 1VD, complicated with anterior STEMI, status post POBAS to LAD 16

17 17 PATIENT 133 A 43-year-old female presented to ER for shortness of breath for two days. (2016/03/10 21:58)

18 CLINICAL PRESENTATION [C. C.] Shortness of breath for 2 days [P. H.] No systemic disease [P. I.] Dyspnea for 2 days, decreased urine output Orthopnea, paroxysmal nocturnal dyspnea (+) Could not climb stairs, only could walk 20 meters [Vitals] BP: 151/69 mmhg, T/P/R: 36.7/122/22 [P. E.] Chest: Symmetric expansion, Breath sound: Coarse over bilateral lower lungs Heart: Irregular Heart Beat, Murmur: (-) No leg edema 18

19 ECG (2016/03/10 22:50) 19

20 What s your interpretation? What s your next step? 20

21 ECG FINDINGS AND DIAGNOSIS Sinus rhythm, HR TWI over V1-V6, III, avr, avf Prominent S wave over I, Q wave over III Sinus Tachycardia with S1Q3T3 21

22 Professor Chen s Comments 這種 pattern 有兩個可能性, 第一個是 pulmonary embolism(pe) due to acute thromboembolism, 但是有一點不合, history 有 Paroxysmal nocturnal dyspnea(pnd), 通常 PE 不會這樣, 這樣要想 heart failure(hf), 要考慮 dilated cardiomyopathy. 要從病史釐清到底有沒有 PND, 因為有 PND 症狀的病人 90% 是 HF. PE 的 EKG 表現 : Sinus tachycardia(80-90%),rbbb(60-70%),twi in precordial leads(30-40%),s I Q III T III (20-30%) 22

23 LABORATORY STUDIES 23

24 COURSE AND TREATMENT C+A+P CT with both contrast 1. Pulmonary thromboembolism with pulmonary hypertension. 2. RUL part-solid opacity and LLL ground glass opacity, suspect inflammatory/infectious process related Clexane and heparin(3/11-3/12), Urokinase(3/12-3/14) APS IgM(+) -->suspect antiphospholipid syndrome 24

25 COURSE AND TREATMENT 25

26 FINAL DIAGNOSIS 1. Subacute pulmonary embolism, with right ventricular dysfunction, status post Clexane and heparin(3/11-3/12), status post urokinase(3/12-3/14) 2. Suspected antiphospholipid syndrome(pulmonary embolism, antiphospholipid antibody IgM positive) 26

27 27 PATIENT 134 A 51-year-old male presented to ER for chest pain for 1 day. (2016/03/18 17:19)

28 CLINICAL PRESENTATION [C. C.] Chest pain since 2-3pm [P. H.] No systemic disease [P. I.] Sudden onset palpitation, black-out sensation and chest tightness this afternoon Symptoms persisted for 10 minutes before relieved under rest [Vitals] BP: 137/75 mmhg, T/P/R: 36.2/131/18 [P. E.] Chest: Symmetric expansion, Breath sound: Clear Heart: Irregular Heart Beat, Murmur: (-) No dyspnea, orthopnea, leg edema 28

29 ECG (2016/03/18 17:22:36) 29

30 What s your interpretation? What s your next step? 30

31 ECG FINDINGS AND DIAGNOSIS Monomorphic QRS with regular rhythm No P wave Ventricular tachycardia 31

32 Professor Chen s Comments 這個是 monomorphic VT, 可以先考慮整流或給藥物, 藥物部分 class I (lidocaine) 或 class III (Amiodarone) antiarrhythmia agent 都能用. 這個 EKG 大部分是 VT, 但如果 history 問到 recurrent attack, 就要考慮可能是 WPW syndrome. 32

33 ECG (2016/03/18 17:36) After cardioversion 100J 33

34 Professor Chen s Comments 假如是 DC shock 後的 EKG, 則 ST segment 的變化此時會比較不可靠, 通常電擊後相關的 ST elevation 會在十分鐘後消失. 十分鐘後追蹤的 EKG 如果還是 avr STE 和 diffuse ST depression 的話, 就可以當成是真的 critical lesion, 如果是真的, 就要想 LM lesion, severe 3 vessels disease, severe aortic stenosis 或 hypertrophic obstructive cardiomyopathy (HOCM). 這個 case 應該要在十分鐘後追蹤 EKG. 34

35 ECG (2016/03/18 20:21) 35

36 LABORATORY STUDIES 36

37 COURSE AND TREATMENT 2016/03/18 18:57:27 Coronary Angiography: LM: patent LAD: patent LCX: patent RCA: patent 2016/03/23 19:35:35 EPS: No VT was induced by programming induction Patient hesitate about ICD installation discharge and OPD follow up 37

38 Professor Chen s Comments 這個病人的 heart echo 很重要, 因為要 rule out aortic stenosis 和 HOCM, 如果 heart echo 報告都還好, 病人不想裝 ICD 可以選擇吃藥. 過去研究, LVEF >45% 的病人裝 ICD 和吃藥的預後差不多. 這個病人做 CAG 很合理, 因為大部分的 VT 都是 coronary artery 的問題. 38

39 FINAL DIAGNOSIS Idiopathic Ventricular tachycardia 39

40 40 PATIENT 135 A 67-year-old female presented to ER for shortness of breath for days with legs edema. (2016/03/06 14:29)

41 CLINICAL PRESENTATION [C. C.] Shortness of breath for one day [P. H.] DM [P. I.] Shortness of breath, legs edema (+) Cough for one week without fever No chest tightness or abdominal pain [Vitals] BP: 171/70 mmhg, T/P/R: 36.8/44/22 [P. E.] Chest: Symmetric expansion, Breath sound: Clear Heart: Irregular Heart Beat, Murmur: - Dyspnea (+), no orthopnea, leg edema (+) 41

42 ECG (2016/03/06 14:42) 42

43 What s your interpretation? What s your next step? 43

44 ECG FINDINGS AND DIAGNOSIS P waves are not related to the QRS complexes (PP interval and QRS interval both constant) Complete AV block 44

45 Professor Chen s Comments Complete AV block symptom 厲害就考慮 pacing, 如果 symptom 不厲害可以先 review medication history. 很多藥物會引起 AV block, 包括 CCB, beta blocker, digoxin, 中藥如蟾酥等. 45

46 LABORATORY STUDIES 46

47 COURSE AND TREATMENT Temporary pacemaker insertion (2016/3/7-3/14), permanent pacemaker implantation (2016/3/14, DDDR mode) 47

48 FINAL DIAGNOSIS Complete atrioventricular block, complicated with lung edema, status post temporary pacemaker insertion (2016/3/7-3/14), status post permanent pacemaker implantation (2016/3/14, DDDR mode) 48

49 49 PATIENT 136 A 94-year-old male presented to ER for shortness of breath for 1 day. (2016/04/06)

50 CLINICAL PRESENTATION [C. C.] Dyspnea and desaturation for 1 day [P. H.] CAD, 1vd s/p POBAS to LAD, infiltrative liver disease, CKD I-V-D, Parkinsonism, Alzheimer disease, DVT [P. I.] shortness of breath, desaturation, sputum(+) diarrhea for times [Vitals] BP: 173/72 mmhg, T/P/R: 37.8/87/38 SpO2 87% [P. E.] Chest: Symmetric expansion Breath sound: Clear Heart: Irregular Heart Beat, Murmur: (-) No orthopnea, leg edema 50

51 ECG (2016/04/06 22:58) 51

52 OLD ECG (2016/03/16) 52

53 What s your interpretation? What s your next step? 53

54 ECG FINDINGS AND DIAGNOSIS Irregular rhythm Abnormally shaped P wave Sinus tachycardia with multiple premature atrial contraction(pac) Multifocal atrial tachycardia(mat) / Chaotic tachycardia 54

55 Professor Chen s Comments Irregular-regular rhythm, 這種一般兩種常見的要想, 一種是 atrial fibrillation, 另一種是 multifocal atrial tachycardia. 這一張 EKG 比較像 MAT. 每一個 Pwave 都長得不太一樣, 這種 MAT 大部分是 respiratory failure related, 第一步做的是 review 有無使用 aminophylline, Beta agonist 過量 ; 第二步 review 有沒有 respiratory distress. 要 treat underlying 的問題, 不要 focus 在這個 rhythm 上. 假如 MAT 快到影響 hemodynamic, 可以考慮用的藥是 amiodarone 或 beta blocker. 55

56 LABORATORY STUDIES 56

57 Image 57

58 COURSE AND TREATMENT Treat as pneumonia at ED observation area Supportive care due to DNR (except drugs) 58

59 ECG (2016/04/09 09:28) 59

60 ECG FINDINGS AND DIAGNOSIS Intermittent episodes of slow and fast rates A burst of atrial fibrillation followed by a long arrest with a junctional escape beat Tachycardia-bradycardia syndrome 60

61 FINAL DIAGNOSIS 1. Pneumonia with impending respiratory failure 2. Tachycardia-bradycardia syndrome 61

62 Professor Chen s Comments 這一張變成 paf (Paroxysmal atrial fibrillation), 太多的 APC, 本來還在 organize, 各在搶拍子 induce 的 long pulse, 重點還是 correct respiratory system 的問題. 問 : 假設不是在 respiratory failure 病人身上看到, long pulse >1 秒需不需要 intervention? 答 : 不用, 通常 Holter 報告上有意義的要 2.5 秒 -3 秒, 會考慮裝 pacemaker. 62

63 KEY WORDS STEMI NSTEMI Pulmonary embolism S I Q III T III (S1Q3T3) Ventricular tachycardia Third degree AV block Complete AV block Multifocal atrial tachycardia Chaotic tachycardia Tachycardia-bradycardia syndrome 63

64 Thanks for Your Attention! 64

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