臺大醫院急診心電圖討論會

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1 急診心電圖案例討論會 2017/03/08 報告醫師 : 張鈞傑醫師指導醫師 : 曲新蘭醫師 / 陳文鍾教授 1

2 Patient

3 Patient Data Age: 80 Sex: Male Chief complaint Shortness of breath with chest tightness 3

4 Present Illness Triage: T/P/R: 37.4/98/22, SpO2: 92%, BP: 149/79 mmhg This 80y/o gentleman has been well until 2 weeks ago Progressive SOB was noted Orthopnea and exertional dyspnea were noted There was no fever, and he was brought to our ED later 4

5 Past History Hypertension, under medication Physical Examination Consciousness: Clear, E: 4, V: 5, M: 6 Vital signs: Blood Pressure: 149/79mmHg, Pulse Rate: 98/min, Respiratory Rate: 22/min, Temperature: 37.4, SPO2: 92% Head: Scalp: Normal Pupils: Isocoric Conjunctiva: Not Pale Sclera: Anicteric Neck: Supple Jugular Vein Engorgement: - Lymphadenopathy: - Chest: Symmetric expansion, Breath sound: Clear Heart: Regular Heart Beat, Murmur: - Abdomen: Soft Bowel sound: Normal Extremities: Normal 5

6 6

7 陳文鍾教授現場指導 Sinus rhythm Left axis deviation LA enlarge Rule out LVH Poor R wave progression 當看到怪的 TWI 在 V1-V6, 除了 poor R wave progression 外, 也要考慮 lead position 可能代表嚴重的 LVH, 也可能是 old anterioinferior MI 7

8 8

9 EKG Interpretation Sinus rhythm with VPCs Left axis deviation R wave, V1-V6 LVH ST-T change at V1-V6 9

10 10

11 EKG Interpretation NSR, with frequent VPC T wave inversion at V1-V6 Rule out pulmonary hypertension Not suggestive for pulmonary embolism May be masked by LVH 11

12 Subsequent Course Consult CV man Echocardiogram D shape LV, RV McConnell's sign Dilated right heart TR, moderate to severe Chest CT McConnell s sign, that is regional RV dysfunction, with akinesia of the mid free wall but normal motion at the apex is a distinct echocardiographic finding described in patients with acute pulmonary embolism. Pulmonary embolism at bil. superior and inferior lobar arteries Patchy consolidation and peribronchial infiltration at the RML and left lung Cardiomegaly 12

13 Supplementary Material: What is McConnell s sign? Echocardiographic pattern of RV dysfunction consisting of akinesia of the mid free wall but normal motion at the apex 77% sensitivity and 94% specificity for diagnosis of pulmonary embolism 13

14 Supplementary Material: Echocardiographic Features of RV Dysfunction in Acute Pulmonary Embolism? RV wall hypokinesia Moderate or severe McConnell s sign RV dilatation End-diastolic diameter >30 mm in parasternal view RV larger than LV in subcostal or apical view Increased tricuspid velocity >26 m/sec Paradoxical RV septal systolic motion Pulmonary artery hypertension Pulmonary artery systolic pressure >30 mmhg Dilated IVC with lack of respiratory collapse 14

15 Subsequent Course Heparin 25000U in N/S 250ml, run 12ml/hr Admission 5CVI EKOS placement to bilateral PA on 2017/02/10 Discharge on 2017/02/24 15

16 Final Diagnosis Acute submassive pulmonary embolism at bilateral superior and inferior lobar arteries, status post thrombolysis via EKOS on 2017/02/10 Impending hypoxic respiratory failure, pulmonary embolism relarted 16

17 Patient

18 Patient Data Age: 35 Sex: Male Chief complaint Chest pain since morning 18

19 Present Illness Triage: T/P/R: 35.9/83/20, SpO2: 99%, BP: 141/86 mmhg Came in the morning of 2017/02/14 and discharge in the afternoon, return due to persistent chest pain since this morning Radiation to jaw and left shoulder No cold sweating or dyspnea 19

20 Physical Examination Physical Examination Head: Scalp: Normal Pupils: Isocoric Conjunctiva: Not Pale Sclera: Anicteric Neck: Supple Chest: Symmetric expansion, Breath sound: Clear Heart: Regular Heart Beat, Murmur: - Abdomen: Soft, no tenderness, no rebound pain Bowel sound: Normal Extremities: Normal No previous history of HTN, DM or CAD 20

21 1 st Time ER - Initial EKG 21

22 1 st Time ER - Follow-up EKG 4 Hours Later 22

23 EKG Interpretation Poor R wave progression TWI at avl Suspect STE at V2, V3; non-typical No dynamic change Non-diagnostic for AMI 23

24 2 nd Time ER (Returned Visit on Next Day) 24

25 陳文鍾教授現場指導 ST elevation at V1-V5 Anteroseptal MI 在初次來診的 EKG 無法診斷出 MI, 故在兩次 cardiac enzyme 追蹤正常後, 給予衛教並回 CV 門診是適當的做法 25

26 2 nd Time ER Follow-up EKG 4 Hours Later 26

27 27

28 Subsequent Course Consult CV Echocardiogram RWMA in LAD territory Primary PCI LM: Patent LAD: proximal total occulsion LCX: proximal stenosis 80% RCA middle diffuse stenosis up to 80%, distal 90% POBAS with DES*1 to LAD 28

29 Final Diagnosis Coronary artery disease, 3 vessel disease, complicated with anterior wall ST elevation myocardial infarction, status post percutaneous occlusive balloon angiography with stent(pobas) to left anterior decending (LAD) on 2017/02/15 Discharge on 2017/02/20 29

30 Patient

31 Patient Data Age: 56 Sex: Male Chief complaint Chest tightness since morning 31

32 Present Illness Triage: T/P/R: 37.1/105/20, SpO2: 95%, BP: 100/63 mmhg Past History DM, HTN; under medication Chest tightness, epigastralgia for 2 days since 02/25, went to FEMH. Gastritis, and then was discharged Chest tightness, epigastralgia, dyspnea and cold sweating in early morning of 02/27.Visit our ED then 32

33 Physical Examination Head: Scalp: Normal Pupils: Isocoric Conjunctiva: Not Pale Sclera: Anicteric Neck: Supple Chest: Symmetric expansion, Breath sound: Clear Heart: Regular Heart Beat, Murmur: - Abdomen: Soft, no tenderness, no rebound pain Bowel sound: Normal Extremities: Normal 33

34 34

35 陳文鍾教授現場指導 Sinus rhythm RBBB RSR 的第一個 R wave 消失, 要想到 anterior wall MI 有 Q wave 即可代表 MI Q wave over V1-V4, II, III, avf 35

36 36

37 Laboratory Results 37

38 Subsequent Course CV Echocardiogram Poor LV systolic function with LVEF 24.0% and enlarged LV chamber RWMA with aneurysmal change at apex and anteroseptal wall Heparin Bolus 4000U 15000U in N/S 250ml, run 10ml/hr Flumarin 38

39 EKG Diagnosis Non-ST elevation myocardial infarction 39

40 CAG Result (2017/03/02) LM: shaft stenosis 30 % LAD: proximal total occlusion LCX: proximal stenosis 60 %, distal stenosis 60 % RCA: proximal stenosis 50 %, middle stenosis 70 %, distal stenosis 60 % 40

41 Patient

42 Patient Data Age: 87 Sex: Male Chief complaint Shortness of breath, bradycardia noted at triage 42

43 Present Illness Triage: T/P/R: 34.7/33/26, SpO2: 100%, BP: 86/48 mmhg Past History Hypertension, Thalassemia; under medication Sudden onset of dyspnea and chest discomfort about one hour ago, with drowsy consciousness, which improved to normal 10 mins later No chest pain, no abdominal pain, no back pain Bradycardia at triage 43

44 Physical Examination Conscious: E4V5M6 Chest: Symmetric expansion, Breath sound: Clear Heart: Regular Heart Beat, Murmur: - Abdomen: Soft, no tenderness, no rebound pain 44

45 45

46 EKG Interpretation Atrial fibrillation, with slow ventricular rate and frequent VPC Complete AV block Inferior wall MI ST elevation at III ST depression at V2-V6 Peak T wave 46

47 Previous EKG (1 Year Before) 47

48 EKG, 1 Minute Later 48

49 陳文鍾教授現場指導 Idioventricular rhythm 給予 Doputamine/dopamine/epinephrine 會降低 VT/VF 的 threshhold 因此此病人重要的是要盡早進導管室在 AMI with bradycardia 的病人, TPM 應優先於 dopamine 49

50 Immediate Management Atropine 1mg, twice Poor response BP decreased to 63/46mmHg Dopamine premix 50

51 EKG, 9 Minutes Later 51

52 陳文鍾教授現場指導此心律不需要用 amiodarone control 因為此 AIVR 是因為給予 dopamine 降低 VT/VF threshold 的 effect 所引起, 不需要給予 amiodarone 應迅速進導管室, 做導管的同時一併放 TPM 控制心律另外 97 下的 VT 也不一定需要治療, 在 cardiac output 裡也只少了 atrial kicking, 故不一定需要把它打下來若要在急診室控制心律, TCP 是較好的選擇 52

53 EKG, 2 Minutes Later 53

54 EKG Interpretation Af, with moderate ventricular response ST elevation at III,aVF ST depression at V2-V6 54

55 55

56 Laboratory Data 56

57 Subsequent Course CV Echocardiogram LVEF:82.3%(M-mode), no visible mural thrombus Moderate AR,MR,TR, mild PR Moderate pulmonary hypertension CT No evidence of aortic dissection on CT Left atrial appendage thrombus Aspirin 3#, Plavix 4#, heparinization 57

58 CAG Results & Final Diagnosis CAG LM: Patent LAD: Patent LCX: Patent RCA: suspect distal embolization with spontaneous recanalization Final Diagnosis Inferior wall ST elevation myocardial infarction, emboli related, status post diagnostic cardiac catheterization on 2017/2/20 Permanent atrial fibrillation, with left atrial appendage thrombus 58

59 Patient

60 Patient Data Age: 63 Sex: Male Chief complaint Chest pain with numbness of 4 limbs 60

61 Present Illness Triage: T/P/R: 36.4/82/20, SpO2: 100%, BP: 174/94 mmhg Past History Hypertension, DM, CKD, CVA, CAD s/p stenting Chest tightness and dyspnea was found since afternoon (about 2 hour ago) Decreased urine outpput in recent one week, BW increased 2kg in 3 days No fever, no cough,no back pain, no orthopnea 61

62 Physical Examination Physical Examination Consciousness: Clear, E: 4, V: 5, M: 6 Chest: Symmetric expansion, Breath sound: Clear Heart: Regular Heart Beat, Murmur: - Abdomen: Soft Bowel sound: Normal Extremities: mild pitting edema 62

63 EKG (20:08) 63

64 陳文鍾教授現場指導 LBBB pattern Peak T wave in V1-V5 單獨 V2 特別高, 會先考慮馬上再做一張 64

65 65

66 Laboratory Data 66 臺大醫院急診醫學部/NTUH-ED

67 Subsequent Course Start treatment for hyperkalemia Calcium gluconate Calcium chloride Insulin Sodium Bicarbonate Beta-agonist Lasix Kalimate Potassium level slowly normalized 67

68 EKG (20:14) 68

69 陳文鍾教授現場指導 Sinus rhythm with new onset LBBB 若 TnT 高, 則須做導管 69

70 EKG (20:37) 70

71 EKG (21:33) 71

72 EKG (00:30) 72

73 Subsequent Course & Final Diagnosis EKG returned to baseline after potassium level normalized LBBB, hyperkalemia related Diagnosis Hyperkalemia, with related new onset LBBB 73

74 Key Words Pulmonary embolism McConnell s sign Acute myocardial infarction Accelerated idioventricular rhythm Hyperkalemia 74

75 Thank You for Your Attention! 75

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