《臨床病理討論會》ppt課件-文庫吧
2024-12-21 04:24 本頁面
【正文】 104 Initial Lab Data VBG: pH pCO2 pO2 HCO3 BE + Cardiac enzyme: CPK(U/L) CKMB Troponin I (ng/ml) 1040 CRP: mg/dl Initial Lab Data EKG (9/12): Initial Lab Data EKG (9/12): Initial Lab Data EKG (9/12): Initial Lab Data Echocardiogram (9/12): ? LV enlargement ? LVEF 45% ? Muscular VSD ? Mild MR, TR, PR Echocardiogram (9/12) Course and Treatment Management ? For cardiogenic shock: Dopamine, Dobutamin, Primacor, Lasix ? For ventricular arrhythmia: Amiodarone, Lidocaine, MgSO4 ? For myocarditis: IVIG, Consider extracorporeal membranous oxygenator (ECMO) support Course and Treatment 9/12 5pm (3 hr after admission) Progressive hypotension Sudden onset of a, BP drop (pulseless) EKG: ventricular tachycardia Start CPR (40 min) Start ECMO, transfer to SICU EKG (9/12, 5 PM) Course in SICU ECMO setting ? VA ECMO: 15 Fr R’t femoral artery, 19 Fr R’t femoral vein by cutdown ? Flow: 2022 ml/min ? Mean BP: 70 mmHg ? Urine output: ml/kg/hr Echocardiogram (9/13) Course in SICU VT persistent despite of cardioversion, Lidocaine, Amiodarone, MgSO4 9/12 ~ 9/17: ECMO 5 days ? Poor LV function ? Persistent lung edema (CXR, clinically) ? TnI slowly decrease ? Aline flatten, no pulsatile wave form Course in SICU Endomyocardial biopsy (9/14) ? Mild to moderate perivascular and interstitial lymphocyte infiltration ? Foci of myocyte degeneration ? Interstitial edema ? No giant cell Compatible with acute myocarditis Course in SICU LA drain (9/17): ? To depress LV, avoid thrombosis ? LA dome cannulation ? connecting to FV cannula ? ECMO ? FA ? LAP: 22 mmHg ? 10 mmHg Echocardiogram (9/17) Course in SICU 9/18, 4am ? Acute thrombosis at LA cannula and ECMO circuit ? poor flow ? CPR for 30 min. and emergent reset ECMO tubing ? Cons. After CPR: E1M1VT ? Light reflex (+) Course in SICU 9/19, 8am: gross hematuria and ECMO tube thrombosis ? reset ECMO Progressive dilated pupils, no light reflex, suspected hypoxic encephalopathy Remove ECMO on 9/23 (10th day) Lab data 9/12 9/13 9/14 9/15 9/16 9/17 TnI 100 74 CK 1040 9124 23421 26759 13864 7026
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