First responder training MMH 15 F Emergency Department

First responder training MMH 15 F Emergency Department Yu-Jang Su, MD 95/6/22 11: 15— 12: 05 6/22/2006 First Responder Training 1

常見內科疾病處 置一 Heart disease 心臟疾病 Stroke中風 Allergy , Asthma 過敏症及氣喘 6/22/2006 First Responder Training 2

衛 生 署 93 年 十 大 死 因 統 計 6/22/2006 First Responder Training 3

First responder重要性 • 緊急救護人數與日俱增 6/22/2006 First Responder Training 4

Heart disease ACS 急性冠心病 Arrhythmia 心律不整 Hypertension 高血壓 6/22/2006 First Responder Training 5

ST segment elevation 心電圖波形異常 6/22/2006 First Responder Training 10

生命之鏈 6/22/2006 First Responder Training 13

心電圖 • ECG or EKG ? –Electrocardiography –記錄心臟電氣活動. –ECG 是比較好的縮寫. 6/22/2006 First Responder Training 14

向量與波形 6/22/2006 First Responder Training 15

Precordial leads 6/22/2006 First Responder Training 16

速率 (心電圖的紀錄紙) 6/22/2006 First Responder Training 17

正常竇性心率, NSR • NSR: Normal Sinus Rhythm –規則心率 –速率正常: 100/min >心率>60/min –PR間隔固定且<0. 20秒 –無AV block –P波在lead II為正向 6/22/2006 First Responder Training 18

心悸VS頻脈 • 心悸: palpitation. 一種心慌的感覺. 自覺 有心跳感. • 頻脈: 脈搏> 100/min. 6/22/2006 First Responder Training 19

Tachyarrhythmia 心跳 >100/min • Narrow-complex tachycardia. (ectopic atrial tachycardia, MAT, PSVT) • Stable wide-complex tachycardia. VT 心室頻 脈 • Af with RVR, Atrial flutter. 心房震顫, 撲動 • Stable monomorphic VT, polymorphic VT • Vf 心室震顫 6/22/2006 First Responder Training 20

Bradyarrhythmia 心跳 < 60/min • • • 傳導阻滯 First degree AV block Second degree AV block type II Third degree AV block. 6/22/2006 First Responder Training 21

PSVT 陣發性心室上心搏過速 • rapid heart rate • which occurs from time to time (paroxysmal). • PSVT starts with events taking place above the ventricles. (supra-ventricular) • No visible P wave. 心電圖看不見P波 6/22/2006 First Responder Training 22

HR = 150/min. no visible P wave. 陣發性心室上心搏過速 6/22/2006 First Responder Training 23

Treatment of PSVT • Stable: vagal stimulation, adenosine. • 頸動脈竇按摩, 20— 25%有效回復正常心率. • 年輕患者常沒效. • preserved heart function: beta-blocker, CCB, digoxin. DC cardioversion. Antiarrhythmia (procainamide, amiodarone, sotalol. ) • EF < 40%, CHF : DC cardioversion, digoxin. Amiodarone, diltiazem. 6/22/2006 First Responder Training 24

VT 心室震顫 • Rate greater than 100 beats per minute (usually 150 -200) • Wide QRS complexes (>120 ms) 大於三小 格 • Presence of atrioventricular (AV) dissociation • Fusion beats • 無法有良好的心輸出 6/22/2006 First Responder Training 26

VT 心室頻脈心電圖 6/22/2006 First Responder Training 27

VT: monomorphic 心室頻脈用藥 : Procainamide, sotalol, Amiodarone, Lidocaine. Poor ejection fraction: Amiodarone 150 mg IV over 10 minutes. or Lidocaine 0. 5— 0. 75 mg/kg IV push. Then use synchronized cardioversion. • preserved heart function • 6/22/2006 First Responder Training 28

Vf 心室震顫 • • pulseless arrhythmia 無脈性心律不整 irregular and chaotic electrical activity loses its ability to function as a pump. Sudden loss of cardiac output with subsequent tissue hypoperfusion • creates global tissue ischemia; 沒有心 輸出 6/22/2006 First Responder Training 29

VF is the primary cause of sudden cardiac death (SCD). • Irregular, choatic. * Loss of cardiac output. Pulse-less. • brain and myocardium are most susceptible. 6/22/2006 First Responder Training 30

Vf, pulseless VT處置 • Primary ABCD. CPR. + defibrillation. (360 J) • 持續Vf, 無脈VT : on endo, IV, monitoring. CPR. DDx. • Bosmin 3— 5 minutes/ 1 Amp IV. • 或 Vasopressin 40 IU, 一次. 6/22/2006 First Responder Training 31

Af 心房震顫 • irregular, chaotic不規則 • ventricular waveforms varying • from bradyarrhythmia to tachyarrhythmia. • Irregular RR interval. • P wave absent. P波消失 6/22/2006 First Responder Training 32

Af symptoms • Sensation of feeling heart beat (palpitations) • Pulse may feel rapid, racing, pounding, fluttering, or it can feel too slow • Pulse may feel regular or irregular • Dizziness, light-headedness 頭暈 • Fainting 昏 • Confusion 意識混淆 • Fatigue 疲乏 • Shortness of breath 喘 • Breathing difficulty, lying down • Sensation of tightness in the chest 悶 6/22/2006 First Responder Training 33

6/22/2006 First Responder Training 34

Atrial flutter , 心房撲動 • very rapid, regular heart beat. • starts in the atria, or upper chambers of the heart. 6/22/2006 First Responder Training 35

6/22/2006 First Responder Training 36

First degree AV block 心房心室傳導 阻滯 • prolonged conduction in the AV junction; P-R interval is > 0. 20 seconds. • Rhythm is regular 規則心律 6/22/2006 First Responder Training 37

Etiology of first degree AV block • • • inferior MI, 心肌梗塞 digitalis toxicity 毛地黃毒性 hyperkalemia 高血鉀 increased vagal tone 副交感活性增加 acute rheumatic fever 風濕熱 myocarditis. 心肌炎 6/22/2006 First Responder Training 38

PR > 0. 20 seconds 6/22/2006 First Responder Training 39

P波與QRS的關係 (搭配) • 1: 1 - sinus rhythm –PR >0. 2 seconds: 1 st degree AV block • 2: 1 to 4: 1 - atrial flutter –P波呈鋸齒狀 • 不規則 –PR間隔愈來愈長, 然後QRS消失: 2 nd type 1 AV block –PR間隔固定, QRS突然消失: 2 nd type 2 AV block • 沒有關係 – 3 rd AV block 6/22/2006 First Responder Training 40

Second degree type I • Type I or Wenckebach: • P-R interval becomes progressively longer with each cycle until a nonconducted atrial beat occurs. PR節段 漸漸延長 • After the dropped beat the P-R interval is shorter. 6/22/2006 First Responder Training 41

PR 漸漸延長 6/22/2006 First Responder Training 42

Second degree type II • Constant P-R intervals preceding a non-conducted atrial beat. • Ventricular rate is irregular. • Atrial rhythm is regular. • 固定心房幾跳就有一跳傳不下去心室. 6/22/2006 First Responder Training 43

Second degree type II 6/22/2006 First Responder Training 44

3 rd degree AV block • 心房和心室各跳各的. 互不相干. 6/22/2006 First Responder Training 45

Intervention sequence • • • Atropine 0. 5— 1 mg. IV TCP if available. 經皮心律調節器使用. Dopamine 5— 20 μg/kg/min Bosmin 2 --10 μg/min Isoproterenol 2 --10 μg/min Consult CV doctor. 照會心臟專科. 6/22/2006 First Responder Training 46

Hypertension 高血壓 6/22/2006 First Responder Training 49

定義, 發生率 • 1. 5 -2. 0% among children aged 4 -15 years. • 年紀越大越多 • In USA, 24% of people. • Definition定義: BP > 140/90 mm. Hg. • Hypertension emergency高血壓危象: 1% of hypertension. 6/22/2006 First Responder Training 50

Hypertension emergency • 合併靶標器官target organ damage損 傷稱之. • LV failure with pulmonary edema. 心 • Unstable angina pectoris. 心血管 • Acute myocardial infarction. 心血管 • Dissection aortic aneurysm. 心血管 • Renal failure. 腎 • Eclampsia. 心血管, 神經系統 6/22/2006 First Responder Training 51

若無target organ damage • 稱之Hypertension urgency. 6/22/2006 First Responder Training 52

常見引起高血壓的原因 • 1. Essential (primary) hypertension (90%) • 2. Renal hypertension (5%) • a. Renal parenchymal disease (3%) • b. Renovascular hypertension (<2%) • Endocrine (4%-5%) • Oral contraceptives (4%) • 1. 1 Primary aldosteronism (0. 5%) • 1. 2 Pheochromocytoma (0. 2%) • 1. 3 Cushing's syndrome (0. 2%) • 1. 4 Coarctation of aorta (0. 2%) 6/22/2006 First Responder Training 53

6/22/2006 First Responder Training 58

Stroke 中風 6/22/2006 First Responder Training 59

分型 • 血管阻塞型. 70— 75% • 出血型25— 30% 6/22/2006 First Responder Training 60

中風有那些現象呢? • • Facial droop 臉部低垂 Arm Drift. 手臂漂移 Abnormal speech. 說話異常. Any 1 of 3, stroke rate: 72%. • Cincinnati Prehospital Stroke Scale. • Acad Emerg Med. 1997; 4: 986 -990 6/22/2006 First Responder Training 61

Facial droop – 6/22/2006 First Responder Training AHA 2005 62

Arm drift – • AHA 2005 AHA 2004 右手無力 6/22/2006 First Responder Training 63

Glasgow Coma Scale • Ｅｙｅ眼睛張開 • - 4: spontaneous. • - 3: to speech. • - 2: to pain. • - 1: none. 6/22/2006 First Responder Training 66

Glasgow Coma Scale • Ｖｅｒｂａｌ說話正確 • - 5: oriented. • - 4: confused. • - 3: words. • - 2: sounds. • - 1: none. 6/22/2006 First Responder Training 67

Glasgow Coma Scale • Ｍｏｔｏｒ四肢運動 • - 6: obey • - 5: localize to pain. • - 4: withdraw to pain. • - 3: decorticate • - 2: decerebrate • - 1: none. 6/22/2006 First Responder Training 68

Position , 病患姿勢 • Head up 30 degrees. 搖高床頭 30度. • 避免腦壓升高 6/22/2006 First Responder Training 70

使用血栓溶解劑(t. PA)適應症 • 1). 大於 18 y/o • 2). 血管阻塞型(Infraction) type. • 3). 中風三小時內. 6/22/2006 First Responder Training 71

絶對禁忌. 不可以用t. PA • • ICH. 顱內出血 顱內腫瘤, AVM, aneurysm, tumor. 中風病史 或 腦手術病史 高血壓控制不良, SBP> 185 mm. Hg. DBP> 110 mm. Hg. 中風合併seizure attack. 急性內出血 血小板< 10萬, 48 hours內用過heparin. INR >1. 7 or PT> 15 sec 因為wafrain 使用 6/22/2006 First Responder Training 72

6/22/2006 First Responder Training 74

Allergy 6/22/2006 First Responder Training 75

Family history • If neither parent is allergic, the chance for allergies is about 15%. If one parent is allergic, the risk increases to 30% and if both are allergic, the risk is greater than 60%. 6/22/2006 First Responder Training 76

treatment • Anti-histamine • Corticosteroid • Adrenaline 6/22/2006 First Responder Training 78

Asthma 氣喘 6/22/2006 First Responder Training 80

Asthma 判斷需小心 • 心衰竭肺水腫也會有喘鳴聲, 注意區分 6/22/2006 First Responder Training 85

References • 重症醫學秘笈. 3 rd ed. 合記. • ACLS精華. 第三版. P. 72 • 行政院衛生署 http: //www. doh. gov. tw/statistic/data/死 因摘要/93年/93. htm 6/22/2006 First Responder Training 90