caz: barbat 51 ani [...]

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caz: barbat 51 ani [...]

Postby cerbu » Sun Nov 02, 2003 2:44 am

barbat 51 ani, nu a mers niciodata la medic, nu ia nici un medicament, vine in camera de garda cu durere precordiala care a inceput in urma cu o ora. a primit 3 nitro. in ambulanta, dar continua sa acuze dureri precordiale cu iradiere in bratul stang, 5-6/10 in intensitate. tensiunea 137/75, pulsul 84. examenul fizic nu identifica galop sau raluri crepitante. care este tratamentul?
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Postby cerbu » Sun Nov 02, 2003 2:19 pm

tratamentul cu cele mai mari sanse de succes este PTCA de urgenta, daca door to angioplasty time este mai putin de 90 minute.

bolnavul a primit retevase 10 unitati repetate la 30 minute, metoprolol 5mg la fiecare 5 minute X3, heparina 5000 u bolus si perfuzie 1000/h.

la o ora dupa retevase ekg arata asa( see attach), dar bolnavul continua sa acuze dureri precordiale, asa ca a fost transferat la un centru cu facilitati de PTCA pentru" rescue" angioplasty.

Fibrinolytic agents induce clot lysis in 60-90% of pacients but normalise coronary blood flow in only 30-60% of IRA( infarct related artery) by 90 minutes, depending on the agent used. -see the Washington Manual of medical therapeutics ed 30 pag 113.
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Postby Hawkeye » Sun Nov 02, 2003 9:58 pm

Cerbu, nu vreau sa fiu carcotas, ci chiar ma intereseaza. Noi, la cardio, am invatat ca in IMA se face obligatoriu si analgezie (chiar Morfina). Bolnavului din acest caz i s-a dat ceva pt durere? Mersi anticipat.
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Postby dankat23 » Sun Nov 02, 2003 11:59 pm

aspirina, O2 si morfina probabil s-au facut in faza prespital.

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Postby cerbu » Mon Nov 03, 2003 1:12 am

scuze, evident a primit morfina cate 2 mg intravenos cam la 10 minute. am uitat sa adaug nitroglicerina( pasta) probabil pentru ca a avut putin efect.

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Re: caz: barbat 51 ani [...]

Postby ssss » Thu Mar 31, 2011 12:28 am

Barbat, 48 ani, cunoscut cu boala coronariana, fumator, se prezinta cu durere precordiala care l-a trezit din somn. Cardiograma arata asa, cam la 8 ore de la debutul durerii:

Image

Durerea persista dupa perfuzie cu nitroglicerina, Enoxiparina-full dose, Aspirina.

Initial durerea relativ controlata cu Nubain, dar pacientul acuza dureri recurente severe in ER, in timp ce asteapta sa fie transferat in Coronary Care Unit ( nu sunt paturi). Tensiunea 98/60, puls 95.

Troponina 1.04 aceeasi repetata la 6 ore ( normal <0.07). Creatinina 0.9.

Intrebarea mea este in ce teritoriu vascular se intampla treaba asta?
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Re: caz: barbat 51 ani [...]

Postby Mephistopheles » Thu Mar 31, 2011 2:52 am

e neobisnuit un infarct de v drept izolat. deobicei s-ar asocia cu un infarct inferior.
hipotensiunea e sugestiva. verificam jugularele daca sunt turgescente. inregistram si un ecg de partea dreapta.

e good practice ca de fiecare data cand avem supradeniv ST in deriv inf (d2 d3 avf) sa facem si un ecg drept.
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Re: caz: barbat 51 ani [...]

Postby vmc » Thu Mar 31, 2011 6:50 pm

am si eu cateva intrebari: cunoscut si cu tensiune arteriala? tensiunea arteriala stanga-dreapta? ecografia cardiaca, CT? pacientul mai traieste?

eu o supradenivelare pe EKG-ul asta nu prea vad, nici semne clare de ischemie, dar poate e prea mic monitorul meu :wink:
nicht wahr?

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Re: caz: barbat 51 ani [...]

Postby Mephistopheles » Thu Mar 31, 2011 7:09 pm

pai, dupa cum ziceam mai sus, cred ca e vba de un infarct de ventricol drept izolat. nu ai cum sa vezi semne de ischemie sau necroza pe derivatiile astea, pt ele 'vad' doar VS.
ssss intreaba de teritoriu vascular deci nu ne gandim la disectii de aorta, pericardite, pneumotoracsi sau altele.
desi acuma ca ma gandesc mai bine ar putea fi vba si de terit vasc pulmonar - embolie pulmonara. deci, dc nu e nimic in dreapta pe ECG, iar d-dimerii nu infirma EP, se recomanda CTPA.
dar asteptam pe ssss cu confirmarea.
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Re: caz: barbat 51 ani [...]

Postby vmc » Thu Mar 31, 2011 8:21 pm

eu tie practic ti-am raspuns cand am zis ca nu vad nici o supradenivelare (ziceai un post mai devreme ca o supradenivelare inferioara, etc). si daca e infarct mai cedeaza durerea la nitro (chiar daca nu total), iar troponimele sunt constante la 6 ore. asteptam. eu pledez pentru disectia de aorta (n-are dispnoe, durere constanta la administrare de nitrati, EKG normal, durerea aparuta brusc, e tanar (putin probabil un sindrom paraneoplagic), neimobilzat sa ma gandesc la o embolie. etc) asa la rece poti face un milion de scenarii, daca-mi venea in ambulanta i-as fi facut urgent un eco si apoi CT.
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Re: caz: barbat 51 ani [...]

Postby Mephistopheles » Thu Mar 31, 2011 10:34 pm

nu sunt supradenivelari nicaieri, eu ma refeream ca in cazul (nu cel de fata) in care vedem semne de infarct inferior (supraden in deriv inf) e good practice sa verificam si ventriculul drept, pt ca merg adesea impreuna, iar managementul difera dc e implicat si VD.

eu ma gandeam ca ssss zice de teritoriu vascular ca sa ne ajute sa mai restrangem din optiuni. altfel putem sa scriem direct tot algoritmul de chest pain presentation.
chestia cu nu cedeaza la nitro nu e un criteriu valabil pt excludere. si nici troponin test-ul nu poate exclude un MI in primele 12 ore de la debutul durerii.
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Re: caz: barbat 51 ani [...]

Postby Mephistopheles » Thu Mar 31, 2011 10:53 pm

ssss wrote:Initial durerea relativ controlata cu Nubain

Interesant, nu folositi morfina? Initial credeam ca esti in UK, dar probabil ca esti in US daca zici de Nubain.
Stiati ca nalbufina, subst activa din nubain, e extrem de gender-dependent? Actioneaza f bine ca analgezic la femei, pe cand la barbati poate chiar sa scada pragul dureros, e antianalgezic :) .
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Re: caz: barbat 51 ani [...]

Postby ssss » Fri Apr 01, 2011 11:58 am

Nu stiu de ce i-au dat Nubain. Rezidenta de ER( IQ 70) s-a gandit probabil ca e indicat. Standard e Morfina. Nu cred ca a dat NUbain din cauza tensiunii, nu era mica initial.

Da, e oarecum de asteptat sa aiba un infarct pe coronara dreapta. Motivul pentru care am postat cazul este pentru ca domnul avea inca unul pe circumflexa si nu e deloc aparent pe EKG.

Am sunat cardiologul de garda si m-am rugat de el sa-l duca urgent la cath lab, desi nu avea STEMI. Nu era pacientul lui( isi concediase cardiologul si nu vroia sa auda de el aici il inteleg, celalalt e un magar). L-a dus la cath lab pentru ca ma cunostea si i-a fost jena sa refuze ( i-am stricat tot programul dimineata aia).

Surpriza a fost la fel de mare pentru amandoi:

Daca aveti timp cetiti tot protocolul operator, daca nu doar concluziile. Am avut noroc ca a fost cardiologul asta de garda, cu altul mai putin skilled sau receptiv putea sa fie naspa.

POSTOPERATIVE DIAGNOSIS: Acute non-ST elevated myocardial infarction
with near occlusion of the circumflex artery with unstable plaque and
thrombus with critical stenosis with ruptured plaque and thrombus in
the right coronary also with successful complex catheter intervention
this procedure.
A. 99-100% circumflex/OMB stenosis with TIMI 0-TIMI I flow at the
bifurcation point of the large obtuse marginal branch with thrombus
and ruptured plaque reduced to 0% stenosis with complex angioplasty
and stenting and adjunctive thrombectomy with 0% residual stenosis and
restoration of TIMI III flow.
2. 95% proximal right coronary stenosis with ruptured plaque and
thrombus reduced to 0% stenosis with thrombectomy and IVUS-guided
stenting with a Xience drug-eluting stent with TIMI III flow.
3. 20% LAD plaquing
4. Mild inferolateral hypokinesis post-intervention with a 45%
ejection fraction.
PROCEDURE IN DETAIL: The patient was taken emergently from the
Emergency Room to the Cath Lab with ongoing 9/10 chest pain and
hypotension with rising troponins and MBs with only minimal injury
noted on the EKG with subtle inferior ST change. This situation was
discussed very frankly with the patient and his wife and daughter (the
daughter is a resident) in the Emergency Room. The high risks
involved were discussed. The alternatives were discussed. The
patient and family stated they understood the risks and accepted them
and wished to proceed with emergency catheterization, catheter
intervention, and if unavoidable, bypass grafting.
The patient was prepped and draped in sterile fashion. Anesthesia was
obtained with 1% Xylocaine with local infiltration. Vascular access
was obtained via the right femoral artery with first pass anterior
stick and a 7 French sheath put in place. Later in the case, a 6
French sheath was put in place in the right femoral vein for vascular
access. A 3DRC and left number 4 Judkins catheters were used to image
the right and left coronaries, respectively. On initial imaging, the
right coronary was critically stenosed with evidence of ruptured
plaque and thrombus. It was felt to be the culprit lesion until the
left coronary was imaged, and left coronary imaging revealed near
complete occlusion of the circumflex artery, which was a very large
vessel at the bifurcation point of a large obtuse marginal branch.
The obtuse marginal branch filled with collaterals from the critically
stenosed right coronary. The situation was very grave and the
patient's blood pressure was in the 80s. Perfusion had been called
and Dr. X, cardiovascular surgeon, was called and came to the
Cath Lab. The situation was reviewed. The options were felt to be
emergency bypass surgery versus emergency catheter intervention. It
was felt that catheter intervention could reestablish flow and
interrupt the infarction and injury more promptly than the bypass
surgery, and the bypass surgery would be fraught with very high risk
under the current circumstances, although so would catheter
intervention. It was decided to proceed with catheter intervention.
If restoration of normal flow in the circumflex territory could not be
reestablished quickly, he would go to bypass grafting.
An Angiomax bolus and infusion was initiated. He had been on full
dose heparin on arrival to the Cath Lab. However, nitroglycerin had
been stopped due to the hypotension. He had been premedicated with
mag sulfate. The vessel was premedicated with intracoronary Cardene.
Later, cautious 50 microgram doses of nitroglycerin were given. Later
in the case, a double bolus of Integrilin with infusion was initiated
as well. ACTs were obtained to ensure adequate anticoagulation.
An EBU 3.5 guiding catheter was placed to the ostium of the left main
followed by passage of two 0.014 Whisper wires. Significant molding
was required to enter the circumflex system. The first wire was
passed across the lesion in the distal circumflex, the second across
the lesion into the obtuse marginal branch. Pronto thrombectomy was
performed. Significant white and red thrombus was retrieved and TIMI
III flow was reestablished to the circumflex system. IVUS
interrogation was performed with a Volcano ultrasound catheter.
Consideration was given whether to try to park the stent in the
bifurcation versus stenting across the marginal or stenting into the
marginal and reopening the AV circumflex. The marginal branch was
significantly larger than the continuation of the circumflex itself.
It was the main branch of the circumflex system, although a
moderate-sized distal marginal was given off as well. The stent was
initially passed across the ostium of the large marginal with plan to
reopen it; however, prior to deploying the stent, it was imaged
carefully and it was felt that reopening the ostium of the marginal
branch and treating the lesion at the ostium would be extremely
difficult. T stenting was felt to be also very difficult under the
current circumstances due to marked size discrepancy between the
circumflex proximal to the marginal and distal. It was felt best to
stent into the marginal branch and then reopen into the AV circumflex.
This stent was placed on the marginal branch wire and placed slightly
into the marginal branch and across the area of occlusion proximal to
the bifurcation. At this point, a 2.75 x 12 mm Xience stent was
deployed initially at 9 atmospheres and taken to 10, and after
withdrawing it into the main body of the circumflex taken to 12
atmospheres. A third Whisper wire was passed through the stent struts
into the distal circumflex. The wire was trapped. The stent was then
removed. A 2.5 NC Voyager was used to dilate into the main body of
the circumflex. Kissing technique was then performed with the stent
balloon in the circumflex and the 2.5 NC Voyager in the main body of
the circumflex, both taken to 6 atmospheres. NC had been previously
taken to 12 atmospheres. The very proximal portion of the stent was
then dilated with a 3.0 x 8 mm Voyager balloon to 10 atmospheres.
IVUS interrogation revealed excellent patency of the circumflex into
the marginal and good patency distal to the marginal. Initially, we
placed a stent into the main body of the circumflex distal to the
initial stent, however, would not readily cross and then after
nitroglycerin was given and additional dilatation performed and IVUS
interrogation was performed, it was felt unnecessary to proceed with
additional stenting. Final images of the circumflex were performed
after guidewire was removed and attention turned to the right
coronary.
A 3DRC catheter with sideholes was placed to the ostium of the right
coronary followed by passage of a 0.014 Whisper wire. This was
followed by passage of a Pronto thrombectomy catheter and thrombus was
retrieved. IVUS interrogation revealed ruptured plaque in the
proximal right coronary with near occlusion. The lesion was stented
with a 4.0 x 23 mm Xience drug-eluting stent deployed at 9 atmospheres
and taken to 14 atmosphere high pressure inflation and balloon size of
4.26 mm. IVUS interrogation revealed full patency of the stent site
with good wall apposition and good proximal and distal edges with no
complication. The guidewire was removed and final images performed.
Ventriculogram then performed in RAO 30 projection. The procedure was
then terminated. He was asymptomatic post-procedure with stable
hemodynamics.
Right femoral site was clear with no bleeding, bruising, or hematoma.
FINDINGS:
HEMODYNAMIC DATA: The left ventricular pressure was 98/4/12 post-PCI
with an aortic pressure of 102/56/78.
VENTRICULOGRAPHY: The left ventricle was normal in size with
hypokinesis of the inferolateral wall with a 45% ejection fraction.
There was no mitral regurgitation.
CORONARY ANGIOGRAPHY:
1. Left main coronary appeared free of stenosis. It bifurcated into
the left anterior descending and circumflex artery.
2. Left descending artery was a large vessel with 20% proximal
plaquing. It was free of significant disease.
3. The circumflex artery was a ________ large vessel and was
essentially occluded in its proximal portion with initially no
significant antegrade flow. On subsequent injections, flow did
develop in the distal vessel and a 99% lesion in the proximal
circumflex just proximal to the bifurcation of the large marginal
branch was noted. Significant thrombus appeared to be present. Some
collateral filling of the circumflex from the right coronary was
subsequently noted.
4. The right coronary is a huge dominant vessel with 95% proximal
lesion with ruptured plaque angiographically with associated thrombus.
As noted above, it did give collateral filling to the circumflex
system.
PCI RESULTS:
1. The 99-100% lesion of the circumflex with TIMI 0-TIMI I flow
involving the obtuse marginal branch was reduced to 0% stenosis
following thrombectomy and stenting with a Xience drug-eluting stent
with complex dilatation into the distal circumflex with kissing
technique with TIMI III flow reestablished in the obtuse marginal
branch and in the distal circumflex with no complications.
2. The 95% proximal right coronary lesion with ruptured plaque and
thrombus reduced to 0% stenosis with thrombectomy and IVUS-guided
stenting with a Xience drug-eluting stent with TIMI III flow and no
complications.
DISCUSSION AND RECOMMENDATIONS: The patient was sustaining a large
non-ST elevated myocardial infarction due to central occlusion of the
circumflex and near occlusion of the right coronary with ruptured
plaques and thrombus in both vessels. After discussion with
cardiovascular surgeon, emergency catheter intervention was proceeded
with treatment of the complex bifurcational lesion in the circumflex
with thrombectomy and IVUS-guided angioplasty and stenting a Xience
drug-eluting stent used with the 99-100% lesion reduced to 0%
stenosis, restoration of TIMI III flow, with no detectable thrombus,
and the 95% lesion with ruptured plaque and thrombus in the huge
dominant right coronary was reduced to 0% stenosis with no visible
residual thrombus following thrombectomy and IVUS-guided stenting with
a Xience drug-eluting stent. At time of this dictation, the patient
is asymptomatic. He was hypotensive on arrival to the Cath Lab and
throughout much of the case. Currently, he is normotensive and is
asymptomatic. The risk of further cardiac morbidity and mortality has
been discussed very frankly with the patient. The need for lifelong
risk factor reduction with which the patient has been very
noncompliant with in the past has been discussed. The need for
absolute cessation of cigarette use, longterm if not lifelong dual
antiplatelet therapy, and probable lifelong statin therapy, along with
other medications and other lifestyle changes have been discussed very
frankly with the patient. The future risk of further cardiac
morbidity and mortality has been frankly explained, and all questions
were answered. Cardiac rehab and dietary consultations to help with
long-term risk factor control have been requested.
TIME SPENT WITH THE PATIENT AND PROCEDURE: 2 hours and 25 minutes.
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Re: caz: barbat 51 ani [...]

Postby Mephistopheles » Fri Apr 01, 2011 4:19 pm

Tare cazul.

ssss wrote: Rezidenta de ER( IQ 70)

:D
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Re: caz: barbat 51 ani [...]

Postby originaltup » Tue Apr 05, 2011 1:42 am

Unghiul e aiurea la poza, dar parca sunt niste ST depressions in V4-V6, nu-mi dau seama cat de semnificative insa.
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Re: caz: barbat 51 ani [...]

Postby ssss » Thu Apr 14, 2011 11:31 pm

Sincer nu am vazut nik in lateral leads, si nici cardiologul.
Nu stiu cum e la tine, originaltup, da' la noi cardio sunt foarte relaxati, si nu vin fuga decat pentru STEMI. Asta a avut noroc.
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Re: caz: barbat 51 ani [...]

Postby originaltup » Fri Apr 15, 2011 2:33 am

ssss wrote:Sincer nu am vazut nik in lateral leads, si nici cardiologul.
Nu stiu cum e la tine, originaltup, da' la noi cardio sunt foarte relaxati, si nu vin fuga decat pentru STEMI. Asta a avut noroc.


Avem cativa care nu vin nici pentru asta daca se intampla sa fie noaptea; si nici pt 3rd degree AV block cu HR pe la 20-30. Dar divaghez.
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Re: caz: barbat 51 ani [...]

Postby marmotul » Fri Apr 15, 2011 2:57 pm

rezidenta cu iq 70 era fica-sa?
qpepsi.gif


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