【論文摘要】鬼門關前的警訊，突如其來的胸痛

【論文摘要】STEMI case of Out of Hospital Cardiac Arrest

吳必榮

《醫療救護與緊急應變》 2022 Special Issue (2022/12) Pp. 65-66

https://doi.org/10.30216/JPER.202212/SP.0016

摘要

介紹：依據2020年美國心臟學會（AHA）建議，急性心肌梗塞的病人應於接觸醫療人員後90分鐘內完成經皮冠狀動脈介入治療（First medical contact-to-balloon inflation（PCI）percutaneous coronary intervention，goal of 90 minutes），為達此標準花蓮縣消防局與花蓮縣緊急醫療網在近年陸續完成相關流程的制定、設備的充實與訓練，務求花蓮縣境內急性心肌梗塞的病人能夠得到最有效即時的醫療照護。本次個案受惠於此項緊急救護服務，及時打通阻塞之冠狀動脈，拯救心肌細胞。個案簡介：48歲男性，有心臟疾病病史，於性行為後覺得胸悶及呼吸喘因此家人通知119，救護人員到達現場評估該患者意識清楚，呼吸24次／分，血氧98%，脈搏80次／分，因主訴胸悶，依據預立醫囑需完成12導程心電圖，並上傳至花蓮縣消防局12導程心電圖群組，線上醫師立刻判讀為ST節段上升之心肌梗塞（STEMI），而且梗塞範圍很大，線上醫師立即要求將病患貼上AED並做好急救準備，急救責任醫院在線上表示已經開啟急性冠心症綠色通道（急診至心導管室），該患者於到院前1分半鐘突然意識改變並出現瀕死呼吸，救護同仁立即開啟AED並開始CPR，心律顯示為心室顫動（VF）AED建議電擊，在完成電擊後約1分鐘個案抵達醫院，持續CPR並於急診裝置葉克膜，接續完成心導管手術，患者完成PCI後隨即清醒，並在一周之後神經功能完好（CPC1）出院。討論：1.Time is muscle!急性冠心症患者到院前心電圖非常有意義，到達醫院之前就能知道是否為STEMI，啟動快速通道，及早到達導管室，搶時間爭取最多的心肌細胞存活。2.建立急性冠心症到院前預立醫囑非常必要，參與者包括EMT，急診醫師和心臟科醫師，需熟練合作模式，此次案例能夠在一周後CPC1出院，關鍵是院前到急診到心導管室無縫接軌的合作。3.冠心症患者失去生命跡象時使用葉克膜可以爭取時間打通冠狀動脈，在葉克膜裝置完成之前，高品質的CPR非常關鍵，此案例到院前已經預知可能隨時失去心跳，AED事先貼好，VF立刻電擊和壓胸，到院後持續ACLS直到葉克膜完成，因此患者腦部持續有氧氣供應，神經功能未受損。

並列摘要

Introduction: Hualien County Fire Department has completed the relevant procedures, equipment, and training to ensure that acute myocardial infarction patients receive the percutaneous coronary intervention (PCI) within 90 minutes after contacting medical personnel. And then that patients with acute myocardial infarction can receive the most immediate treatment. Case presentation: A 48-year-old man called for help because of chest tightness. The emergency medical technician assessed that the patient was conscious, with a breathing rate of 24 beats/min, oxygen saturation of 98%, and a heart rate of 80 beats/min. The EMT completed a 12-lead electrocardiogram according to an advance medical order and uploaded it to the line group. The doctor interpreted the ECG as ST-segment elevation myocardial infarction (STEMI) and considered the infarction range was extensive; the doctor immediately asked the patient to be attached to the AED and prepared for resuscitation, and the hospital immediately set the green channel for the acute coronary syndrome to the cardiac catheterization room. Unfortunately, the patient lost vital signs before arriving at the hospital. The AED showed ventricular fibrillation (VF), an electric shock was recommended, then ECMO was administered in the emergency department. After percutaneous coronary intervention for one week, he was discharged with a Cerebral Performance Category (CPC) scale1. Discussion: Time is muscle! Pre-hospital ECG for ACS patients is very crucial. Before arriving at the hospital, the emergency physicians could diagnose STEMI immediately and then begin the green channel for PCI. Pre-hospital ECG makes it possible to maximize the survival of myocardial cells. It is essential to establish a pre-order for EMTs to do pre-hospital ECG. In addition, we have assembled a seamless collaborative team, including EMTs, Emergency Physicians, and Cardiologists, to complete the chain of ACS. Therefore, this patient could be discharged after one week without sequelae. In this case, the cardiologist online predicted that the patient might lose his life at any time, so the EMTs prepared resuscitation with AED. When AED detected VF, defibrillation was done immediately. Keep high-performance CPR until the ECMO is completed so the patient's brain perfusion has enough oxygen supply and the neurological function is not damaged.