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【論文摘要】院前心包膜填塞死亡救護個案分享
【論文摘要】Experience sharing of Prehospital Cardiac tamponade OHCA case
摘要
研究背景：ACLS中OHCA流程治療可逆的原因5H5T其中之一就是心包膜填塞，若到院前發現OHCA患者有可能是心包膜填塞導致，到院前的救護技術員能為病患多做些什麼呢？案例描述：患者為氣切病患、過去病史有肺積水及洗腎，112/4/12求救原因為意識不清、呼吸喘，EMT到達現場時評估病患有低血壓、頸靜脈怒張及心音模糊，符合Beck's triad懷疑有心包膜填塞的情形，量測血糖98mg/dl排除低血糖昏迷，SpO2:58%EMT由病人氣切造口給予手動BVM氧氣治療，搬運到車上重新測量生命徵象時發現病患OHCA，立刻給予病患CPR、AED不建議電擊、持續由氣切造口給予BVM給氧、骨針建立輸液管線、Q3分鐘給予Epinephrine後送醫，送醫途中病患ROSC，到院2分鐘後INCA，醫院急救時使用心臟超音波掃描發現有心包膜填塞的問題，立刻進行心包膜穿刺術引流積液，成功引流後病人順利ROSC且生命徵象逐漸穩定，後續轉ICU治療。案例討論：到院前發現有心包膜填塞的病人：一、理應大量輸液以改善Preload不足的情形，但聽診有crackles給予輸液又可能造成肺積水或其他體液過多，輸液治療院前應如何取捨？二、院前超音波對此類個案的幫助？三、OHCA前，院前做心電圖會有幫助嗎。
並列摘要
Background: One of the reversible causes of out-of-hospital cardiac arrest (OHCA) in in Advanced Cardiac Life Support (ACLS) is pericardial tamponade, which falls under the 5H5T classification. If it is determined that OHCA in patients might be caused by pericardial tamponade prior to hospitalization, what actions can ambulance technicians take for the patients before they reach the hospital? Case presentation: The patient had a tracheostomy and a past medical history of pulmonary edema and kidney dialysis. The reason for seeking assistance on 112/4/12 was unconsciousness and shortness of breath. When the EMTs arrived at the scene, they assessed the patient and observed hypotension, jugular venous distension, and muffled heart sounds, indicative of Beck's triad and suggesting a suspected pericardial tamponade. A blood sugar measurement of 98mg/dl was taken to rule out hypoglycemic coma, and the oxygen saturation found to be 58%. The EMTs provided manual Bag-Valve-Mask (BVM) oxygen therapy through the patient's tracheostomy. Upon transporting the patient to the ambulance and reassessing vital signs, cardiac arrest was identified. The EMTs initiated CPR immediately, and the AED did not recommend an electric shock. They continued to administer BVM oxygen through the tracheostomy, established intravenous access using bone needles, and administered Epinephrine every 3 minutes. The patient was then transported to the hospital. During the journey to the hospital, the patient achieved Return of Spontaneous Circulation (ROSC). However, within 2 minutes of arriving at the hospital, the patient experienced In-Hospital Cardiac Arrest (IHCA). During the emergency treatment at the hospital, a cardiac ultrasound scan was employed to identify the issue of pericardial tamponade. Following this diagnosis, the medical team promptly carried out pericardiocentesis to drain the accumulated effusion. With the successful drainage, the patient achieved Return of Spontaneous Circulation (ROSC) and his vital signs gradually normalized. Subsequently, he was transferred to the Intensive Care Unit (ICU) for further treatment. Case Discussion: Patients found to have pericardial tamponade before hospital: 1. It is reasonable to infuse a large amount of fluids to improve the situation of insufficient Preload, but if there are crackles on auscultation, giving infusions may cause hydropneumonia or other excessive body fluids. How should I choose before infusion treatment? 2. How does pre-hospital ultrasound help such cases? 3. Before OHCA, will it be helpful to do an EKG before the hospital?