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RIGHT TIME, RIGHT PLACE

Dr. Morosan Petruta Anca Medicina de urgenta Spital “Sf.Spiridon” Iasi. RIGHT TIME, RIGHT PLACE. Scoala de vara a tinerilor internisti

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RIGHT TIME, RIGHT PLACE

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  1. Dr. Morosan Petruta Anca Medicina de urgenta Spital “Sf.Spiridon” Iasi RIGHT TIME, RIGHT PLACE Scoala de vara a tinerilor internisti Sibiu 2014

  2. 16.04.2014, ora 5:26, a fost adus de catre ambulanta, pacientul L.D., sex masculin, 68 ani,mediu urban, pentru : • dureri abdominale • greata • varsaturi • senzatie de gust amar ~ 3 zile • cefalee • vertij

  3. 1983 – DZ tip 2 insulinotratat • 1985 – HTA grad III grup de risc foarte inalt • 1995 – Hernie de disc L4- L5, L5-S1 operata • 2008 – ICC cls II NYHA – By pass aorto coronarian (LAD) – Proteza valvulara mecanica in pozitie aortica – Fibrilatie atriala permanenta cu AV lenta • 2013 – AVC ischemic pontin stang sechelar. Infarcte cerebrale lacunare multiple APP

  4. Sintrom 2 mg/zi • Atacand 16 mg/zi • Insulina TRATAMENT

  5. Constient, cooperant, OTS, t=38 Celsius, tegumente icterice • TA=160/75 mmHg, AV=76/min, zgomote cardiace aritmice, fara sufluri supraadaugate • SO2=95 %, FR=18/min, MV fiziologic • Abdomen marit de volum pe baza tesutului adipos, mobil cu miscarile respiratorii, dureros spontan si la palpare in hipocondru drept Examen Clinic

  6. PARACLINIC

  7. Sdr dureros abdominal • Obs Colangita • Fibrilatie atriala cu AV medie Diagnostic de etapa

  8. ph = 7,49 (7,35 – 7,45 ) pCO2 = 30,1 mmHg (32,0-48,0) pO2 = 59 mmHg (83 – 102) Hb = 131 g/dl (120 - 175) sO2 = 94,2 % (95 - 99) K = 3,83 mmol/L (3,5 - 5) Na = 136 mmol/L (136 – 146 ) Ca = 0,84 mmol/ L (1,15 – 1,29 ) Cl = 98 mmol/L ( 98 – 106) HCO3 = 24,5 mmol/L PARACLINIC CK-MB = 1,6 ng/ml (0,0 – 4,3) MYO = 144 ng/ml (0,0 - 107) TNI < 0,05 ng/ml ( 0,00 – 0,40) BNP = 491 pg/ml ( 0,0 – 100) DDMI = 929 ng/ml ( 0,0 – 400 )

  9. Pacientulinstaleaza o crizacomitialatonico-clonica, urmata la scurt timp de doua episoade de sincopa. • Monitorizare ecg a evidentiat bradicardie cu AV=10/min urmata de o pauza ventriculara > 3 sec. Evolutie

  10. S-a administrat pumn precordial (fist pacing) ca gest de prima intentie, Atropina 1mg si pacing transcutanat extern(I=80mA, Frecv=70/min) • Ora 6:45-aviz de transfer IBCV “G.Georgescu” Iasi EVOLUTIE

  11. Sindromul Adams - stokes • Sincopa +/- crize convulsive • cauza:tulburare de ritm cardiac • Scaderea brusca a debitului cardiac, implicit si a debitului cerebral, prin: • Asistolie • Pauza ventriculara • Bloc atrioventricular complet • Fibrilatie ventriculara

  12. CAUZE - SINCOPA

  13. Sindrom Adams – Stokes • Boala de nod sinusal ( pauza ventriculara >3 sec ) • Bradiasistolie • Pacing transcutanat extern • Fia permanenta cu AV medie • ICC cls II NYHA • By pass aorto coronarian • Protezamecanica in pozitieaortica • DZ tip 2 insulinotratat • Obs Colangita Diagnostic final

  14. Pacient cunoscut cu patologie cardiaca importanta, stabil hemodinamic in momentul examinarii, este adus pentru acuze gastrointestinale incepandu-se investigarea unei posibile patologii digestive. • Prognosticul in cazul acestui pacient putea fi fatal daca prezentarea la spital ar fi fost intarziata sau nu ar fi fost posibila monitorizarea ecg in timpul episoadelor de sincopa si accesibilitatea la pacingul cutanat extern. Particularitatea cazului

  15. Importanta monitorizarii pe tot parcusul investigatiilor, in special a pacientilor varstanici si a celor cu vasta patologie cardiaca. • Fist pacing poate fi o manevra salvatoare de viata. • Existenta in unitatile de primire urgente a aparatelor de pacing cutanat extern si a defibrilatoarelor este indispensabila. • Necesitateaunui transfer rapid catre un centru de cardiologieinterventionala. CONCLUZII

  16. “Do not take life too seriously. You will never get out of it alive.” Elbert Hubbard

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