5月OHCA 報告者:郭靖怡.

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1 5月OHCA 報告者:郭靖怡

2 5月份基隆院區共有OHCA17人,其中review 15 紙本病歷
17 例中有內科 16 人,外科 1 人 有2例IHCA

3 OHCA死因分析 內科 Cardiogemic:5 Respiratory:5 Unknown:6 外科 溺水

4 OHCA存活 2人, ROSC 2 人

5 OHCA ROSC case 1 5/23 2:04 Sudden collapse after chest pain in the early morning 家人說在家有反應,在自家車轉送期間才無呼吸 After CPCR, patient was ROSC and CXR showed acute pulmonary edema. EKG showed diffuse T wave inversion with wide QRS. CV man suspected with STEMI. PTCA was arranged Admission to ED ICU

6 CXR Total CK U/L 30 BB % 0.0 MB % 0.0 MM % 100.0 Cr:5.65 Na:138 K:3.57
Cl:99.1 

7 BNP:2020 Trop-I:0.069 Lactate 85.9 CRP:6.567 CK-MB:1.4 Blood culture: G(+) 1/1

8 PTCA&2-D echo RCA stenosis was impressed, s/p stenting EF(M): 58 %
1. left vnetricular hypertrophy (+) 2. Calcified aortic valve with moderate aortic stenosis 3. mild tricuspid regurgitation 4. Grade I - mild left ventricular diastolic dysfunction with normal left  ventricle filling pressure; adequate right ventricular relaxation 5. adequate left and righyt ventricular contraction 6. SEVERE pulmonary hypertension

9 Case 1 5/26 expired 出院診斷 1.OHCA s/p CPCR, ROSC, MI related 2.myocardial infarction, 2-vessel disease 3. suspect septic shock 4.hypoxic encephalopathy

10 Case 2 5/19 OHCA到院. Family 自訴在家中pregressive dyspnea with asthma attack and medication use. Progressive dyspnea noted at 5/19 afternoon, sudden onset of loss of conscious. Vf and DC was arranged twice Admission to MICU

11 Temperature 37 pH 6. 829 pCO2 148. 2 mmHG pO2 78. 1 mmHG HCO3 24
Temperature           37                             pH                 6.829                                  pCO2               148.2               mmHG           pO2                 78.1               mmHG                     HCO3                24.1               mm/L          TCO2                28.6               mm/L           ABE                -13.1               mm/L            SBE                -10.0               mm/L                            SBC                 14.1               mm/L                  SAT                 80.8               %         

12 Cr:1.88 K:6.01 WBC:9000 without left shift

13 Brain CT and 2-D echo 1. No evidence of acute intracranial hemorrhage.
2. Diffuse loss of gray-white matter differentiation of bilateral cerebral hemisphere, C/W hypoxic-ischemic encephalopathy.   3. Calcification of the vertebro- basilar artery and bilateral carotid siphons. 4. No evidence of hydrocephalus. 5. No midline structure deviation. 6. Well aerated paranasal sinuses and bilateral mastoid air cells. EF:33.9% 1.poor echo window 2.no chamber dilatation 3.no wall hypertrophy   4.POOR LV CONTRACTILITY   5.akinesis of septum   6.atrial fibrillation

14 Critical AAD at 5/20

15 Case 3 5/11 15:53 檢傷三級 主訴:上吐下瀉 36 70 16 98/44 WBC:12500 Hb:11.7
Cr:1.52 Lipase:26 Na:133.4 K:3.36 With AGE medication MBD

16 Case 3 5/12 00:24 Send by EMT with OHCA 十點多去睡覺,十二點孫女發現叫 不醒
EKG:asystole CPCR for 30 mins failure Expired at 00:54

17 IHCA 內科:1 外科:1

18 基本資科分析及品質資料分析

19 性別與年齡

20 發生地點-內科

21 發生地點-外科

22 送醫方式

23 可調閱紙本病歷中 救護紀錄表保存率

24 EMT反應時間 安樂 仁愛 百福 七堵4.6.5 中山 萬里

25 送醫方式比較 119(15) others(2) ROSC 1 survival > 2 hours

26 送醫地點比較 家中13 公眾場所1 送醫途中2 安養院1 總數17 CPCR failure或放棄急救 12 1 15 ROSC 2
2 survival > 2 hours survival > 24 hours

27 IHCA分析 沈X三 周X芝 主訴 開車撞山壁 在家暈倒，現意識清楚，頭暈不 檢傷級數 一級 二級 Age and gender 69M
52F Viital signs /76 E1V1M1 /93 E4V5M6 EKG PEA cause of CPR hypovolemic shock related to trauma pneumonia with cancer meta

28 Case discussion

29 Case 1 外科

30 Case 1 5/2 13:18 檢傷1級 Vital sign:,36, 52. 111/76 E1V2M4
開車撞山壁, send by 119 Conscious change as arriving. Multiple wound

31 Abdomen: soft and flat, no rebounding pain
hematoma over abdominal wall(+) Extremities: free movable, bilateral lower limb open wound and deformity

32 Check lab Prepare blood ( emergency) Brain CT including c spine Abdominal CT (+/-), plevic On Endo Challenge L-R 2000ml stat On critical Fast

33

34 Temperature           37             pH                 6.848                          pCO2                29.5               mmH G    pO2                329.4               mmH G HCO3                 5.0               mm/L        TCO2                 5.9               mm/L    SAT                 99.5              PT:11.4 INR:1.09 APTT:40.9

35 Sugar487 Num:15 Cr:2. ALT:106 Na:144 K:4.37 WBC:13100 RBC 3.45 Hb:11
Hematocrit:34 MCV:98.6 MCH:31.9 MCHC32.4 RDW:136 Platelet Myelocyte 1% Meta-myelocyte 3% Segment 53% Band 3% Lymphocyte 37% Sugar487 Num:15 Cr:2. ALT:106 Na:144 K:4.37

36 At 15:42 Arranged angiography of pelvis

37 Dopamine line Challenge Family agree with angiography for r/o pelvic fracture with internal bleeding SBP around 90 mmHg Bradycardia at angiography room 16:30 CPCR 17:09, no response to CPCR send to ED

38 堅持 AAD at 18:27 家屬要求要帶回,再請檢察宫及法醫至家中相驗

39 Case 2 內科

40 Case 2 5/28 General weakness after discharge from oncology ward
Falling down related to weakness Past history: Periampulla cancer, choledochocholangioma ,T0N0M1 Stage Ⅳ,s/p OP and C/T

41 Check Lab Admission Symptoms treatment B/T WBC:49000 Hb:5.6 Platelet:175000

42 Chest echo aspiration:1500ml
Ascites tapering cm

43 5/29 Hb:5.3 Add Tranexamic acid 入一觀

44 還沒有入觀就sudden collapse
hypotension, air hunger pattern, no response Bradycardia: with atropine Ca:7.3 Na:138.9 K:7.9 Trop-I:0.205

45 一小時後 Sudden onset of bradycardia about 20 bpm
CPCR: endo and bosmin use ROSC after10 mins

46 兩個小時後 現在兒子來 完全不知道之前cancer 轉移跟治 療的事 要求救到底 五個小時 After discuss with 病人真正的 丈夫(前夫?) 決定DNR expired at 19:10

47 Thank you