Trên cơ sở của lịch sử một mình, đó là nghi ngờ cho AMI, bước ban đầu của chúng ta sẽ bắt đầu O2, kết nối với một màn hình / máy khử rung tim, và bắt đầu một IV, nếu tất cả đã có sẵn trong văn phòng, để bảo vệ Ray một bất lợi sự kiện như rung tâm thất | 154 Chapter 14 Case Presentations On the basis of the history alone which is highly suspicious for AMI our initial step would be to start O2 connect to a monitor defibrillator and start an IV if all were available in the office to protect Ray from an adverse event like ventricular fibrillation. Our next step would be to perform a stat electrocardiogram. There is nothing in Ray s history that suggests a contraindication to thrombolytics although you may have chosen a contraindicated to question number 3 because he has had the pain for three days outside the window for thrombolytic therapy. If so go ahead and give youself credit. Ray s electrocardiogram is illuminating. LAD of approximately -45 degrees and a small Q in lead I and a small R in lead III meet criteria for LAH. Most disturbing however are the Q waves in Vj-V3 with deep T wave inversion characteristic of an anterior wall STEMI in evolution. The question of how old this infarction is arises. T wave inversion takes hours to days to evolve at least so the ECG would suggest that it is probably at least more than several hours old. Often however the most accurate way to judge the age of an evolving infarction is on the basis of the patient s history. Ray tells us that his pain has been constant for nearly 3 days and that on the first night of the pain he had diaphoresis and vomiting. Clinically then the infarction commenced 3 days ago. Too late for thrombolytic therapy but still early enough that he remains at some risk and should be hospitalized. Other interventions should now be taken probably including nitrates and beta blockers as well as antiplatelet therapy and perhaps anticoagulation. His continuing pain suggesting ongoing ischemia may lead a consulting cardiologist to refer him for urgent PCI. Our final step in question 6 then would be to call 911 for an ambulance trip to the hospital with ACLS services. Case 10 When Robert Freuhauf was admitted to the coronary care unit you learned during your nursing
