interesting case, can you save this patient. [复制链接]

文字

i just had this interesting case, like to share with you guys:

end stage renal disease, on dialysis. had vascath (hemadialysis catheter) in right IJ, unsuccessful, but successful in left IJ. went to interventional radiology for A-V fistulagram and lysis of thrombus with tPA (4 mg). developed right neck expanding hematoma. now the patient complains of dyspnea, pulse: 135, BP: 160/90, SaO2: 70%.

What would you do?

airway oppressed

Making progress

very good.

several of you guys realize the emergency, and want emergent tracheostomy or neck exploration. very good.

as i mentioned above, the ABCs of medicine, which means: airway, breathing and circulation. the chief complaint from this patient is "can't breath". why?, expanding hematoma compressed the trach. the airway is blocked. cartilages in the trachea locate anteriorly and are semicircular. trachea is easy to be compressed. with a BP of 160/90, his carotid arteries are not so easy to be blocked by compression.

now we all know he has an airway problem. how can we protect his airway? emergent trach is one option. does anybody want to intubate this petient first, which is less invasive, easy to do and equally effective to protect the airway. if you do an emergent trach, what do you worry? are you sure the hematoma was from the right IJ? what if the guy who placed the vascath poked the carotid artery and now the patient is bleeding from his coratid artery. so, do you want to do a neck exploration at the same time of tracheostomy? What do you want to do with the expanding hematoma which was the cause of all the problems?

making progress, very good!

那就慢慢学习啊

最惨的是对救治病人一点概念也没有.只是看懂了也没用

怎么是英文的 不能翻译过来吗

further discussion


Ok.

Patient was already on 12 liters of oxygen with facial mask. he grasped your arm and said: "doc, i can't breath." you noticed his neck was bigger than his head, especially on the right side. skin at the right neck was tight.

now, vital signs: T: 36.8, pulse: 156, bp: 160/90, SaO2: 50%.

What would you do?

one hint: think about what is the most critical thing you want to for this patient and remember "A,B,C" of medicine.

PS: A-V fistula is the hemodialysis access created by vascular surgeon. it is common to be thrombosed after a couple of years. the thrombus can be lysed by tPA to regain the access.

PPS: please feel free to ask any questions. thanks for the responces.

引用第6楼liu_redsnow于2006-07-02 15:36发表的“”:该不是为了溶栓，因为有静脉侵入性操作，所以需要用药防止血栓形成气管切开插管已经用的不多了么？.......

本人轮转经验：
一般的静脉抗凝用LMWH  
tPA是用来溶栓的 是要有强适应征的 并且价格很贵 一支大约6000RMB
曾经值班有个病人怀疑肺栓赛   呼吸科指示后tPA溶栓后出现了肺泡出血的情况 血直接从口腔里往外涌   一个小时内病人就over了  
所以还是想知道为什么用tPA

气管切开在我所转的内科用得不多  
有创操作 家属好多不会同意   我们谈话也不倾向于他们同意气管切开
同意如果特别紧急气管切开
至于呼麻科 是要他们做气管插管的 一般五分钟内能到 总值班有时也做 但有时插不进去
准备呼吸机是常规准备 如同心电监护/静脉通路建立/。。。。

引用第5楼liu_redsnow于2006-07-02 15:20发表的“”:breviation，该是abbreviation吧？不好意思，英语太烂，vath啥意思？

breviation本身就是“缩写”的意思吧

引用第2楼guodon于2006-07-01 21:19发表的“”:没转过肾科 简单说几句A-V fistulagram 行动静脉瘘术有个疑惑 .......

该不是为了溶栓，因为有静脉侵入性操作，所以需要用药防止血栓形成

气管切开插管已经用的不多了么？
倒是有不少相关的文章的
不过感觉还是该有不少应用的
记得讲外科学甲状腺手术的时候，马榕老师曾经说甲状腺大部切除术后床边常规放置气管切开包

呼吸机、麻醉科要很长时间的
救人要紧

这方面的急救知识太少，还请大虾们给讲解一下

breviation，该是abbreviation吧？
不好意思，英语太烂，vath啥意思？

引用第0楼peterhe400于2006-07-01 20:01发表的“interesting case, can you save this patient.”: 文字i just had this interesting case, like to share with you guys:end stage renal disease, on dialysis. had vascath (hemadialysis catheter) in right IJ, unsuccessful, but successful in left IJ. went to interventional radiology for A-V fistulagram and lysis of thrombus with tPA (4 mg). developed right neck expanding hematoma. now the patient complains of dyspnea, pulse: 135, BP: 160/90, SaO2: 70%........

看的累死我了
感触就是
赶紧再啃啃专业英语

引用第1楼liu_redsnow于2006-07-01 21:00发表的“”:终末期肾病，透析中。右侧颈内动脉插管失败，左侧成功。介入治疗行A-V fistulagram （？），tPA 4mg溶栓，导致右侧颈部血肿病人现在呼吸困难，pulse: 135, BP: 160/90, SaO2: 70%.......

Thank you for the translation. very close.

this was an emergent consult from interventional radiology when i was on call last Friday. they were panic when they called me.

SORRY about the breviations. they are quite common. IJ: internal jugular vein. IJ is the common site for central venous access and vascath (the introducer and sheath is very big, about 4-5 mm). tPA: tissue plasminogen activator.

the vath cath was placed in the morning and patient had hemodialysis for 10 minutes afterward. then he was transfered to interventional

没转过肾科 简单说几句

A-V fistulagram 行动静脉瘘术

有个疑惑
为什么要溶栓？有适应征么？


首先和家属交待病情 终末期肾病 尽量往劝家属放弃的方向谈话 也要注意保护自己
心电监护 HR快/SaO2太低 注意周围循环情况 观察尿量
建立静脉通路
吸氧 排床胸 明确有无溶栓后DAH 尤其是SaO2进行性下降时
完善辅助检查 查ABG/凝血/dic全套/生化

现在气管切开已经很少应用   呼麻醉科气管插管
准备呼吸机
呼叫总值班/肾内科/外科会诊 同时承担责任

终末期肾病，透析中。
右侧颈内动脉插管失败，左侧成功。
介入治疗行A-V fistulagram （？），tPA 4mg溶栓，导致右侧颈部血肿
病人现在呼吸困难，pulse: 135, BP: 160/90, SaO2: 70%

翻译的真困难
有几个词的意思不是很确定，楼主帮帮忙
大致能看明白意思吧

泌尿外透析方面的知识了解甚少

简单说一下，不当之处楼主给指出
感觉此病例主要是插管损伤右颈内静脉，又加上溶栓，导致右侧颈部血肿压迫器官导致呼吸困难
氧分压现在太低，需首先解决气道压迫问题

下面妄谈了
行气管切开术，解决主要矛盾
下面处理血肿与损伤的右颈内静脉