MI 与心力衰竭：分钟与磅

🧠 为什么重要

MYOCARDIAL INFARCTION（心肌梗死）：压榨性胸痛或压迫感，休息或 nitroglycerin 不能缓解，放射到手臂、下颌或背部，伴有出汗、恶心和呼吸困难；女性、老年人和糖尿病患者可能表现为疲劳、消化不良或气短。获得 12 导联 ECG 的时间应在到院后 10 分钟内，并检测 TROPONIN 水平。给予嚼服的 ASPIRIN、nitroglycerin（如果收缩压 BP 低于 90 mm Hg、怀疑右心室梗死，或近期服用过 phosphodiesterase-5 inhibitor，则暂停使用），血氧饱和度低于 90% 时给予氧气，硝酸盐不能缓解的疼痛给予 morphine；对于 ST 段抬高型 MI，目标是在到院后 90 分钟内进行经皮冠状动脉介入治疗，或在到院后 30 分钟内给予溶栓药，前提是无法及时 PCI（首次医疗接触后 120 分钟内）。监测心律失常（这是早期死亡的主要原因），以及心力衰竭和心源性休克。HEART FAILURE（心力衰竭）：LEFT（左侧）心衰使血液淤积在肺部，出现湿啰音、呼吸困难、端坐呼吸、粉红色泡沫痰和咳嗽；RIGHT（右侧）心衰使血液淤积在全身，出现颈静脉怒张、外周水肿、肝肿大和体重增加。每天早上同一时间称 DAILY WEIGHTS（体重）；一天增加 2 至 3 磅或一周增加 5 磅意味着要联系医疗提供者。教导低钠饮食、按医嘱限制液体，以及药物：sacubitril-valsartan（或 ACE inhibitor 或 ARB）；beta blocker；spironolactone（一种 MRA）；SGLT2 inhibitor；用于除液的利尿剂；有时还有 digoxin。BNP 随心衰加重而升高。急性 PULMONARY EDEMA（肺水肿）：坐直并让双腿下垂，给予高流量氧气，按医嘱给予 IV furosemide、硝酸盐和 morphine。

MYOCARDIAL INFARCTION: crushing chest pain or pressure unrelieved by rest or nitroglycerin, radiating to the arm, jaw or back, with diaphoresis, nausea and dyspnea; women, older adults and diabetics may have fatigue, indigestion or shortness of breath instead. Obtain a 12-lead ECG within 10 minutes of arrival and TROPONIN levels. Give chewed ASPIRIN, nitroglycerin (hold if systolic BP is below 90 mm Hg, right ventricular infarction is suspected, or a phosphodiesterase-5 inhibitor was taken recently), oxygen if saturation is below 90%, and morphine for pain not relieved by nitrates; for ST-elevation MI the goal is percutaneous coronary intervention within 90 minutes of arrival, or fibrinolytics within 30 minutes of arrival when timely PCI (within 120 minutes of first medical contact) is not possible. Monitor for arrhythmias, the leading cause of early death, and for heart failure and cardiogenic shock. HEART FAILURE: LEFT-sided failure backs up into the lungs with crackles, dyspnea, orthopnea, frothy pink sputum and a cough; RIGHT-sided failure backs up into the body with jugular venous distention, peripheral edema, hepatomegaly and weight gain. Daily WEIGHTS at the same time each morning; a gain of 2 to 3 pounds in a day or 5 pounds in a week means call the provider. Teach sodium restriction, fluid limits as ordered, and medications: sacubitril-valsartan (or an ACE inhibitor or ARB); a beta blocker; spironolactone (an MRA); an SGLT2 inhibitor; diuretics for fluid; and sometimes digoxin. BNP rises with failure. Acute PULMONARY EDEMA: sit upright with the legs dependent, high-flow oxygen, IV furosemide, nitrates and morphine as ordered.

🏥 真实场景

⚖️ 一位心力衰竭患者带着一台秤和一条规则出院。四天后，她的体重比前一天多了 3.5 磅，脚踝肿胀，于是她给诊所打电话，而不是等到出现气喘。调整利尿剂让她避免了住院。体重规则有效，是因为液体在出现在肺部之前一至两天就会先显示在秤上。

⚖️ A client with heart failure is discharged with a scale and a rule. Four days later she weighs 3.5 pounds more than the day before and her ankles are puffy, so she calls the clinic instead of waiting for breathlessness. A diuretic adjustment keeps her out of the hospital. The weight rule works because fluid shows up on the scale a day or two before it shows up in the lungs.

📌 要点总结

• 10 分钟内做 ECG；给予 aspirin、nitro，血氧低于 90% 时给氧；STEMI 在 90 分钟内 PCIECG within 10 minutes; aspirin, nitro, oxygen if under 90%; for STEMI, PCI within 90 minutes
• 左侧心衰：湿啰音和呼吸困难；右侧心衰：水肿和 JVDLeft failure: crackles and dyspnea; right failure: edema and JVD
• 每日体重：一天增加 2 至 3 lb 或一周增加 5 lb 意味着要打电话Daily weight: 2 to 3 lb in a day or 5 lb in a week means call

✅ 自我测试