Source of this article: Listen to Dr. Lee
Male patient, 38 years old.
The first year after the National Day, I went to work, and suddenly I was uncomfortable, at first it was back pain, that kind of intense back pain as if someone had cut inside the body with a saw, no wonder the doctor said that this is called knife cutting pain.
The back pain came very, very suddenly, no matter what position he used, the back pain was not relieved, he tried to lie down, find a sofa to lie on his side, lie on his stomach, stand, etc., to no avail, the back pain seemed to tear him in half.
He has also had back pain before, but most of them are muscle strains, and it would be better to change positions or rest for 2 days. But this back pain made him feel panicked, and he knew that if he didn't go to the hospital next, he would die in the office.
Just as he was about to call 120, the chest pain also came, that is, the feeling that there was really a big stone pressing on his chest, and even breathless.
Colleagues also noticed his abnormality and asked if it mattered, and he said bitterly that if he did not go to the hospital, this time next year might be his death day.
Originally planned to let colleagues drive him to the hospital, but colleagues are more cautious, saying that in case there is a problem on the road, it will be tricky, so it is decided to hit 120, waiting for 120 is safer than driving directly.
When the 120 car arrived, his chest and back hurt so much that he was already sweating.
I measured my blood pressure and went straight to the emergency department of the city hospital.
The doctor first suspected that it was acute myocardial infarction, a middle-aged man of this age, the work pressure is high, although he did not find high blood pressure before, but the chest pain and back pain are too prominent, the doctor gave him an electrocardiogram before and after 3 times.
I'm really afraid of myocardial infarction. The coronary arteries of the heart are specially nourished by the heart, if the coronary arteries are blocked by blood clots or severely narrowed, the heart will be ischemic, ischemia to a certain extent, the heart muscle will necrosis, and then a loud person may be gone.
However, except for the ECG, which found that the heart rate was fast, there were no obvious abnormalities.
Blood was also drawn, and the test for troponin was negative, which is mainly present in cardiomyocytes, and if the cardiomyocytes have destructive necrosis, troponin will be elevated. It is now normal, indicating that it does not initially look like a typical myocardial infarction.
The doctor was not idle for a moment, and the doctor was even more nervous than the patient himself. Because the doctor considers another disease, a disease that will kill people immediately if misdiagnosed.
Aortic dissection.
To be sent to the CT room immediately, do the chest and abdomen CTA, the doctor explained that to do CT angiography, but also to do CT, but you must first inject contrast agent into the vein, in order to better judge whether the blood vessel has a dissection.
The three most common causes of death for emergency department physicians are acute myocardial infarction, the second acute pulmonary embolism, and the third aortic dissection. All three diseases are devilish emergencies, and any one of them that is missed will kill people.
The patient is 38 years old, middle-aged, the current blood pressure is high, bilateral blood pressure is still symmetrical, but the chest and back pain is obvious, and now it is said that the thigh is also painful, which is very likely to be aortic dissection.
The aorta comes out of the heart, turns a bend (aortic arch), and then walks all the way along the chest and abdomen, reaches the pelvic cavity and divides the left and right two iliac arteries, this large artery will also be divided into very small blood vessels in the middle, nourishing the organ tissue nerves all the way down, if the aorta has a dissection, then the blood vessels along the way may be affected, the organs will be ischemic necrosis, manifested as severe chest and back pain, if the dissection tears to the kidney blood vessels, it will be kidney necrosis, if it is torn to the iliac artery, the thigh will be ischemic pain...
There is not much time left for patients.
There is not much time left for doctors.
The patient's family came, signed it, and immediately sent it to the CT room for examination.
The emergency department doctor guessed correctly, and the CTA results came out, confirming that it was aortic dissection.
This is a mortality rate of more than 50% of the disease, the doctor said, although our hospital can diagnose this disease, but there is no way to treat this disease, if it is usually fine, you can ask experts to come, but now it is the end of the National Day holiday, experts may not be asked to get, for the sake of patient safety, have to be transferred.
Oh my God, this disease is so dangerous, is it too late to transport it now? The family is impatient. The family is the patient's wife, she saw her husband in pain, her whole body was in a cold sweat, and she was helpless.
Turn, you have to turn, or you have to die here. The emergency department doctor still said this after consulting the doctor of the relevant department. The patient's aortic dissection is a type B (De Bakey III)
Type B, that is, the dissection originated from the thoracic descending aorta, and fortunately did not involve the ascending aorta, did not involve the three hairs (the three major arteries separated from the aortic arch: the trunk of the head arm, the left common carotid artery, the left subclavian artery), relatively better prognosis, the difficulty of surgery is also smaller, but even so, this is still a high fatality rate of the disease, the hospital does not have the ability, do not have the confidence to do this operation.
Therefore, several doctors suggest that patients should still transfer to higher hospitals.
The operation is mainly to put a stent into the blood vessel, block the rupture, prevent the rupture of the blood vessel, which is a good thing, but we have also seen that this thick artery has divided so many small branches along the way, and the stent with membrane will block some arterioles while blocking the dissection break, injuring the enemy with a thousand self-damage eight hundred, and there will inevitably be various complications after surgery.
They don't have the confidence to do it, they don't have the ability to do it, and it's impossible to transfer patients.
The best local hospital was contacted that night. But the doctor has no contact information, can only say that the recommendation to go there, can not turn, how to turn, but also the patient's family to find their own way.
(2)
The relationship between parents and in-laws was all mobilized, fortunately, the social relations of the patient's family were OK, and after inquiring from all sides, I found a local hospital that was very powerful, vascular surgery, and a bed.
Here to complain about the first hospital, some doctors will take the initiative to help contact the higher hospitals, some hospitals will not. There are many reasons, which may be that the doctor on duty does not know anyone, or it may be that the procedures are more complicated, the emergency department is busy, and the matter of contacting the transfer can only be done by the family.
After finding the hospital, how to get there? The patient had severe chest and back pain, and the doctor gave him some antihypertensive drugs and painkillers, but it seemed that the effect was not good. The doctor also said that if the blood pressure cannot go down, I am afraid that the blood vessels will be broken, and then the Great Luo Immortal will also return to the sky and lack of surgery. You have to hurry up.
The doctor gave the way, the hospital ambulance is not enough, there is no way to help transport patients, hundreds of kilometers of road, have to find some regular ambulances in the society, but have to spend money, may have to get thousands of dollars.
The ambulance will arrange drivers, doctors, nurses, necessary rescue items.
It cost 3,000 yuan and finally got on the car.
The doctor gave antihypertensive drugs, as well as analgesics, and told the family not to let the patient be too excited, the blood pressure should never be too high, do not say irritating words, and comfort the patient.
On the way, the patient's chest and back pain gradually improved, but it was still uncomfortable, blood pressure monitoring to about 150mmHg (systolic blood pressure), the doctor said that this distance target value is still a lot worse, the target is 120mmHg, or even lower, blood pressure on the basis of maintaining basic needs The lower the better, the lower the less likely it is to tear the blood vessels.
Finally arrived at the provincial city hospital.
It was already dark, and after the emergency doctor evaluated the condition, he was sent to the CT room non-stop and re-did a CTA. At that time, the patient's left leg was no longer able to move, and it was estimated that the dissection was torn into the left iliac artery, affecting the blood supply of the left lower limb, or the spinal cord blood vessels were affected, and there was a possibility of paralysis.
The doctor said that this is Stanford B type, did not involve the aortic arch, relatively better, but the blood vessels may still burst at any time, because from the thoracic aorta all the way to the common iliac artery, the organs affected in the middle are many, many, the risk of surgery is still very large, and many complications may occur after surgery, which is a life of nine deaths.
You have to enter the ICU first.
Stabilize the condition, wait for all the indicators to meet the requirements, and then consider surgery.
Is it surgery? The patient's mother asked.
No, it's interventional surgery, where a small opening is made in the groin, the guide wire enters the blood vessel, and then it is brought into the stent, and the stent with the laminated film is propped up inside the vascular dissection to cover the dissection opening.
Is it dangerous?
Extremely dangerous. If this disease is not treated, the mortality rate is more than 90%, if it is treated in time, it may not be passed, because the operation involves many, you have not yet affected the aortic arch is good, even so, there will be a variety of problems after surgery, and the probability of people and money is not small.
Then you really have to ask the Buddha to bless you. The patient's mother said.
It is useless to just ask the Buddha, first bookmark the consent, prepare the money, at least 200,000, and may need more in the follow-up. The doctor said lightly.
Doctors are probably used to seeing life and death.
Regarding the various possible outcomes of aortic dissection, as well as possible accidents during surgery, as well as various complications that may occur after surgery, several doctors have said it back and forth several times, confirming that they know, understand, and sign.
In fact, the family did not understand much at all, but they knew that if they did not sign and did not operate, they would undoubtedly die.
Originally thought that it would be sent to the operating room immediately, but after careful evaluation, it was believed that the circulation was still unstable, and it was necessary to actively treat conservatively with drugs first, and then operate after stabilization, which could reduce the risk.
Stayed in the ICU for 5 days in a row.
The doctor repeatedly told the patient not to get excited, to defecate in bed, and to use kaiser dew every day to moisten the intestines and laxative. The purpose is to prevent an increase in blood pressure caused by excessive force in the stool, and then it may break the artery, which is really a lack of surgery.
The strongest intravenous antihypertensive drugs were also given, as well as various painkillers, all designed to make the patient comfortable.
Only when you are comfortable, your blood pressure can come down, your heart rate can slow down, and you will have a chance to wait until the next surgery.
Fortunately, the situation slowly stabilized after 5 days.
The elderly patient in the same ward and the next bed that night there is another aortic dissection, really have a fate to the extreme. The children of the old man have all come, it seems that the economic situation is very good, and the albumin is bought in a whole box.
But the difference is that from the doctor's mouth, I learned that the aortic dissection of the old man was a type A, involving the aortic arch, then the three hairs (arteries) were affected, this type of dissection surgery is very difficult, and the mortality rate is very high.
Although he was admitted to surgery that night, he remained in a coma for several days after the operation, supposedly suffering from cerebral embolism. This may be related to the operation, the hospital is the best in this operation, but it still can't completely avoid such a thing, even if you have money, you can't fight the devil.
Seeing that his patients were not in good condition, he was a little anxious, especially when he heard the nearby doctor discussing the condition of the patient in the next bed, it was even more uncomfortable, as if he was talking about himself. But he restrained his fear, tried a few more deep breaths, and finally suppressed his restless heart.
(III)
After 5 days, his condition generally stabilized, his blood pressure was stable, the pain was significantly reduced, there was no need to pump intravenous antihypertensive drugs, and the target value could be reached simply by oral antihypertensive drugs (blood pressure systolic blood pressure was stable at 100-120, and the heart rate was 60-70 beats / min).
Finally waited for the operation.
Do interventional surgery, a bit similar to acute myocardial infarction patients do stents, from the root artery of the thigh to inject an injection, the guide wire into the artery, all the way to the arterial dissection nearby, and then open the stent, but this stent is covered, must have a membrane to cover the dissection rupture intact, the cover is less effective, more cover may damage the blood supply of other organs, so this is a very difficult operation, only in some top hospitals can be well carried out.
At the beginning, the patient himself has figured it out, looked down on life and death, and if the operation is successful, then thank the doctor. If the operation fails, don't blame anyone else. He had even explained the aftermath to his wife.
The operation is general anesthesia, interventional surgery, and it ends in about 1 hour. The stent that fits into the blood vessel is almost 20 centimeters long, which is an exaggeration. Some patients with complex conditions may need surgery to directly replace the ruptured blood vessels, which is simply understood to truncate the diseased blood vessels, replace the artificial blood vessels (instead of placing stents), and then dismiss them. The process requires the establishment of extracorporeal circulation, and the operation is big, and the light doctor group has to have more than a dozen people, and the operation time may take more than ten hours, from morning to night.
The whole family was worried that they would not wake up after the operation, just like the patient in the next bed, perhaps the Buddha had blessed it. Smooth awakening, except for the pain of the wound, everything else is fine.
After the operation, the doctor also said that the B type treatment is relatively good, if it is A type, involving the aortic arch, it will be much trickier. In this way, it is relatively lucky.
After the operation, I lay in the ICU for a few more days.
During the period there is also fever, the maximum body temperature burned to nearly 39 ° C, the family is worried about whether it will be infected with bacterial virus, the doctor explained, it is more likely that the postoperative vascular pseudolumen congestion is absorbed, aseptic inflammation, so there will be fever, and even the pain will continue for a period of time, you have to continue to use analgesics.
In addition, the patient's dissection tear is actually very long, almost tearing to the iliac artery, but the stent is not so long, nor is it completely covered to the distal end, because the blood vessels will have small arteries throughout the process, there are also many nerves, if covered all the way, I am afraid that it will cause greater damage, the kidneys may be damaged, and the spinal cord blood vessels may also be affected or even cause paralysis.
So what to do? Won't it happen again in the future? Patients are also worried.
As long as we control the source and block the breach, the following can only be slowly absorbed and restored. The doctor explains.
Fortunately, it was not misdiagnosed as a myocardial infarction, otherwise it would have been even more unimaginable. Because myocardial infarction and aortic dissection sometimes behave very similarly, they can even occur simultaneously. For example, the aortic dissection has been torn to the ascending aorta, and there is a coronary opening on the ascending aorta, if the false cavity blocks the coronary opening, it will not cause myocardial infarction.
The key to the rescue of myocardial infarction is the need to resist platelets, thrombolysis, and restore the blocked coronary arteries as soon as possible.
The aortic dissection, which is taboo against antiplatelet drugs, can not be thrombolytic. The reason is very simple, the blood vessel is ruptured when the dissection, close to the outermost membrane painstakingly supported, if at this time to go to antiplatelet aggregation, anti-coagulation, very easy to aggravate the fracture, maybe it will trigger a burst, a life whimper.
Therefore, when the emergency department doctor faces patients with myocardial infarction, he must exclude aortic dissection, and when considering aortic dissection, he must also exclude myocardial infarction. It is true that the treatment principles of these two diseases are opposite (and not exactly opposite, such as the need for stents), and misdiagnosis can easily lead to death.
The patient was eventually discharged from the hospital, not all patients with aortic dissection can be discharged smoothly, more is death, or death after surgery, or death without surgery, or death before diagnosis, he is lucky. Back pain occasionally occurs when I am discharged from the hospital, but it is not so severe. The doctor instructed that it was necessary to control blood pressure and heart rate. This is the main task of the second half of life.
Good luck to him.
(End of this article)