NEJM 「Case Records」
March 15, 2007さんへのお返事です。 > Twelve hours after presentation, the chest pain increased in severity. The electrocardiogram was unchanged. Results of laboratory tests performed at this time are shown in Table 1. Morphine, at a dose of 2 mg, was administered intravenously, and the pain resolved. > > Approximately an hour later, in the early morning of the first hospital day, the cardiac monitor showed ventricular tachycardia at 260 beats per minute, and the patient was found pulseless and unresponsive. A biphasic shock at 150 J resulted in asystole for several seconds, followed by sinus bradycardia at 35 beats per minute without a pulse. Magnesium, at a dose of 2 mg, and atropine, at a dose of 1 mg, were given intravenously, and sinus tachycardia developed, with palpable distal pulses and a systolic blood pressure of 160 mm Hg. He awoke almost immediately and was alert and oriented. A central venous catheter was placed; during the procedure he became agitated, and lorazepam was given for sedation. Shortly thereafter, his blood pressure fell to 60/40 mm Hg, and he again became unresponsive. Norepinephrine by intravenous infusion was initiated, and the trachea was intubated for airway protection; amiodarone, as a 150-mg bolus followed by infusion of 1 mg per minute, was administered intravenously, and he was transferred to the coronary care unit. > > Two more specimens of blood were obtained for culture. The norepinephrine was quickly tapered, then discontinued, and the patient was extubated. He remained hemodynamically stable and alert, without chest pain; he had normal vital signs. Amiodarone was discontinued. Results of laboratory tests performed at this time are shown in Table 1. Later that day, cardiac catheterization showed left ventricular apical hypokinesis and normal coronary arteries. That evening, the temperature rose to 38.4°C, and two more samples of blood were obtained for culture. A nasal-swab specimen was negative for influenza A and influenza B, parainfluenza, respiratory syncytial virus, and adenovirus, and a culture of urine yielded no growth. > > On the second hospital day, the patient felt well. The temperature was 37.5°C; no pericardial rub was heard, and the remainder of the physical examination was normal. The cardiac monitor detected no ectopy or arrhythmias. Treatment was initiated with metoprolol, at a dose of 25 mg orally twice a day. On the third hospital day, an electrocardiogram showed nearly complete resolution of the ST-segment elevation. On the fourth hospital day, the temperature was 37.6°C. A diagnostic test result was received. > > ---------- > > Table 1. Results of Laboratory Tests.
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