#Eugene讀的300多本myON電子書記錄
(此圖不包含同myON的『Kaite Woo』和『Dino』系列)
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大概是從5月中疫情爆發的時候,
SJE女孩兒門關在家防疫課時哪兒也不去,
沒上學的自學生Eugene則維持學習的步調,
卻增加了 #myON電子書 的量!
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延伸上一篇文 ‧ 傳送門https://www.facebook.com/ingrid.ing.1024/photos/a.1661247717465782/3058233677767172
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這張圖是5月~7月底的myON電子書+AR測驗記錄,
部分介紹找時間將截圖在留言處,
其他還有很多橋梁書套書、小說的閱讀同時進行~
#SJE閱讀記錄 #Eugene6Y7M #英文閱讀 #英文有聲書
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以下是Eugene讀『myON電子書記錄』書名提供給大家,
字數不多,並且很精彩!
Eugene讀的共有300多本,
字數約在1千上下,
而且精彩的說書人真是讚!
超多好看的書讓小E會想一讀再讀呢!
很多書小E看完就不測AR了,
所以列書單如下:
◆ The Elves Help Puss in Boots
◆ Quest for the Unicorn's Horn
◆ Medea Tells All: A Mad, Magical Love
◆ Medusa Tells All: Beauty Missing, Hair Hissing
◆ Three Blind Mice Team Up with the Three Little Pigs
◆ The Tooth Fairy
◆ Seriously, Snow White Was SO Forgetful!
◆ Trust Me, Hansel and Gretel Are Sweet!
◆ Snow White and the Seven Robots: A Graphic Novel
◆ Red Riding Hood Meets the Three Bears
◆ Red Riding Hood Meets the Three Bears
◆ The Robo-battle of Mega Tortoise vs. Hazard Hare: A Graphic Novel
◆ Medea Tells All: A Mad, Magical Love
◆ Helen of Troy Tells All
◆ Pandora Tells All: Not the Curious Kind
◆ Robin Hood, Time Traveler
◆ The Ugly Dino Hatchling: A Graphic Novel
◆ Keep It Simple, Rapunzel!
◆ Mermaid Midfielders
◆ Hansel and Gretel
◆ Say "Cheese"!
◆ Big Pig
◆ Cass the Monkey
◆ Rapunzel
◆ Honestly, Our Music Stole the Show!: The Story of the Bremen Town Musicians as Told by the Donkey
◆ The Recess Bully
◆ The Runaway Robot
◆ Alice, Secret Agent of Wonderland
◆ Frankly, I'd Rather Spin Myself a New Name!
◆ Sleeping Beauty, Magic Master
◆ Quest for the Unicorn's Horn
◆ Secret Matter
◆ Truthfully, Something Smelled Fishy!: The Story of the Fisherman and His Wife as Told by the Wife
◆ Pandarella
◆ Hansel and Gretel Stories Around the World
◆ Red Riding Hood, Superhero: A Graphic Novel
◆ Beauty and the Beast Stories Around the World
◆ Goldiclucks and the Three Bears
◆ Believe Me, Goldilocks Rocks!
◆ Believe Me, I Never Felt a Pea!
◆ Poodle and the Pea
◆ Kitten Who Cried Dog
◆ Ack's New Pet
◆ Pandarella
◆ Goldilocks and the Three Vampires
◆ The Silver Spurs of Oz
◆ Rapunzel vs. Frankenstein
◆ Peter Pan in Mummy Land
◆ Mouse Says "Sorry"
◆ Mouse Says "Sorry"
◆ Hippo Says "Excuse Me"
◆ Monster Knows Table Manners
◆ Monster Knows Excuse Me
◆ Party Problems
◆ Miles McHale, Tattletale
◆ Yasmin the Chef
◆ Truthfully, Something Smelled Fishy!: The Story of the Fisherman and His Wife as Told by the Wife
◆ The Robo-battle of Mega Tortoise vs. Hazard Hare: A Graphic Novel
◆ Max Goes to the Dentist
◆ Listen, My Bridge Is SO Cool!: The Story of the Three Billy Goats ◆ Gruff as Told by the Troll
◆ Buzz Beaker and the Speed Secret
◆ Buzz Beaker and the Growing Goo
◆ Marconi the Wizard
◆ Hair-pocalypse
◆ Little Tiger Picks Up
◆ Penguin Says "Please"
◆ Little Dinos Don't Push
◆ Little Dinos Don't Hit
◆ Dino Hunt
◆ Prize Inside
◆ Pizza Palace
◆ What's That Sound, Cinderella?
◆ Pet Costume Party
◆ Even Fairies Bake Mistakes
◆ Counting Money!
◆ Maybe When I'm Bigger
◆ Traveling Shoes
◆ When Thomas Edison Fed Someone Worms
◆ The Swim Race
◆ Ruth's Pink Pajamas
◆ Me and My Cat
◆ Boo Bat
◆ Incredible Rockhead and the Spectacular Scissorlegz
◆ Truly, We Both Loved Beauty Dearly!
◆ Poodle and the Pea
◆ Marshmallow Mermaid
◆ Green Queen of Mean
◆ Evil Echo
◆ Yum!
◆ My Body
◆ My Day
◆ My Neighborhood
◆ Marvelous Me
◆ Paid to Game
◆ Mr. Bones
◆ Little Dinos Don't Yell
◆ Do Not Let Your Dragon Spread Germs
◆ Friends All Day
◆ Field Day Rules!
◆ The Goose that Laid the Rotten Egg: A Graphic Novel
◆ Plans Gone Wrong
◆ The Ants and the Grasshopper
◆ The Boy Who Cried Wolf
◆ The Boy Who Cried Vampire: A Graphic Novel
◆ Frankly, I'd Rather Spin Myself a New Name!
◆ Little Red Riding Hood Stories Around the World
◆ Rapunzel Stories Around the World
◆ Hansel and Gretel Stories Around the World
◆ Beauty and the Beast Stories Around the World
◆ Little Red Riding Duck
◆ Goldiclucks and the Three Bears
◆ Kitten Who Cried Dog
◆ Princess Harper Gets Happy
◆ Pandarella
◆ How Do We Stay on Earth?
◆ Scary Night
◆ Aliens and Energy
◆ The Big Mistake
◆ The Black Hole Report
◆ Ack's New Pet
◆ Ooze Slingers from Outer Space
◆ Eek Discovers Earth
◆ Tap Dance Troubles
◆ First Base Blues
◆ Soccer Switch
◆ Snow Dance
◆ Jack and the Beanstalk
◆ Lacey Walker, Nonstop Talker
◆ Crabby Pants
◆ Eleanore Won't Share
◆ Clara's Crazy Curls
◆ The Perfect Birthday Recipe
◆ The Little Bully
◆ You Get What You Get
◆ Zombies and Meatballs
◆ Boy Under the Bed
◆ Welcome to Third Grade, Gus!
◆ Going on a Field Trip
◆ Honestly, Red Riding Hood Was Rotten!
◆ No Lie, Pigs (and Their Houses) Can Fly!
◆ Seriously, Snow White Was SO Forgetful!
◆ Really, Rapunzel Needed a Haircut!
◆ Ninja-rella: A Graphic Novel
◆ Farms
◆ A Nature Walk on the Farm
◆ Bree's Bike Jump
◆ The Lion and the Mouse and the Invaders from Zurg: A Graphic Novel
◆ Lucille Gets Jealous
◆ Terrible, Awful, Horrible Manners!
◆ First Day of Unicorn School
◆ Trust Me, Hansel and Gretel Are Sweet!
◆ Clara's Crazy Curls
◆ Cat That Disappeared
◆ Super Billy Goats Gruff: A Graphic Novel
◆ Day of the Field Trip Zombies
◆ Shark in the Library!
◆ Sleeping Beauty
◆ Robin Hood, Time Traveler
◆ Red Riding Hood
◆ Rapunzel
◆ Puss in Boots
◆ Medusa Tells All: Beauty Missing, Hair Hissing
◆ Freestyle Fun
◆ Pandora Tells All: Not the Curious Kind
◆ Punk Rock Mouse and Country Mouse: A Graphic Novel
◆ Hansel and Gretel
◆ Chicken Little Saves the Moon Base: A Graphic Novel
◆ Johnny Slimeseed and the Freaky Forest
◆ The Goose that Laid the Rotten Egg: A Graphic Novel
◆ Believe Me, Goldilocks Rocks!
◆ No Lie, I Acted Like a Beast!
◆ Morning Mystery
◆ Johnny Slimeseed and the Freaky Forest
◆ Curse of the Red Scorpion
◆ Rapunzel
◆ Jak and the Magic Nano-beans: A Graphic Novel
◆ Goldilocks and the Three Vampires
◆ The Silver Spurs of Oz
◆ Peter Pan in Mummy Land
◆ Hansel and Gretel
◆ Rapunzel vs. Frankenstein
◆ Private Eye Princess and the Emerald Pea
◆ First Day, No Way!
◆ Beauty and the Dreaded Sea Beast
◆ Cinderella Stories Around the World
◆ Frog Prince
◆ Do Not Bring Your Dragon to Recess
◆ For Real, I Paraded in My Underpants!
◆ Olivia Bitter, Spooked-Out Sitter!
◆ Willy the Worm
◆ My Home
◆ Three Princesses
◆ The Frog Prince Saves Sleeping Beauty
◆ Sleeping Beauty
◆ Princess Bella's Birthday Cake
◆ Princess Addison Gets Angry
◆ The Tortoise and the Hare
◆ The Voice in the Boys' Room
◆ Servant and the Water Princess
◆ Because I Stubbed My Toe
◆ Yasmin the Builder
◆ New Kid from Planet Glorf
◆ Monster of Lake Lobo
◆ Golden Goose
◆ Dozer Strikes!
◆ Incredible Rockhead vs Papercut!
◆ Super-Powered Sneeze
◆ Up the President's Nose
◆ Blastoff to the Secret Side of the Moon!
◆ Hercules and the Pooper-Scooper Peril
◆ Witch's Brew
◆ Princess and Her Pony
◆ Day Mom Finally Snapped
◆ Boy Who Burped Too Much
◆ Secret of the Summer School Zombies
◆ Peek-a-Boo Dinosaurs
◆ My Little Bro-Bot
◆ Night of the Homework Zombies
◆ Max and Buddy Go to the Vet
◆ Invasion of the Gym Class Zombies
◆ Buzz Beaker and the Putt-Putt Contest
◆ Buzz Beaker and the Cave Creatures
◆ Lost Lunch
◆ Good, the Bad, and the Monkeys
◆ Frank 'n' Beans
◆ Little Lizard's New Baby
◆ Missing Monster Card
◆ Bus Ride Bully
◆ Buzz Beaker and the Cool Caps
◆ Eek and Ack vs the Wolfman
◆ Buzz Beaker and the Outer Space Trip
◆ Buzz Beaker and the Super Fast Car
◆ Snorkeling with Sea-Bots
◆ Buzz Beaker and the Race to School
◆ Jimmy Sniffles vs the Mummy
◆ Wright Brothers
◆ Double Trouble
◆ Dognapped!
◆ Fuchsia Fierce
◆ Do Not Bring Your Dragon to the Library
◆ My First Guide to Paper Airplanes
◆ Nose for Danger
◆ Helen Keller
◆ Thomas Edison: Physicist and Inventor
◆ People of the World
◆ Christopher Columbus and Neil Armstrong
◆ When Neil Armstrong Built a Wind Tunnel
◆ Jane Goodall
◆ Malala Yousafzai's Story
◆ Going to School: Comparing Past and Present
◆ Dinosaurs for Breakfast
◆ What Do You Think, Katie?
◆ Too Much RainRain
◆ A Is for Albatross
◆ Tricky Tooth
◆ The Best Baker
◆ Big Lie
◆ Jay-Z
◆ You Can Work in Music
◆ Spiders
◆ The Best Club
◆ I Can Reuse and Recycle
◆ How Effective Is Recycling?
◆ No Valentines for Katie
◆ Pony Party
◆ Piggy Bank Problems
◆ No More Teasing
◆ Moving Day
◆ Katie's Vet Loves Pets
◆ Drawing and Learning About Cats
◆ Moo, Katie Woo!
◆ Keep Dancing, Katie
◆ Katie's Spooky Sleepover
◆ Katie's Noisy Music
◆ Katie's New Shoes
◆ Katie Woo, Super Scout
◆ Katie Woo's Crazy Critter Jokes
◆ Katie Woo Has the Flu
◆ Katie Saves the Earth
◆ Katie Saves Thanksgiving
◆ Katie in the Kitchen
◆ Katie Goes Camping
◆ Mystery Coins
◆ Missing Trumpet
◆ Slime Attack
◆ Beach Bandit
◆ Crazy Clues
◆ Surprise Prize
◆ Ghost Sounds
◆ Katie Finds a Job
◆ Katie Blows Her Top
◆ Haunted House
◆ Alice in Wonderland
◆ Katie and the Haunted Museum
◆ Katie and the Fancy Substitute
◆ The Story of Ursa Major and Ursa Minor: A Roman Constellation Myth
◆ Katie and the Class Pet
◆ It Doesn't Need to Rhyme, Katie
◆ Helping Mayor Patty
◆ Goodbye to Goldie
◆ Nervous Night
◆ Good Morning, Farmer Carmen!
◆ Friends in the Mail
◆ Fly High, Katie
◆ Flower Girl Katie
◆ Daddy Can't Dance
◆ Cowgirl Katie
◆ Cartwheel Katie
◆ Boss of the World
◆ Boo, Katie Woo!
◆ Best Season Ever
◆ Happy Day
◆ Underworld Clash
◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆
同時也有213部Youtube影片,追蹤數超過6萬的網紅Jordan到處走,也在其Youtube影片中提到,#觀音吊橋 #人止關 #春陽部落 #雲龍橋 #廬山溫泉 #廬山老街 #廬山吊橋 #南投景點 🔑【副頻道「Jordan日常」】https://bit.ly/3hhOQDg 🔑【「Jordan到處走」粉絲頁】 https://bit.ly/2XaazF9 🔑【「Jordan到處走」】Instagram ...
e bridge 在 NYDeTour Facebook 的最讚貼文
NYDeTour週末何處去:9/18-9/19 (Sat & Sun)
*9/18 (Sat) Photoville Opening Day @ Pier 1 of Brooklyn Bridge Park
每年最期待的活動之一Photoville這星期六開跑!和往常集中在貨櫃裡的攝影展,現在的Photoville在紐約多個地點都可以看到。而星期六在Brooklyn Bridge Park的Pier 1則有開幕日的Community Day活動,除了攝影展外,也有許多攝影相關廠商的攤位,workshop等。還有Smorgasburg的攤位可以吃吃喝喝。是攝影愛好者不能錯過的活動。也可以到連結網站看看其他地方還有什麼精彩的攝影展!
地點:Pier 1 of Brooklyn Bridge Park
時間:9/18 (Sat) 1pm-9pm
https://photoville.nyc/openingday/
*9/18-9/19 (Sat & Sun) Bushwick Open Studio
因為疫情停辦一年的Bushwick Open Studio,這週末又回來了!想看看在紐約各種藝術工作者的工作室和他們的作品或是需要一些啟發的話,週末就來Bushwick走走吧!
地點:Various locations in Bushwick (請看連結網址的地圖)
時間:9/18-9/19 (Sat & Sun) 12pm-6pm
https://artsinbushwick.org/bos2021/
*9/18-9/19 (Sat & Sun) Brooklyn Americana Music Festival
喜歡音樂的朋友,這週末兩天在Brooklyn幾個地點都有音樂節活動,像是DUMBO Archway Plaza,Pier 6 of Brooklyn Bridge Park以及Sunny Bars at Red Hook等。票價從免費到10元,趕快燒腦一下,看要去聽哪一場吧!
地點:Various locations in Brooklyn
時間:9/18-9/19 (Sat & Sun)
http://www.bkamf.com/
*9/18 (Sat) Brooklyn Flea mini Record Fair
星期六在LES的Hester Flea有一個唱片展。喜歡黑膠唱片的朋友可以來挖寶。
地點:26 Essex Street, New York (at Hester Street)
時間:9/18 (Sat) 11am-6pm
https://www.brooklynflearecordfair.com/
9/18 (Sat) Pete’s mini ZINE Fest
喜歡小誌與漫畫的朋友,星期六在Williamsburg的Pete’s Candy Store有一個迷你小誌展,可以去挖寶或與志同道合的人交流。
地點:Pete’s Candy Store, 709 Lorimer Street, Brooklyn, NY
時間:9/18 (Sat) 2pm-7pm
https://www.facebook.com/events/203148085123635
*9/18 (Sat) Morbid Anatomy Library Open House at Industry City
想多認識了解人體構造的朋友,Morbid Anatomy Library搬到Industry City後第一次Open House可以免費入場參觀,並有專人進行導覽。把握難得機會。
地點:Morbid Anatomy Library, 254 36th Street, Brooklyn, Building 2, Room B421
時間:9/18 (Sat) 12pm-5pm
https://www.morbidanatomy.org/events/2021/9/18/morbid-anatomy-library-open-house
*9/18 (Sat) Smithsonian Magazine Museum Day
每年由Smithsonian Magazine主辦的免費博物館日這星期六舉行。紐約有18個參與的博物館,包括Museum of Art and Design和Museum of The City of New York,New York City Fire Museum以及很多比較私人平常不易去參觀的地方。是很棒的親子教育活動。
地點:Various locations in New York City
時間:9/18 (Sat) 10am-6pm
https://smithsonianmag.com/museumday/search/?q=&around_zip=%C2%A010003&states=US::NY&
*9/18 (Sat) The Village Trip 2021
從星期六開始到9/26的The Village Trip活動是來認識格林威治村很棒的活動。除了以Washington Square為主的免費音樂會外,也有其他付費的活動如Open Studio,街區歷史導覽等。有興趣的朋友可以到連結網址看看。
地點:Various location in Greenwich Village
時間:9/18 (Sat)-9/26 (Sun)
https://www.thevillagetrip.com/program/
*9/19 (Sun) Japan Fest at East Village
今夏第二輪的Japan Fest星期天在East Village舉行。有多個日式街頭美食攤位以及遊戲活動等。
地點:4th Avenue between E. 9th & E. 10th Street, New York
時間:9/19 (Sun) 10am-6pm
https://www.japanfes.com/new-blog/2021/6/8/sep19-east-village4th-ave-9th-14th-st
*9/19 (Sun) Forest Hills Fall Festival
住在Forest Hills附近的朋友星期天在Austin Street有街坊節,可以來逛逛吃吃喝喝。
地點:Austin Street from 69th Rd to Ascan Avenue
時間:9/19 (Sun) 11am-6pm
https://www.foresthillschamberofcommerce.org/
這週末是今年入秋前最後一個週末了,時間過的飛快啊!很多很棒的活動,wish you all have a great weekend, my friends.
e bridge 在 Facebook 的最讚貼文
急性心衰竭 (心衰竭指引 ESC guidelines, 2021)
Part 2~~
key words:
AHF: 急性心衰竭(Acute heart failure)
ADHF: 急性失償心衰竭(Acute decompensated heart failure)
Cardiogenic shock: 心因性休克
MCS:機械式循環輔助 (Mechanical circulation Support)
RRT:腎臟替代療法(Renal replacement therapy)
Natriuretic peptides (BNP, NT-proBNP, MR-proANP)
MR-proANP = mid-regional pro-atrial natriuretic peptide
NT-proBNP = N-terminal pro-B-type natriuretic peptide
AHF流行病學、診斷和預後
AHF 是指 HF 的症狀和/或癥兆迅速或逐漸發作,嚴重到足以使患者尋求緊急醫療照護,導致意外入院或急診就診。AHF患者需要緊急評估,隨後開始或積極治療,包括經由靜脈治療或裝置步驟。AHF在院內死亡率為4%-10% 。出院後一年死亡率: 25–30%,死亡或再入院率高達 45% 以上。
AHF 可能是 HF第一次發作,或者是由於慢性 HF 的急性失償。與急性失償心衰竭相比,新發HF患者的院內死亡率可能較高,但出院後死亡率和再住院率較低。
AHF的診斷檢查包括心電圖、心超、胸部X光、檢查和肺超檢查。尤其無法檢測Natriuretic peptides(NP)時。如果診斷無法確定是否心因性心衰竭時,則檢驗血漿 NP數值(BNP 或 NT-proBNP 或 MR-proANP)。
NPs正常:排除AHF 的診斷。
急性 HF 的臨界值是:
BNP <100 pg/mL、
NT-proBNP <300 pg/mL
MR-proANP <120 pg/mL。
但NP值升高與多種非心臟疾病相關, 在一些患有晚期失償末期HF、肥胖、突發性肺水腫(flash pulmonary edema)或右側AHF的患者可測得低值NP。有AF和/或腎功能異常,其NP數值較高。
AHF診斷流程
• 初步驗血檢驗包括肌鈣蛋白(troponin)、血清肌酐、電解質、血尿素氮或尿素、TSH、肝功能檢查及D-dimer(疑似肺栓塞);和procalcitonin (感染),動脈血氧分析(呼吸窘迫),以及lactate(低灌注的情況)。(註:procalcitonin降鈣素原可用於肺炎的診斷,數據 >0.2 μg/L 時,可能有使用抗生素治療的適應症。)
• 特定檢查包括冠狀動脈造影(疑似 ACS)和 CT(疑似肺栓塞)。
• 急性心衰診斷的NT-proBNP臨界值:
<55歲:> 450 pg/mL
55 -75 歲:> 900 pg/mL
> 75 歲> 1800 pg/mL
AHF臨床表現
AHF呈現四種主要的臨床表現,主要根據充血和/或外周血流灌注不足的原因所呈現出來不同的臨床表現。(參考表21)
四種臨床表現分別是:
1.急性失償心衰竭
2.急性肺水腫
3.孤立性右心室衰竭
4.心因性休克
各種急性心衰竭的臨床表現:
1.急性失償心衰竭(Acute decompensated heart failure, ADHF)
急性失償心衰竭 (ADHF) 是 AHF 最常見的形式,佔臨床表現的 50-70%。它發生在有HF病史和心臟功能異常,包括 RV 功能異常。與急性肺水腫表型不同,發作時程呈現漸進,主要變化是導致全身充血,液體滯留。
治療:
a. 使用環利尿劑,減少水份滯留。
b. 強心增壓劑(Norepinephrine):於周邊低灌注時使用。
c. 短暫使用機械式循環輔助(MCS):於周邊低灌注,器官受損時使用
c.腎臟替代療法(RRT: Renal replacement therapy):如果利尿劑無效或腎病末期時,可考慮使用RRT (Class IIa)
2.急性肺水腫
急性肺水腫診斷的臨床標準包括:
呼吸困難合併端坐呼吸、
呼吸衰竭(低血氧症-高碳酸血症)、
呼吸急促、
>25 次/分鐘和呼吸功增加。
治療:
a. 給予氧氣,持續氣道正壓通氣、非侵入性正壓通氣和/或高流量鼻管。
b. 給予靜脈利尿劑。
c. 如果收縮壓 (SBP) 高,可以給予靜脈血管擴張劑,以減少 LV 後負荷。在少數晚期 HF 病例中,急性肺水腫可能與低心輸出量有關,在這種情況下,需要使用強心劑(Inotropics)、血管加壓藥(vasopressors)和/或MCS 來恢復器官灌注。
3. 孤立性右心衰竭 (Solitary RV Failure)
a. RV 衰竭是由於 RV 和心房壓力增加以及全身充血。RV 衰竭也可能損害 LV 填充功能,最後導致心輸出量減少。
b. 利尿劑通常是治療靜脈充血的首選藥物。
c. Norepinephrine,強心劑、血管加壓劑:適用於低心輸出量和血流動力學不穩定。可能優先選用能降低心臟充填壓的強心劑, 如,levosimendan, phosphodiesterase type III inhibitors。
d. 由於強心劑可能會使動脈低血壓更嚴重,必要時,可以與norepinephrine合用。
4.心因性休克
心因性休克是由於原發性心臟功能異常導致心輸出量不足的症候群,包括危及生命的組織低灌注狀態,可導致多器官衰竭和死亡。
心因性休克的診斷要件:
灌注不足的臨床症狀:例如四肢冷汗、少尿、精神錯亂、頭暈、脈壓變窄、低灌注。血清肌酐升高、代謝性酸中毒和血清乳酸升高,反映出組織缺氧和細胞代謝改變導致器官功能障礙。低灌注並不常合併低血壓,因為可以通過代償性血管收縮(使用/不使用升壓劑)來維持血壓。
應儘早開始治療心因性休克:早期識別和治療潛在原因。
尋找病因(口訣:CHAMPIT):(see photo)
包括急性冠心症,高血壓急症,快速心律不整,嚴重心搏過慢,傳導阻滯,機械性原因(如,急性瓣膜返流,急性肺栓塞,感染,心肌炎,心包填塞)
嚴重休克病人則需要考慮將MCS(Class IIa)作為移植的過渡時期使用。
急性心衰竭的藥物治療:
利尿劑
靜脈利尿劑是AHF治療的基本。它們增加鈉和水份的排泄,適用於治療大多數AHF患者的體液過度負荷和充血。
a. Furosemide: 起始劑量為 20-40 mg,或靜脈推注 10-20 mg。Furosemide可以每天 2-3 次推注或連續輸注。由於給藥後,會有鈉滯留的可能性,因此不鼓勵每日單次推注給藥。連續輸注時,可使用負荷劑量以更早達到穩態。
b. 利尿劑治療開始後應立即評估利尿反應,並可通過在2或6小時後進行當時尿鈉含量(urine sport sodium) 和/或通過測量每小時尿量來評估。
c. 適當的利尿反應可以定義為2小時後,尿鈉(urine spot sodium) >50–70 mEq/L and/or
d. 前6小時尿量 >100–150 mL/h。
e. 如果利尿反應不足, 環利尿劑IV劑量可以加倍,並進一步評估利尿反應。
f. 如果利尿反應仍然不足,即使利尿劑劑量加倍,但每小時利尿量<100 mL,可以考慮同時使用其他作用於不同部位的利尿劑,即thiazides, metaolazone, acetazolamide。但需要仔細監測血清電解質和腎功能。
血管擴張劑
a. 靜脈血管擴張劑,如nitrate,可以擴張靜脈和動脈,因此減少靜脈返回心臟,充血減少,後負荷降低,增加心搏出量,因此緩解症狀。
b. Nitrate主要作用於靜脈,而nitroprusside則是動靜脈擴張。由於它們的作用機制,靜脈注射後,血管擴張劑可能比利尿劑更有效。急性肺水腫是由於後負荷增加和液體重新分配到肺部,而沒有周邊積液。
c. 當 SBP > 110 mmHg 時,可以考慮使用靜脈血管擴張劑來緩解AHF症狀。它們可以以低劑量開始並逐漸增加以達到臨床改善和血壓控制。應注意避免因前負荷和後負荷過度降低而導致的低血壓。因此,對於 LVH 和/或嚴重主動脈瓣狹窄的患者,應謹慎地使用。
強心升壓劑 (Inotropes)
a. 低心輸出量和低血壓患者的治療需要強心升壓劑(見表 22)。使用於左室收縮功能障礙、低心輸出量和低收縮壓(例如 <90 mmHg)導致重要器官灌注不良的情況。必須從低劑量開始謹慎使用,並在密切監測下逐漸增加。
b. Inotropes其是那些具有腎上腺素能機制的藥物,可引起竇性心動過速,增加 AF 患者的心室率,可能誘發心肌缺氧和心律異常,增加死亡率。
血管加壓藥(Vasopressors)
a. Norepinephrine具有顯著動脈收縮,適用於嚴重低血壓患者。主要目的是增加對重要器官的灌注。但會增加 LV 後負荷。因此,可以考慮同時併用Intropes + Norepisnephrine,特別是對於晚期 HF 和心因性休克的患者。
a. 休克患者第一線血管加壓藥的比較:Dopamine vs Norepinephrine,顯示在心因性休克患者Dopamine發生較多的心律不整,和死亡率。但低血容量或敗血性休克則沒有。
b. 在另一項前瞻性隨機試驗中,在急性 MI 引起的心因性休克患者中比較了Epinephrine vs Norepinephrine,由於頑固性心因性休克發生率較高,該研究提前終止。
c. Epinephrine會有較快的心率和乳酸中毒。儘管存在樣本量相對較小、追蹤時間短以及缺乏有關最大達到劑量的數據,但該研究表明Norepinephrine有較好的療效和安全性。這些數據與一項包括 2583 位心因性休克患者的綜合分析一致,顯示與Norepinephrine相比,心因性休克患者使用Epinephrine的死亡風險增加了三倍。因缺乏有關劑量、持續追蹤時間,和病因,使這些結果仍需進一步探討。
鴉片類製劑(Opoid)
a. Opoid類藥物可緩解呼吸困難和焦慮,在非侵入性正壓通氣期間用作為鎮靜劑,以改善患者的適應能力。 副作用包括噁心、低血壓、心搏過緩和呼吸抑制。
b. Morphine給藥與會使機械通氣頻率更多、住院時間延長、重症監護病房入院次數增加和死亡率增加。因此,不推薦在AHF中常規使用opoid類藥物。嚴重頑固性疼痛或焦慮治療的情況下,亦可考慮使用opoid類藥物。
c. SBP <90 mmHg時,勿用Morphine.
d. Morphine會抑制呼吸,使用時特別注意呼吸狀況及保持呼吸道通暢。
Digoxin
a. AF患者使用了乙型阻斷劑,但仍有心室心率過快(AF with RVR) (>110 b.p.m.) ,可考慮使用Digoxin。
b. 如果未曾使用過Digoxin,可以靜脈推注 0.25–0.5 mg。
對於CKD或影響Digoxin代謝的其他因素(包括其他藥物)和/或老年人,維持劑量可能難以理論上估計,應檢查血清Digoxin level。
血栓栓塞預防
a. 推薦使用肝素(例如低分子量肝素)或其他抗凝劑預防血栓栓塞。
c. 若正服用服抗凝劑或禁忌,則不需使用肝素。
短期機械式循環輔助(MCS)
a. 心因性休克可能需要短期 MCS 以增加心輸出量和維持器官灌注。
b. 短期 MCS 可用作恢復前(BTR, bridge to recover),治療策略決定前(是否繼續積極治療或視為無效醫療, BTD, Bridge to decision) 暫時過渡期的使用。臨床研究證據仍然很少。因此,不支持在心因性休克患者中未經選擇地使用 MCS。
c. 心因性休克 II (IABP-SHOCK-II) 研究中的IABP-SHOCK-II顯示,主動脈內球泵浦 (IABP) 和合適藥物治療之比較,於心因性休克患者接受早期血管再灌注的急性 MI 後之休克中,30天和長期死亡率沒有差異。根據這些結果,不推薦 IABP常規用於 MI後的心因性休克(Class III)。然而,其他非ACS引起的心因性休克,對藥物治療無效,IABP作為BTD、BTR ,仍有幫助(Class IIb)。
d. 在小型隨機試驗和傾向匹配分析中將其他短期 MCS 與 IABP 進行了比較,但結果不確定。ECMO與 IABP或 MT進行比較的RCT亦無確定結果。
e. 一項僅包括觀察性研究的綜合分析顯示,與對照組相比,接受靜脈-動脈 (VA-ECMO) 治療的心因性休克或心臟驟停患者的預後良好。 VA-ECMO 也可用於治療暴發性心肌炎和其他導致嚴重心因性的疾病。
f. 根據心肌功能異常和/或合併二尖瓣或主動脈瓣閉鎖不全的嚴重程度,VA-ECMO 可能會增加 LV 後負荷,同時增加 LV 舒張末期壓力和肺充血。在這些情況下,可以通過經中隔/心室心尖通氣口或使用解除LV 負荷(例如 Impella 裝置) 。
本文出處:
https://reurl.cc/VEy9Gn
Ref:
European Heart Journal (2021) 00, 1-128
https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab368/6358045#292214341
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e bridge 在 ALI HOÀNG DƯƠNG Youtube 的最佳解答
ALI HOÀNG DƯƠNG - CHẬM MỘT PHÚT (#CMP)
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Sáng tác: Lưu Thiên Hương
Đạo diễn: Giang Đặng
Lyric: Chậm Một Phút
I can hear my soul is so sweat
And i can hear my love is crazy
But i can’t tell you any thing
Any thing
Bao lần dặn lòng đừng lo âu
cứ đến gần và nói thật lòng mình
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để em biết
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Thế nhưng sợ lời từ chối
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Chậm một phút sẽ không bao giờ có thêm cơ hội
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Chậm 1 phút có khi lỡ nhau trong đời
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BRIDGE:
Tôi chẳng hiểu chính tôi
Bao lần thế
Im lặng nhớ thương
BRIDGE:
I can hear my soul is so sweat
And i can hear my love is crazy
But i can’t tell you any thing
Any thing
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