Management of acute STEMI
A 46 years old clerk presented with central chest pain for 1 hour duration. This is his ECG. How are you going to manage the patient?
Sir, the ECG shows an acute inferior ST elevation MI. This is a medical emergency. My task is to relieve the symptoms of the patient, stabilize him and reperfuse the ischemic muscle as quickly as possible. I will make sure that evaluation and management will happen simultaneously with minimal delay.
I will immediately get the patient to an HDU and call my support staff to help me with the management. I will get them to attach the patient to a continuous cardiac monitor, check RBS, get blood for basic investigations and cardiac biomarkers and to insert a wide bore cannula while I'm evaluating the patient.
I will assess his airway and then breathing paying specific attention to the presence of bibasal crepitations indicative of cardiac failure and oxygen saturation. If saturation is less than 90% I will start oxygen via face mask. I will also check his blood pressure and look at the JVP. I will auscultate to detect any murmurs. If the patient is in pain I will administer IV morphine with an antiemetic.
My further management depends on the availability of facilities. If PCI facility is available within 120minutes I will immediately inform the cardiology team to prepare the cath-lab and in the meantime will give the patient stat doses of antiplatelets; soluble aspirin 300mg dissolved in water and a loading dose of a novel potent antiplatelet like ticagrelor and high dose statins. I will start anticoagulation with IV heparin and once the cardiology team is ready will send the patient with continuous monitoring.
If PCI facility is not available within 120min, the preferred treatment would be administering a fibrinolytic agent within 10minutes from the presentation. While giving stat doses, I will quickly exclude contraindications for thrombolysis and administer a weight-based dose of IV tenecteplase which is the preferred drug. However, depending on the availability I may have to consider alteplase or streptokinase. It is also important to start anticoagulation before administering tenecteplase.
I will continuously monitor the patient to look for development of complications and in one hour I will assess the patient to see if the fibrinolysis is successful. (and the rest of management will be discussed on another day!)
Sir, the ECG shows an acute inferior ST elevation MI. This is a medical emergency. My task is to relieve the symptoms of the patient, stabilize him and reperfuse the ischemic muscle as quickly as possible. I will make sure that evaluation and management will happen simultaneously with minimal delay.
I will immediately get the patient to an HDU and call my support staff to help me with the management. I will get them to attach the patient to a continuous cardiac monitor, check RBS, get blood for basic investigations and cardiac biomarkers and to insert a wide bore cannula while I'm evaluating the patient.
I will assess his airway and then breathing paying specific attention to the presence of bibasal crepitations indicative of cardiac failure and oxygen saturation. If saturation is less than 90% I will start oxygen via face mask. I will also check his blood pressure and look at the JVP. I will auscultate to detect any murmurs. If the patient is in pain I will administer IV morphine with an antiemetic.
My further management depends on the availability of facilities. If PCI facility is available within 120minutes I will immediately inform the cardiology team to prepare the cath-lab and in the meantime will give the patient stat doses of antiplatelets; soluble aspirin 300mg dissolved in water and a loading dose of a novel potent antiplatelet like ticagrelor and high dose statins. I will start anticoagulation with IV heparin and once the cardiology team is ready will send the patient with continuous monitoring.
If PCI facility is not available within 120min, the preferred treatment would be administering a fibrinolytic agent within 10minutes from the presentation. While giving stat doses, I will quickly exclude contraindications for thrombolysis and administer a weight-based dose of IV tenecteplase which is the preferred drug. However, depending on the availability I may have to consider alteplase or streptokinase. It is also important to start anticoagulation before administering tenecteplase.
I will continuously monitor the patient to look for development of complications and in one hour I will assess the patient to see if the fibrinolysis is successful. (and the rest of management will be discussed on another day!)
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