MYOCARDIAL INFARCTION Cardiac Arrest – patient loss his consciousness

YOU ARE AN INTERN IN THE ED A 55 YEAR OLD MAN WHO Expected to follow ACLS
WAS BROUGHT TO THE ED BY HIS WIFE WITH SEVERE DRABC
CENTRAL CHEST PAIN Look for Danger
HE WAS ALSO FEELING SOB AND SWEATY. Call for help
TAKE RELEVANT HISTORY Ask if there is any cardiology registrar to come
DIAGNOSE THE CONDITION AND DIFFERENTIAL DIAGNOSIS TO Check for response from patient
THE EXAMINER Check Airway
MANAGE THE CONDITION Breathing
ANSWER EXAMINER’S QUESTIONS Circulation

Put the patient in a resuscitation room – to have a
resuscitation trolley nearby
Attach to cardiac monitor
Give oxygen
Ask nurse to insert 2 wide bore cannulas (16g)
Any ECG available
Give morphine 2.5-5mg + 10mg Metoclopramide – IV
Give 300mg soluble ASA
Give 300-600mcg Anginin SL stat (can be 3x) up to 1000
microgram
Or spray 400microgram, repeated once
If systolic blood pressure is >100
Pain questions: duration, site severity, radiation
character, aggravating and relieving factor – specially if
related to breathing or posture
Any previous episodes of similar chest pain
Associated symptoms: cough fever, chest trauma history,
palpitations, calf muscle pain or swelling
Any previous diagnosis with HPN, DM, any high lipid
profile,
Family history CVS
SAD
Job
Exercise
Stress
Medication allergy
Bleeding disorder: bleeding peptic ulcer
Recent stroke?
What is the Diagnosis?
My working Diagnosis is AMI because the pain is
suggestive of cardiac origin, because the pain is central,
lasting for more than an hour radiating to left shoulder,
sweating (diaphoresis)
Cardiac Causes: Acute coronary Syndrome
Aortic dissection, Pericarditis
Respiratory Causes:
Pneumonia, Pneumothorax, PE
Less likely: Esophagitis, Reflux,
Esophageal spasm, Costochondritis
Anxiety and Panic Disoder
Management
1. Oxygen: high flow 8L
2. ASA 300mg stat
3. Glyceryl nitrate
4. in the first 10 mins – give 2.5-5mg Morphine –
can repeat until the patient is pain free
5. after the patient is pain free- do ECG
6. MEtoclopramide 10mg TDS or 8 hourly
Is my patient responsive can I have an ECG now.
Candidate is also expected to detect the cause of the
ECG or cause of the unresponsiveness – Heart attack –
arrhythmia
Defibrillation – What type of defibrillator to we have?
What are the doses of the shock that you will give
360 kj– monophasic
Biphasic 200kj
After the patient is stabilized, ask for ECG which will
show ST elevation of inferior infarction
Interpret the ECG to the examiner –
Rhythm, rate, diagnosis, axis deviation, hypertrophy, ST
elevation
How many leads – 12 leads II, III, AVF
Management:
If in tertiary hospital:
The type of reperfusion
1. PCI – percutaneous coronary intervention–
treatment of choice, performed promptly – by a
qualified interventional cardiologist in an
appropriate facility. The maximum acceptable
delay from the balloon 60 minutes from symptom
of onset or 90 minutes if the patient presents later
2. thrombolysis or
Indications:
ST segment elevation of 1 mm in 2 contiguous limb leads
or
2 mm ST elevation in 2chest limbs or
onset of new LBBB
IF the patient presents later after 3-12 hours of symptoms
onset, it is appropriate to transfer for primary PCI if the
transport time is less than 2 hours or thrombolize them at
the country hospital
Fibrinolysis should be considered early in rural and
remote areas
Reperfusion is not recommended routinely in patients
presenting for more than 12 hours – clopidogrel.
LMWHeparin 1mg.kg BD or 1.5mg daily and ASA
Clopidogrel 75mg
Relevant history taking
Appropriate management of Cardiac arrest
Critical errors:
If you are not able to describe and interpret the ECG with
the right localization of AMI
If the candidate did not manage the situation as an
emergency, did not check VS and do DRABC