stemi case scanarios

PPCI and Direct Admission of High Risk NSTEMI Conference

STEMI Case Scenarios

Dr Kieran DochertyClinical Fellow

GJNH

Evidence Based Practice

PPCI – Gold Standard

Hartwell D, Colquitt J, Loveman E, Clegg AJ, Brodin H, Waugh N, et al. Clinical Effectiveness and CostEffectiveness of Immediate Angioplasty for Acute Myocardial Infarction: Systematic Review and Economic Evaluation. Health Technology Assess 2005;9(17).

NHS QIS Heart Disease Standards• Call to diagnostic ECG time – 30 minutes

• ECG to Balloon time - ?

1. 40 minutes

2. 60 minutes

3. 90 minutes

4. 120 minutes

Scenario 1• SAS Crew Govan– called to office block

• Male 45y• Central chest pain for 1 hour (“thought it was indigestion”) with nausea &

vomiting. • Ongoing pain.

• Smoker• No medications or PMHx

Assessment

• A – maintained – talking

• B – RR 25, SpO2 96% on air, chest clear

• C – Clammy and diaphoretic, HR 90 SR, BP 140/80

• D – GCS 15/15

• E – NAD

ECG diagnosis

1. Normal ECG

2. Left Bundle Branch Block

3. Anterior STEMI

4. Inferior STEMI

Management Plan1. Establish diagnosis and make referral to ORS2. Determine best ORS option• PPCI

3. Initiate life-saving treatment• Aspirin 300mg• Clopidogrel 600mg• IV heparin 5000IU

4. Symptom control • Sublingual GTN• Morphine/metaclopramide

5. Facilitate rapid transfer to ORS

Scenario 3• Braehead shopping centre• 72 year old female• Smoker, COPD, stable angina (worse recently)

• Sudden onset central chest pain 13:00• Vomited *2• Ongoing pain radiating to left arm/jaw

ECG diagnosis

1. Normal ECG

2. Left Bundle Branch Block

3. Anterior STEMI

4. Inferolateral STEMI

Assessment• A – maintained – talking

• B – RR 18, SpO2 98% on air,

• C – CRT <2s, diaphoretic, HR 60 SR, BP 124/72

• D – GCS 15/15

• E – NAD , BM 7.8

Then…

• Starts to feel dizzy• HR 32bpm, low volume pulse• BP 74/30mmHg

Management Plan• What are the goals during transfer?

1. Get here ASAP!2. Communicate any changes in clinical stability• Resuscitated VF/VT• Respiratory arrest• Hypotension• Complete heart block

3. Communicate any anticipated delay• Is pre-hospital TNK indicated?

4. Continuous cardiac monitoring door-to-table.

Scenario 4• 58 year old Male – Dumfries

• Background – Hypertension/TIAs

• Chest pain on-off 24 hours

• Worse in the AM – phoned ambulance

Assessment• A – maintained – talking

• B – RR 20, SpO2 95% on air,

• C – CRT <2s, diaphoretic, HR 85 SR, BP 145/92

• D – GCS 15/15

• E – NAD , BM 7.8

• Ongoing chest pain 7/10 – looks uncomfortable

ECG diagnosis1. Normal ECG

2. Inferior STEMI

3. Posterior STEMI

4. High-Lateral STEMI

Initial Management• No PPCI centre within 40 minutes transport time

• -> Thrombolysis

• Rx: Aspirin 300mg, Clopidogrel 300mg, 5000iu Heparin, TPA as per protocol

• Immediate Transfer to PPCI centre – Transmit ECG to CCU @GJNH 90 minutes post thrombolysis

NHS QIS Heart Disease Standards

• ECG to Needle time - ?

1. 15 minutes

2. 30 minutes

3. 45 minutes

4. 60 minutes

90 minutes post Rx – ongoing pain

Timeline• Called for Ambulance – 10:08• FMC – 10:15• Diagnostic ECG – 10:31• D/W GJNH – 10:34• Thrombolysis – 11:00• Arrived at GJNH 13:55• First Balloon Inflation: 14:19

23 minutes

29 minutes

24 minutes

Conclusions• PPCI is gold standard treatment for STEMI

• Early diagnosis and communication with ORS is vital to aid initiate life saving treatment

• Complications do happen! Ongoing discussion with ORS is important during transfer

stemi case scanarios

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