STEMI case scanarios
Download as PPTX, PDF2 likes1,942 views
1. This document discusses several scenarios involving patients experiencing potential heart attacks and the appropriate emergency response, including ECG diagnosis and management plans. 2. Per NHS QIS standards, the goal is to minimize time from ECG to balloon (PPCI) or needle (thrombolysis). If PPCI isn't possible within 40 minutes, thrombolysis may be administered instead. 3. One scenario details a patient receiving thrombolysis more than 90 minutes after symptoms due to long transport time, who then underwent PPCI at the hospital with first balloon inflation 23 minutes later, meeting NHS standards.
STEMI case scanarios
- 1. PPCI and Direct Admission of High Risk NSTEMI Conference STEMI Case Scenarios Dr Kieran Docherty Clinical Fellow GJNH
- 3. 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).
- 4. 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
- 5. 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
- 7. 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
- 8. 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
- 10. ECG diagnosis 1. Normal ECG 2. Left Bundle Branch Block 3. Anterior STEMI 4. Inferior STEMI
- 11. ECG diagnosis 1. Normal ECG 2. Left Bundle Branch Block 3. Anterior STEMI 4. Inferior STEMI
- 13. Management Plan 1. Establish diagnosis and make referral to ORS 2. 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
- 16. 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
- 18. ECG diagnosis 1. Normal ECG 2. Left Bundle Branch Block 3. Anterior STEMI 4. Inferolateral STEMI
- 19. ECG diagnosis 1. Normal ECG 2. Left Bundle Branch Block 3. Anterior STEMI 4. Inferolateral STEMI
- 21. 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
- 22. Then… • Starts to feel dizzy • HR 32bpm, low volume pulse • BP 74/30mmHg
- 25. 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.
- 26. Scenario 4 • 58 year old Male – Dumfries • Background – Hypertension/TIAs • Chest pain on-off 24 hours • Worse in the AM – phoned ambulance
- 27. 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
- 29. ECG diagnosis 1. Normal ECG 2. Inferior STEMI 3. Posterior STEMI 4. High-Lateral STEMI
- 30. ECG diagnosis 1. Normal ECG 2. Inferior STEMI 3. Posterior STEMI 4. High-Lateral STEMI
- 32. 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
- 33. NHS QIS Heart Disease Standards • ECG to Needle time - ? 1. 15 minutes 2. 30 minutes 3. 45 minutes 4. 60 minutes
- 34. NHS QIS Heart Disease Standards • ECG to Needle time - ? 1. 15 minutes 2. 30 minutes 3. 45 minutes 4. 60 minutes
- 35. 90 minutes post Rx – ongoing pain
- 38. 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
- 39. 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