CRITICAL INTERVENTIONS ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

Transcription

1 EMERGENCY DEPT WORK FLOW PROCESS FOR PATIENTS WITH STEMI DOOR Time registered at the Emergency Department (Time written on card) ECG Time first ECG was taken (Time written on ECG) - Target: Must be less than 10 minutes DECISION Time decision made for intervention in STEMi patients (Time written on card) DRUG Time Streptokinase infusion* started (Time written on card) * Or time PCI initiated / Metalyse given IMPORTANT INITIAL ACTIONS FOR ALL PATIENTS PRESENTING WITH ACUTE CORONARY SYNDROME Fast track to ECG within 10 minutes Give oxygen; maintain SpO2 > 98% Sublingual GTN if chest pain persisting (unless SBP < 90 mm Hg) Aspirin 300 mg chewed Focussed clinical examination IV access and bloods for biomarkers Continuous ECG monitoring Morphine IV 2 mg every 5 minutes until pain relieved. Clopidogrel 300 mg stat if diagnosis of STEMI made Please avoid: Arterial punctures Intra-muscular injections

2 CRITICAL INTERVENTIONS FOR STEMI PATIENTS IN THE EMERGENCY DEPT PERCUTANEOUS CORONARY INTERVENTIONS 1. Within 2 hours of onset of maximal chest pain 2. Extensive Anterior MI 3. Proximal (R) Coronary Block (RV + Post + Inferior) 4. Contraindications to Thrombolytic therapy 5. Killip Class III and IV STREPTOKINASE 1. Within 8 hours of onset of maximal chest pain 2. ST elevation or new LBBB 3. No contraindications to SK OR METALYSE* 1. Known allergy to Streptokinasse 2. Previous Streptokinase 3. Pre-hospital Thrombolytic Therapy ABSOLUTE CONTRAINDICATIONS FOR STREPTOKINASE ADMINISTRATION Risk of IntraCranial Haemorrhage Any previous history of intra-cranial haemorrhage Ischaemic stroke within the previous 3 months Known structural cerebral vascular lesion (eg. AVM) Known intracranial neoplasm Risk of Bleeding Active Bleeding or Bleeding diastesis (excluding menses) Significant head trauma within 3 months Suspected Aortic Dissection RELATIVE CONTRAINDICATIONS FOR STREPTOKINASE ADMINISTRATION Risk of IntraCranial Haemorrhage Severe uncontrolled hypertension on presentation (BP > 180 / 110) Ischaemic stroke more than 3 months ago History of chronic, severe, uncontrolled hypertension Risk of Bleeding Current use of anticoagulation in therapeutic doses (INR > 2) Recent major surgery < 3 weeks Traumatic or prolonged CPR > 10 minutes Recent internal bleeding within 4 weeks Non-compressible vascular puncture Active Peptic Ulcer Other Risks Pregnancy Prior exposure to Streptokinase

3 STANDARD 15-LEAD ECG All patients presenting to the Emergency Department with Chest Pain should have a 15-lead ECG done and seen by the doctor within 10 minutes of registration. Procedure: 1. ECG standard 12 lead 2. V4 lead placed on V4R (see above) 3. V5 lead placed on V8 (either ask patient to sit up or lie laterally) 4. V6 lead placed on V9 5. Repeat V4 - V6 reading 6. Do Long Lead II 7. Write date / time / patients particulars 8. Pass immediately to the doctor in charge This ECG must be repeated within 15 minutes, if the first ECG is not confirmatory. The most sensitive method to diagnose STEMI is a serial ECG. RISK STRATIFICATION USING TIMI SCORE AGE > 64 YEARS TIMI SCORE CATEGORY SCORE [1] CAD RISK FACTORS [ANY 3 WILL GIVE POSITIVE SCORE 1] FAMILY HISTORY OF CAD DIABETES MELLITUS HIGH CHOLESTEROL HYPERTENSION SMOKER KNOWN CAD [STENOSIS > 50%] ASPIRIN USE IN LAST 7 DAYS AT LEAST 2 ANGINA EPISODES IN LAST 24 HOURS ST SEGMENT DEVIATION AT FIRST ECG ELEVATED CARDIAC MARKERS TIMI SCORE = [MAX 7]

4 ECG Pattern Recognition for STEMI Evolution of ST changes in STEMI Hyperacute T waves (first 30 mins) ST elevations followed by tombstone ST segment Q waves start developing; T begin inversions Normalizing of ST segment Acute Inferior Myocardial Infarction ST elevation in II, III, avf Watch out for reciprocal ST depression in I, avl Extensive Anterior Myocardial Infarction ST elevation in V1 - V6; I, avl Reciprocal ST depression in II, III, avf Infero-Lateral Myocardial Infarction ST elevation in II, III, avf; V3 - V6 Reciprocal ST depression in I, avl Acute AnteroSeptal Myocardial Infarction ST elevation in V1 - V4 True Posterior Myocardial Infacrtion Reciprocal ST depression in V1 - V2 ST elevation in V7 - V9 Often associated to Inferior MI and RV infarction Left Bundle Branch Block QRS > 0.12 sec rs pattern V1 Slurred S wave V5, V6 Presumed new unless previously documented

5 KILLIP CLASSIFICATION CLASS CLINICAL SIGNS MORTALITY RATE Killip Class I No clinical signs of heart failure 6% Killip Class II Crepitations, raised JVP and S3 gallop 17% Killip Class III Frank Acute Pulmonary Oedema (Acute Heart Failure) 38% Killip Class IV Cardiogenic Shock / Hypotension SBP < 90 mm Hg 81% Life-threatening conditions that need to be ruled out in patients with chest pain Acute Coronary Syndrome Tension Pneumothorax Acute Pulmonary Embolism Dissecting Thoracic Aneurysm Conduction blocks / arrhythmmias Oesophageal perforation Perforated Peptic Ulcer Cardiac tamponade / pericarditis Clinical history, serial ECGs, cardiac markers Clinical examination, chest x-ray SpO2, ABG, Chest X-ray, ECG, CT Pulm Angio Typical history, Chest X-ray, Ultrasound (contraindication for SK) ECG, continuous vital signs monitoring Typical history, chest x-rays, CT thorax Upright CXR, Upper GI contrast study (water soluble contrast) Chest X-ray, USS-FAST, CT Thorax OVERALL FLOWCHART FOR PATIENTS WITH CHEST PAIN IN THE EMERGENCY DEPT CATEGORY DIAGNOSIS AND DECISIONS CRITICAL ACTIONS Chest Pain with ST Elevation New onset LBBB ST Depression TIMI Score > 4 Non-specific ECG changes TIMI 3 or 4 Normal ECG TIMI 0, 1 or 2 AMI requiring immediate revascularization Acute Coronary Syndrome requiring admission Require Serial ECGs and Cardiac Markers. To be observed. Search for alternate cause of chest pain. Determine if safe for discharge Consider Primary PCI if anterior MI, pain onset < 2 hours, Killlip III or IV, contraindicated to SK Start SK if otherwise no contraindication Admit to ward [Aspirin, GTN, O2, monitor] Observe, repeat ECG in 15 mins, cardiac markers. Serial ECG after 1, 3, 6 hours. Repeat ECGs if history / symptoms suspicious. Chest X-ray required.