PUSAT PERUBATAN UNIVERSITI MALAYA

Transcription

1 NAMA DOKUMEN: NOMBOR DOKUMEN: CLINICAL GUIDELINE FOR THROMBOLYTIC THERAPY IN UNCOMPLITED ACUTE ST ELEVATED MYOCARDIAL INFARCTION (STEMI) IN TRAUMA AND EMERGENCY DEPARTMENT, UMMC DS-0706 MUKA KULIT TARIKH KELULUSAN : TARIKH BERKUATKUASA : TARIKH KAJISEMULA : PENULIS DOKUMEN : Mohd Idzwan Zakaria DISEMAK OLEH : Ketua, Jabatan Trauma & Kecemasan DILULUSKAN OLEH : Wakil Pengurusan-QMS DISAHKAN OLEH WAKIL PENGURUSAN : DOKUMEN INI ADALAH HAK MILIK SEPENUHNYA (PPUM). SEBARANG SALINAN SEBAHAGIAN ATAU SELURUHNYA DOKUMEN INI TIDAK DIBENARKAN SAMA SEKALI KECUALI MENDAPAT KEBENARAN SECARA BERTULIS DARI BAHAGIAN PENGURUSAN KUALITI,.

2 NOMBOR DOKUMEN: DS-0706 MUKA: 2/7 Time is Myocardium. In STEMI time lost equals myocardial lost. Coronary reperfusion therapy is to be achieved in the shortest time possible. WHO & Ministry of health Malaysia proposed a target door to needle time (time of appearance of patient in ED to the start of thrombolytic therapy) of 30 minutes. Thrombolytic therapy is still the main treatment modality in PPUM. This guideline with the checklists is developed to achieve targeted door to needle time of 30 minutes. In this guideline, intravenous infusion of Streptokinase is used as thrombolytic therapy. This guideline is developed by Dr. Tint Lwin, Dr. Alexanda Loch, Dr. Mohd Idzwan B Zakaria & Prof. Dr David Choon.

3 NOMBOR DOKUMEN: DS-0706 MUKA: 3/7 Notes on Acute Myocardial Infarction 1. Complications of thrombolytic Treatment Bleeding* - It usually occurs at sites of venepuncture & intramuscular injection. - Severe bleeding occurs in less than 1% of cases, the most catastrophic being intra-cerebral bleeding. - The following should be done if bleeding occurs: a) The thrombolytic agent must be discontinued. b) FFP (fresh frozen plasma) should be given (2-4 units) c) Tranexamic acid (10mg/kg) by slow IV injection repeated after 30mins if necessary. Hypotension* - May be due to the infract per se or the drug administered. - If due to thrombolytic treatment following should be done: a. Tilting the patient s head down or elevating the legs. b. Discontinuing the thrombolytic agent. c. Administrating fluids cautiously. d. Inotropic therapy (dopamine) if required. e. Continue thrombolysis if hypotension is corrected. Allergic Reactions* - Anaphylaxis is uncommon. If occurs : a. Discontinue thrombolytic agent b. Administer anti-histamines and steroids. E.g. IV Chlorpheniramine 10mg & Hydrocortisone 200mg. 2. Failed thrombolysis* - Continuing chest pain - Persistent ST segment elevation

4 NOMBOR DOKUMEN: DS-0706 MUKA: 4/7 3. Indicators of Successful Reperfusion - Resolution of chest pain ( may be confounded by the usage of narcotic analgesic) - Early return of ST segment elevation to isoelectric line or decrease in the height of the ST elevation by 50% upon completion of thrombolytic therapy. - Early peaking of CK level. *needs to consult cardiologist on call* contact CCU ext: Other special circumstances A. AMI in Elderly - Atypical presentation or silent AMI occur in about 40% of elderly patients. E.g. dyspnoea (30-40%), syncope, palpitations, acute confusion or acute stroke, acute pulmonary oedema & arterial embolism. - Difficult to diagnose : a) The ECG often shows ST segment depression rather than elevation b) The presence of baseline abnormalities in resting ECG may mask the typical changes of AMI (LV hypertrophy & conduction abnormalities). c) The Serum cardiac markers tend to be minimally elevated, often out of proportion to the haemodynamic changes observed. B. AMI in Diabetes - Higher in-hospital mortality (about times) than non-diabetics following AMI - Higher frequency of atypical & silent presentations. C. Right Ventricular Infarct - clinically recognized almost exclusively in patients with Inferior AMI - Clinical triad of hypotension, clear lung fields & elevated JVP (Jugular venous pressure) or Elevated JVP in the setting of Inferior AMI suggests RVI. - ST elevation in V4R & V5R is most specific.

5 NOMBOR DOKUMEN: DS-0706 MUKA: 5/7 - Treatment strategies depend on the severity of peripheral hypo perfusion & degree of co-existing LV dysfunction. Drugs that reduce the preload, such as nitrates & diuretics should be avoided. - If RVI with hypotension, volume loading with normal saline (up to 1-2 L) will improve the cardiac out put. D. General Precautions During Thrombolysis - Use peripheral venous access only. - Antecubital access for long line if pacing. - No arterial puncture E. Other Causes Of Chest Pain a. Life-threatening - Acute Coronary Syndrome - Aortic Dissection - Pneumothorax - Pulmonary Embolus - Oeosphageal Rupture - Pancreatitis - Acute Abdomen b. Others - Pericarditis - Pneumonia - Empyema - Pleurisy - Oesophagitis, spasm, reflux - Cholecystitis - Peptic ulcer pain - Chest wall pain

6 NOMBOR DOKUMEN: DS-0706 MUKA: 6/7 ECG Cardiac Biormarkes Chest Pain STEMI Concomitant initial managements SublingualGTN - Continuous ECG monitoring - Oxygen - Aspirin - Clopidogrel - Analgesia Assessment for reperfusion Onset of symptoms : < 3hrs 3-12 hrs > 12 hrs Preferred option : Primary PCI or Fibrinolytics Primary PCI Medical therapy +/ _ Anti thrombotics Second option : Fibrinolyics Primary PCI MEDICAL THERAPY REFERENCES:

7 NOMBOR DOKUMEN: DS-0706 MUKA: 7/7 1. Clinical practice guidelines, Management of Acute ST Segment Elevation Myocardial Infarction (STEMI): nd edition, Ministry of health, National Heart Association & Academy of Medicine MALAYSIA. 2. Advance Cardiac Life Support: 2006, American Heart Association 3. Handbook of Emergency Cardiovascular Care: 2006; American Heart Association. 4. Guidelines and Policies at London Health Sciences Centre 5. Review article: Current concepts of Time to Treatment in Primary PCI: Bramajee K. Nallamothu, Elizabeth H. Bradley & Harlan M. Krumholz: NEJM 356:16 6. Cardiovascular Disease, Section 7, Emergency Medicine; Judith E. Tintinalli, 6 th edition 7. Cardiovascular Disease, Chapter 18, Davidson s Principles & Practice of Medicine: 20 th edition. 8. Rang & Dale; Pharmacology: 5 th edition. 9. Keeley EC, Hillis LD. Primary PCI for myocardial infarction with ST-segment elevation. N Engl J Med 2007;356: Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361: Giugliano RP, Braunwald E. Selecting the best reperfusion strategy in STelevation myocardial infarction: it s all a matter of time. Circulation 2003;108: