A walk through a STEMI

Transcription

1 A walk through a STEMI M.M. s Story Kim Robison Ashley Corcoran Situation M.M. is an 82 year old male brought in by private vehicle on 10/22/17 to the Emergency Department Pt. c/o left arm numbness, pain radiating into back after doing yardwork. Onset was 90 minutes prior to arrival Background Pertinent Medical History: CAD PTCA/stent to RCA in April 1999 Re-stenosis January 2000 Stent to first diagonal in January 2003 Mitral regurgitation HTN GERD Hyperlipidemia Prostate Cancer Background Family History CAD-1 brother, 1 sister Cancer-1 brother, 2 sisters Upon arrival to ED, objective assessment was unremarkable General: Alert, nontoxic, no acute distress. Skin: Warm, dry, Nonspecific drug rash on chest. Neck: Supple. Cardiovascular: Regular rate and rhythm, No murmur, No edema. Respiratory: Lungs are clear to auscultation, respirations are nonlabored, breath sounds are equal. Gastrointestinal: Soft, Nontender, Non distended. Musculoskeletal: no leg swelling/negative Homans sign bilaterally. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed, normal motor observed, normal speech observed, GCS 15, cranial nerves intact, Constant tremor. Psychiatric: Cooperative. Pertinent labs: Troponin-0.00 on admission ProBNP-93 Potassium-4.9 Sodium-142 Creatinine-1.49 BUN-25 Glucose-129 Vital signs: Temperature-98.3 Heart rate-80 Respirations-12 Blood pressure-154/64 Oxygen-96% RA CXR results Suspect developing early pneumonitis left lower lung 1

2 Initial EKG Question #1 By looking at this EKG, how do you know this patient has had a previous MI? : Nitro SL administered at 14:03 Vitals after Nitro given-bp 71/39 Dr. McCaslin documented at 14:25: Patient was briefly hypotensive after the nitroglycerin. He now states that his chest pain is pretty much gone but he has some epigastric and abdominal pain and feels like he might have to have a bowel movement. Was nauseated but that is also improving. Dr. McCaslin documented 15:14 I just went in the room to check on the patient and he told me he is still having some epigastric pain. Then he said he still felt dizzy. I looked at his rhythm and he was in ventricular tachycardia which then deteriorated into ventricular fibrillation. We did very brief CPR while we are still looking up the defibrillator. With one defibrillation he went back into sinus rhythm and woke up with a good pulse. Repeat EKG at this time now shows inferior ST elevation consistent with an inferior MI and code STEMI was called, At the time of transport from here to the Cath Lab he was awake alert and talking and said he was feeling better. Vital signs stable. Amiodarone was given. Cardiologist notified. Question #2: Name this rhythm Question #3 What is the initial intervention for ventricular fibrillation? 2

3 -EKG 15:09 Question #4 What area of the heart is involved? Question #5 What leads do you see reciprocal changes? Question #6 What do you do next? 15:40-To Cath Lab Findings: Left Main: normal LAD: 50% proximal stenosis, existing stent in 1 st diagonal branch Circumflex: irregular without significant stenosis Right: mid 90% in stent restenosis Dr. Olson documented: The patient developed ventricular fibrillation 3 times during the coronary intervention and required countershock with 200 J of energy. 16:30 Patient transferred to 9 South for post-operative care Vitals HR-64 RR-18 BP-99/50 SaO2-94% 4 L NC Negative physical assessment 3

4 Question #7 What primary lead should you be monitoring with RCA involvement? Medical Emergency initiated at 17:34 Question #8: After shock delivered, name this rhythm Question #9: What of the treatment of choice for Torsades? Troponins 1407: : : : : 0.22 Question #10: When do you expect troponin T to peak? 4

5 What is Troponin T? Normal <0.01 Troponin measures proteins in the blood that are released when the heart muscle has been damaged. The more damage to the heart, the greater the amount of troponin T in the blood. Summary Echo results 1210: Interpretation Summary Qualitatively, the left ventricular ejection fraction is 55-60%. There is mild mitral regurgitation. There is minimal tricuspid regurgitation Question #11 What medications would you expect M.M. to have on his discharge list? Recommendation/Summary M.M. continued to progress and was discharged home on 10/25/17. Outpatient Cardiac Rehab on 10/30/17 Follow up with PCP on 10/31/17 Follow up visit with cardiology on 11/1/17 Milton is doing quite well following his recent acute inferior myocardial infarction. He has not had any symptoms to suggest restenosis. He is gradually increasing his activity. He has had no palpitations or syncope. His ventricular fibrillation was likely ischemic mediated. Planning to follow up with Dr. Cassling again on 12/21/17. In review Wall Affected Leads Artery Involved Reciprocal Changes Anterior V2 V3 V4 Left Coronary Artery II III avf Left Anterior Anterolateral 1 av1 V3 LAD and Diagonal II III avf Branches, circumflex and marginal branches Anteroseptal V1 V2 V3 V4 LAD None Inferior II III avf Right Coronary Artery I avl RCA Lateral 1 avl Circumflex branch of left coronary artery II III avf Posterior V8V9 RCA or circumflex V1 V2 V3 V4 (R greater than S in V1 & V2. ST segment depression, elevated T wave) Right Ventricle 5

6 Let s practice! What part of the heart is affected? 6