Rapid
Response. 59 y/o Male admitted to tele floor for NSTEMI. Initial CP in ED
improved but has now worsened. He has ST depressions in II, III, F, V5-6. Trop
0.95->2.9. MB 45. SBP has dropped into the 70s. He was Tachy, now Brady in
50s. What are your next steps?
As the patient initially arrived with the diagnosis with an NSTEMI it is very likely this could be a conversion to a significant cardiac event likely posterior vs. inferior wall STEMI with the EKG pattern seen with changes in 2, 3, and AVF indicative of a an MI as stated above.
ReplyDeleteWith the patient's likely inferior vs. posterior wall MI I would give patient large volume resuscitation due to likely AV node disruption decreasing patient's CV. DO NOT give the patient an venodialator such as nitroglycerin which will likely cause the patient to have a poor outcome/death.
Otherwise in addition to getting large volume resuscitation, obtain a right sided EKG, and serial troponins, and CXR, as well as get a full set of vital signs, and stablize the patient and promptly call STEMI cardiologist and transfer the patient to the ICU for close monitoring, otherwise patient could potentially need vasopressor support to maintain CV.
Finally this patient will need to be taken to the cath lab for cardiac catherization due to above, and continue close monitoring, otherwise patient could have a large PE, multifocal PNA all of which would need to be addressed if patient's symptoms and EKG are not cardiac in nature.
Otherwise would avoid AV nodal blocking agents.
If PCI is not available, emergent thrombolytic therapy is appropriate and transferred to a PCI capable facility.
https://academic.oup.com/eurheartj/article/39/2/119/4095042
This patient was admitted with an NSTEMI. With his persistent pain, decompensation and hemodynamic instability he may have progressed to develop a STEMI. Hopefully he was started on a Heparin drip and Aspirin 325g at the time of admission. He should already be monitored on telemetry. At this point he emergently needs to go to the cath lab.
ReplyDeleteHe should also on supplemental oxygen and can be bolused normal saline as he is hemodynamically unstable. With the distribution of ST depressions on EKG he likely has an inferior MI involving the right coronary artery with infarction of the right ventricle and possible right atrium. The AV node also likely has decreased perfusion causing him to become bradycardic. As he has an inferior MI a right sided EKG can be taken. As he is preload dependent he should be bloused normal saline as above to keep his pressures up. Vasodilators such as nitroglycerin should be held as this can decrease preload. I would give him morphine for chest pain. If he was not given Aspirin and Heparin previously I would give him that as well. All antihypertensives and AV nodal blockers should be held. A STEMI alert should be called and the patient should be taken to the cath lab. An EKG, serial troponins, and CXR can also be considered, but none of these should delay the patient being taken to the cath lab. If PCI is not available, the patient should receive thrombolytic therapy and be transferred to the closest facility where PCI is available.
https://resident360.nejm.org/pages/home?resource_collection_id=cardiology&subtopic=cad-acs&subgroup=fast-facts
Based on the above information, it appears that the pt is experiencing a conversion from his presenting NSTEMI to an inferior STEMI due to the ST depressions in II, III, and AVF. Pt is clearly hemodynamically unstable given his decrease in SBP along w/ the tachy to brady heart rate likely due to AV nodal dysfunction from this cardiac event. Treatment in the ICU would be most appropriate for this pt given the severity of his status. Pt's hemodynamic status should be improved as pt is being evaluated for PCI therapy or fibrinolysis. This includes oxygen supplementation as well aggressive fluid resuscitation. A right-sided EKG should be performed as well as serial troponins. Cardiology should be immediately consulted and pt should be taken to the cath lab as soon as possible for further management. If PCI is not available at the current facility, fibrinolysis should be performed, then transfer to a PCI facility should be performed if at all possible. Beta blockers and nitrates should be avoided in this pt due to low BP and concerns for a low output state. Statin and aspirin therapy should also be started for this pt.
ReplyDeletehttps://www.uptodate.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction?search=STEMI&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
With patient’s presentation, this is most likely a NSTEMI that turned into a STEMI that is hemodynamically unstable. For the NSTEMI, patient should have been started on a heparin drip and given aspirin 325 mg. Patient’s troponin should also be trended. Once patient became hemodynamically unstable, he should have 2 large bore IVs inserted and started on fluids in attempt to stabilize the patient and be transferred to the ICU for close monitoring and possible need for pressors. STEMI alert should be called right away, with emergent consult to cardiology. Right sided EKG should be obtained for suspected inferior MI. Patient should be taken to cath lab emergently, to have PCI performed within the first 90 minutes. If PCI is not available, fibrinolysis should be started and patient should be transferred to a facility with the capacity. In the meantime, start MONA (Morphine, Oxygen, Nitrates, and ASA). However, in the case, Nitrates should not be given in the setting of inferior MI since it is a venodilator which can cause hypotension by decreasing the preload. Other differential diagnosis should be excluded, including aortic dissection, PE, and esophageal rupture.
ReplyDeletehttps://www.uptodate.com/contents/initial-evaluation-and-management-of-suspected-acute-coronary-syndrome-myocardial-infarction-unstable-angina-in-the-emergency-department?search=inferior%20MI%20treatment&source=search_result&selectedTitle=1~51&usage_type=default&display_rank=1
What was the initial EKG? He now has ST depresions in the inferior leads along with V5-V6. You should get a right sided EKG like previously stated could likely be a posterior STEMI which would required IV fluids and lots of them. Send them to the ICU for closer monitoring. Notify cardiology for the potential of a emergent heart cath. If that is not available then should be transferred out. The ideal time is < 120min from onset of symptoms. If the patient does not have any contraindications and cannot be transferred to a PCI capable hospital in the < 120min time frame then fibrinolytic therapy is an option. A new study suggested Tenectaplase is non inferior to Alteplase and actually is better due to not having to worry about the bolus 1hr time frame. If PCI is an option I would start the person on a heparin drip, along with the Bolusing NS to maintain a MAP > 65. Continue to trend the troponin, again notify cardiology. Depending on time frame would need to give something for pain, but don't won't the BP to tank. In the ICU, continuous monitoring, titrate O2>94%, Fluid bolus, possibly need pacing pads on the patient, atropine at bedside in case patient goes into heart block or is in heartblock. Isoproterenol is contraindicated in this case.
ReplyDeleteBraunwald's Heart Disease Eleventh Edition.
Lifeinthefastlane.com
https://academic.oup.com/eurheartj/article/39/2/119/4095042