VAQ 8

A 46yo man is brought to Emergency. You are in a regional hospital with no interventional cardiology service.

He is diaphoretic, mottled and agitated, with the following vital signs.

PR 140 RR 36 BP 60/- T 36.8 Sat unrecordable

His ECG is shown below:

AMI

a) Describe and interpret his ECG     (50%)

b) Outline your management           (50%)

2 Responses to VAQ 8

  1. Rahul Deshpande June 19, 2013 at 4:36 pm #

    VAQ

    Rate : 144 /min

    Rhythm: Regular Narrow Complex Tachycardia. Unable to appreciate P waves.. therefore hard to call it sinus

    Axis: Normal

    P:
    PR:
    QRS: Narrow complex.
    ST :
    Elevation in AVR 2mm
    Elevation in V1-V4 1-3 mm
    Elevation in Avr > elevation in V1

    Reciprocal ST depression in II , III, avF

    Q waves in V1- V3

    QT: Appears prolonged … but is hard to interpret in setting of a HR 140/min

    This ECG shows an Anterior Wall STEMI with Elevation in AVR > elevation in V1 suggestive of a proximal LAD or Left main disease.
    Reciprocal changes seen.
    Q waves in V1-V3 ? time of infarct , with the anterior wall affected causing cardiogenic shock

    This mandates urgent Resusciation, reperfusion therapy, Liason with Interventional Cardiology for rescue Angioplasty and Likely Balloon Pump, ICU and Retrieval services.

    Management.

    Resus Area, Team based, Non Invasive monitor with defibrillator pads and Oxygen via 15 L NRB.

    IV access X2 and Stat Fluid Bolus of 20ml /kg stat.

    Resus as per ABC approach.
    Optimise C prior to RSI, Fluids/ Metraminol

    A+B:

    Preoxygenate/ Use Hiflo oxygen/ BMV with PEEP valve as likely Pulmonary edema. Non invasive mask can be tried to preoxygenate.
    Non hypotensive RSI,
    Rocuronium, 1.2 mgs/kg
    Fentanyl 500 MCG
    Midaz 1-2 mgs

    Intubate with 8 .O ETT 24 at lips. cHeck Capnograph and CXR to confirm.

    Ventilate
    500/5/ RR 12/ 100%

    C: Optimise
    Fluid Bolus as above, Metraminol initially, will require Ionotropes, initially
    Adrenaline 6mgsin 100 ml NS at 5- 10 mls/ hr
    Dobutanmine 5- 15 MCG/kg/min

    Cardio version to Sinus rhythm to aim to stabilise rhythm and hemodynamics.
    Synchronised shock 100-200 Joules. Aim to get patient back to Sinus rhythm. May be difficult secondary to conduction pathways disrupted sec to large MI

    D: Keep Sedated

    E: Ensure Euglycemia and euthrermia. ( Blankets)

    Specific:

    Thromobolysis if no contarindications and Consent
    Tenecteplase Bolus over 10 seconds as per weight .From 30 mgs for a %0 kg male to 50 mgs for a 90 kg and above male.

    Supportive:

    Check Oxygenation and Airway.
    Check Hemodynamics. Titrate inotropes.
    IDC for Urine output.
    CXR looking for Pulm edema. May need to increase PEEP
    D/w NOK for transfer.
    Liase with Cardiology in a tertiary hospital for urgent rescue plasty.
    Involve ICU/ Retrival teams.

    Disposition.

    Should be transferred for an urgent rescue Angioplasty, and ICU admission to a tertiary centre. Is likely to need Balloon Pump for cardic support. In View of being a proximal lesion / Left Main disease may require CABG . This may change where we send him.

    • shankykhan13 July 25, 2013 at 1:45 am #

      Well written Rahul, except we can use ketamine 2mg- 4 mg / kg + rocuronium 1 mg/ kg instead of above as well, any thoughts

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