STEMI / ACS Treatment – ECG Interpretation Case 15 (Part 2)


Okay so welcome to part 2 of our EKG
case now we showed you this EKG that clearly shows ST segment elevation and
we have reviewed it methodically as we do in our EKG course at MIT cram comm
but what we left for the end of course as part of our protocol that we go
through is looking for ST segment changes and we found significant ST
segment changes significant ST segment elevation in the precordial leads with
reciprocal ST segment depression this is highly concerning for a ST segment
elevation mi now in our course we go through differential diagnosis for ST
segment elevation like pericarditis etc so beware of those distractors from a
true ST segment elevation myocardial infarction so the question is is what do
we do and this is a very specific case this is not just a regular heart attack
that would be an N STEMI where you have an elevation in troponin and otherwise
the patient doesn’t have these signs this is an emergency this has to be
dealt with very quickly and there are timings that are dealt with the major
thing that we look at in ST segment elevation or St e mi STEMI there’s two
possible things that you should consider in this and the one is called
PCI or percutaneous coronary intervention or the other one is TPA
tissue plasminogen activator what’s going on here is we are trying to open
up the coronary arteries so which is it that you would choose well there are
different side effects TPA is where you give a medication that dissolves all the
blood clots in the body and that could be highly risky especially if someone’s
had a recent stroke or if they’ve had surgery recently and so what you look at
all things being equal is the amount of time it’s going to take to get one of
these two things done and that one in terms of PCI is known as the
door-to-balloon time and for TPA it’s known as the door to needle time so what
they recommend ideally you should have no more than 90 minutes from
door-to-balloon time and if you can’t get
90 minutes than that is not an optimal situation but the real cutoff that they
use is actually 120 minutes so if there’s no contraindications for TPA and
you can’t get a patient to PCI that means as soon as they see the ambulance
as soon as they come in the door to when they get balloon time if it’s not gonna
be less than 120 minutes then go to TPA if it’s going to be less than 120
minutes then go ahead and do PCI PCI is where they do coronary catheterization
they either use a balloon or a stent then they try to open up that coronary
arteries so that the patient can get reperfusion 90 minutes is ideal but
really 120 minutes is the cutoff the other question is what are you supposed
to be doing during this time what medicines are you supposed to be giving
sometimes that can be confusing so let’s talk about that okay so the thing that
we look at is mouna think about a patient moaning and pain when they come
in so this will get you started with what you need to do but certainly it’s
not everything that you need to do so the first thing is morphine and that
actually causes the pain to go down it helps with sympathetics and it can
actually cause some vasodilation which is helpful o stands for oxygen there’s
no real evidence that shows that norm oxic patients with myocardial infarction
benefit from oxygen but we do it as a good thing anyway
especially the patient’s hypoxemic the recommendations are anywhere between two
and three liters depending on the guidelines that you look at nitrates we
use sublingual nitroglycerine so that’s what the M stands for and we can do that
every three to five minutes if this is helpful the thing that you have to be
aware of those a couple of things number one it can drop your blood pressure and
therefore it can prevent you from giving other medications further on down the
list that are probably more important so be aware of that the other thing that
you have to watch out for is if they’re on phosphodiesterase type v inhibitors
like sildenafil etc because that can cause some real problems with blood
pressure probably the biggest one that you’ve got to know is a for aspirin or a
SI and the initial dose is 162 to 325 milligrams and they have to make sure
that they chew it because we’re looking for sublingual absorption
and then lifetime after that then you’re looking at seventy-five to a hundred and
sixty two milligrams a day so that’s Mona now that’s not where it
stops there’s other things that you do in a STEMI this is for a STEMI or an ST
segment elevation mi the other thing that we look at are the final Pyrrha
Dean’s and you’re like what is that well when I start giving you the medications
in there you’ll start to understand who they are so we’re talking about plavix
like clopidogrel another one that you might see is take a girl or another one
is tyke lopa Dean and passerelle so pasture grill is the last one that we
look at these ones should not be given if you’re going to be doing surgery so
contraindicated if surgery so if you’re going to cabbage coronary artery bypass
grafting then these need to be stopped five to seven days prior to that we
rarely used high Khloponin because the risk of TTP look that up and we don’t
use Pascrell if there is a history of stroke or TIAA but clopidogrel etc these
are ones that also should be used and we typically will continue these especially
if a stent has been place for about 12 months that’s typically what we do okay
next on the list are the to be 3a inhibitors these inhibit fibrinogen from
binding and some of the ones that you might see here I’ll list those here these are medications that very strongly
inhibit the ability for fibrinogen to bind you might know them as integral and
etc and these medications are used generally as a bridge to PCI so be aware
of those the next one that we’ll look at is full-out anticoagulation and so what
are we looking at we’re looking at unfractionated heparin we’re looking at
low molecular weight heparin and we’re looking at things like by Val
Rudin which we rarely use if we’re going to be using a to be 3a inhibitor
unfractionated heparin should be at least for 48 hours low molecular for 8
days or until hospital discharge the list keeps going though beta-blockers or
you can use a calcium channel blocker if they have a contraindication like asthma
so remember don’t use these if the patient has signs of heart failure or
pulmonary edema it’s best used if they have angina
because it can reduce the ability of the amount of angina another one that you
can use ace inhibitors or ARVs and you would not start these while they’re
still in the hospital because it can cause problems with hypotension
so do it at discharge another one since we’re on the topic are the aldosterone
inhibitors and the big one there is a pleura known but you’ve got to be
careful with a pleura known it was used in patients with ACE inhibitors if the
ejection fraction was less than 40 percent if the creatinine was less than
2.5 and if the potassium was less than 5.0 great the other one that you need to
be on is statins and we’re looking for an LDL reduction of greater than 50% so
we want a pretty large reduction in LDL so statins beta blockers ACE inhibitors
aldosterone etc and going back to Mona nitrates oxygen morphine aspirin all of
those medications we talked about should be going on as we are considering what
we need to do for the patient with a STEMI so take a look again at this EKG
and you’ll see what are all the signs and symptoms of a STEMI and know what
there is to do next time a patient comes in to the emergency room and presents
with those symptoms and this EKG thank you for joining us today and join
us at make rom-com