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