Introduction
- Mrs Bahira Ceyhan is a 68-year-old female with no known allergies (NKA)
Situation
- Bahira Ceyhan arrived at the Emergency Department at 1030 hrs with central crushing chest pain radiating to her jaw since 1000 hrs.
- Findings from the 12 lead ECG recorded by paramedics showed ST elevation in leads V2, V3, V4.
- 300mg Aspirin administered on route to hospital.
Background
- Hypertension (Captopril 12.5mg bd)
- Hyperlipidaemia (Simvastatin 40mg nocte)
- Type 2 Diabetes Mellitus (DM) (diet controlled)
- Weight: 87kg
Assessment
- Airway: Patent
- Breathing:
- Respiratory rate 22
- bilateral air entry
- breath sounds clear
- SpO2 on room air 92%
- Circulation:
- Sinus Tachycardia 104bpm.
- BP 152/92.
- Diaphoretic and peripherally cool.
- Central crushing chest pain radiating to the jaw.
- COLDSPA
- Character: Crushing chest pain
- Onset: 10am
- Location: Central, radiating to jaw
- Duration: Ongoing
- Severity: 8/10
- Pattern: At rest, not relieved by SL Anginine Spray
- Associated symptoms: Diaphoresis
- Disability:
- Alert and oriented.
- Pupils equal and reacting to light (PEARL).
- Pain score 8/10.
- Equal strength in all four limbs.
- Exposure: IVC Left cubital fossa.
- Fluid:
- NBM
- NO IVF
Results
- Elevated Troponin 35ng/L/troponin
- 12 lead ECG: ST elevation (>2mm) V2, V3, V4
- A diagnosis of acute anterior STEMI is made.
Recommendation
Plan
- Supplemental oxygen if SpO2 < 93%
- Continuous cardiac ECG monitoring
- 12-lead ECG now, then every 30 minutes
- Keep in resuscitation bay (Triage category 2)
Blood tests
- Troponin now, then again in 2 hours
Medications
- Morphine 2.5mg IVI 2/24 (PRN maximum dose 10mg)
- Nitro-glycerine 600mcg SL (PRN maximum 3 doses); if pain persists, consider IV Glyceryl Trinitrate infusion
- Clopidogrel 300mg PO STAT
- Heparin 5000IU IV STAT
As per STEMI reperfusion flowchart
- Transfer to Cardiac Cath Lab for urgent primary PCI when ready (<90mins)
- If PCI delayed, give Tenecteplase 45mg IV as per PACSA @ 1130am
Answer the following questions in relation to the case study.
Question 1 two hundred and fifty w
Choose one clinical manifestation from the following list and discuss the related pathogenesis:
- central crushing chest pain with radiation to the jaw
- ST elevation
- elevated Troponin (35ng/L).
Your response should include an accurate and clear explanation of the pathogenesis causing the clinical manifestation of Mrs Ceyhan.
Question 2, five hundred w
Choose one intervention listed in the following table from each of the following categories:
- non-pharmacological interventions
- pharmacological interventions
- reperfusion interventions.
For each intervention provide a rationale for its use as a strategy to manage a patient presenting with STEMI. Support your answer with evidence and/or pathophysiology information.
| Non-pharmacological interventions | Pharmacological interventions | Reperfusion interventions |
|---|---|---|
|
|
|