Acute Myocardial Infarction/Cardiac Arrest

Case: You are an intern in ED and are about to see Mr. Smith who is a 55-year-old man brought by his wife because of
severe central chest pain. He is also breathless and sweaty.

Task
a. History
b. Provisional diagnosis and differential diagnosis from examiner
c. Manage patients condition
d. Answer examiners question

Case 2: You are in ED where youre working as an HMO. A 50-year-old man comes complaining of sudden onset of chest
pain 1 hour ago.

Task
a. History (ECG: VF)
b. Manage the patient

- Is my patient hemodynamically stable enough to proceed?

- I would like to put my patient in a resuscitation cubicle. Before starting my history I would like to check his oxygen
saturation, hook him to high-flow oxygen (8L) and cardiac monitor and I will ask the nurse to do ECG while I take
my history. Is he in severe pain?
- I would like to offer the patient morphine (2.5-5mg every 4 hours) and metoclopramide.

History
- You are in experienced hands. I am here to help you.
- Do you have any gastric bleeding, gastritis or allergy to aspirin? If not, then give aspirin 300 mg. Are you ready to
talk?
- SORTSARA: Where exactly is the pain? When did it start? How severe is it on a scale of 1-10? Is the pain
constant or does it come and go? Does the pain travel anywhere? Can you describe to me the character of pain?
Squeezing, stabbing or constricting? Are you aware of any factors that relieve or aggravate the pain like when
stooping forward or aggravated by deep breathing? Have you had this pain before? What were you doing before
the onset of chest pain? Do you have associated symptoms like SOB, diaphoresis, palpitations, cough, leg
swelling, stress, fever, trauma, heartburn or indigestion, soreness of the chest? Any problems with bowel motions
(r/o hematochezia and anemia) or waterworks?
- CV Assessment Risk: Smoking, DM, hypertension, hyperlipidemia, stress and sedentary lifestyle, FHx,
- Past Medical history that I need to know such as previous MI, PVD, cardiac disease? Any history of bleeding
disorders, previous stroke, surgery or head injury, or any medications such as ASA or warfarin or viagra?

Provisional diagnosis and Differential Diagnosis

- The most likely diagnosis is AMI. I have built my assumption upon the description of the pain which indicates a
cardiac origin. It is a central chest pain, squeezing in character, 8/10 in severity, lasting for about an hour, radiating
to the shoulder and jaw and associated with diaphoresis.
- My other differential diagnoses are other cardiac disease such as ACS, aortic dissection and pericarditis.
- Others include respiratory causes such as pneumothorax, Pleural effusion, and pneumonia.
- Less likely are GI causes such as esophagitis, gastric reflux, esophageal spasm and PUD.
- Musculoskeletal causes include herpes zoster, costochondritis, and fractured rib.
- Psychiatric condition such as anxiety and panic disorder.

Drugs:
- Oxygen 8L (4-6L)
- Asprin 300mg
- GTN (Anginine) sublingual (300mcg or tablet) or spray repeat every 5 minutes x 3 doses systolic BP
should be >100 and monitor BP
- Morphine sulphate (2.5mg every 10 minutes up to 10 mg in the first hour) with metoclopramide 10mg (Maxolon)
OR 2-5mg at 1mg/minute max 15mg

What to DO:
- Call for help: MET or Code Blue
 - Resuscitation table
- Trolley
- Check DR ABC
- ECG of VT: Biphasic defibrillator at 200 J x 3
- After resuscitation: check vital signs and ECG (inferior infarction or anterolateral)
- Precordial thump no longer recommended for VF but for pulseless VT if defibrillator not available

If Collapsed:
- Call for help: MET or Code Blue
- DR ABC (know pulse rate and ECG)
- Start CPR (30:2) 100:1 (5cm depth) x 2 minutes then assess rhythm
- IV line and take blood for cardiac enzymes
- ECG:
o Shockable: VF or pulseless VT
Manual Biphasic 200J
Manual Monophasic 360J
Automatic External defibrillator
o Non-schockable: PEA/asystole (1mg adrenaline every 3-5 minutes)
- Give adrenaline 1mg every 3 minutes after 2nd shock
- Give amniodarone after 3rd shock: amiodarone 300mg every 5 minutes
- Manage reversible causes:
o Hypoxemia, hypovolemia, hypo/hyperthermia, hypo/hyperkalemia, hypoglycemia
o Tamponade, tension pneumothorax, toxins, thrombosis

Management
- Blood will be sent for cardiac enzymes, FBE, and other baseline workups, CXR and possible echo.
- I will call registrar or cardiologist and send him to cath lab ASAP for reperfusion therapy Percutaneous Coronary
Intervention (angioplasty) or fibrinolysis/thrombolysis (recombinant Tissue Plasminogen Activator [rTPA]
alteplase) or CABG
- Indication: new-onset chest pain and persistent ST-segment elevation of >1mm in 2 contiguous limb leads or >
2mm in 2 contiguous chest leads or new LBBB
- PCI is treatment of choice. It provides a good outcome especially if done by experienced hands. Maximum
acceptable delay is 60 minutes within 1 hour of symptom onset and 90 minutes if patient presents longer
Symptom onset PCI
1st hour 60 min
2-3 hours 90 mins
3-12 hours 90-120 mins
- Start ACEI, beta-blockers and statins, ASA+Clopidogrel
- Others: warfarin, nitrates, furosemide
- Manage risk factors

Complications
- Acute left ventricular failure, cardiogenic shock, ventricular septal rupture, MV papillary rupture, Dressler
syndrome, pericardial effusion, left ventricular aneurysm