ACUTE MYOCARDIAL INFARCTION: THROMBOLYTIC THERAPY IN THE EMERGENCY DEPARTMENT

Jason R. is a 38-year-old white male who called the ED about 30 min prior so arrival to ask if he should
come to the hospital. Jason said over the phone. "\fy wife's bugging me to come over there. I've got a
heavy pressure in my chest, sort of like indigestion. I've had it before, but it always went away. This time
I can't gel rid of it. "Jason was advised by the ED nurse to come to the hospital, preferably by ambulance.

Jason arrived by car and is noted to look pale and uncomfortable. He complains of pain in the center of
his chest that feels like a heavy pressure that is now going down both arms. The pain has increased in
severity since he left home. Jason rates his pain as 8 on a scale of 1 to 10. Jason is assisted to a stretcher
and while lying in semi-Fowler's position has no dyspnea. His vital signs are temperature 99° F. pulse 60
and regular, respiratory rate 22, and BP 108/60. Lung sounds are clear and heart sounds are regular with
normal s1 and S2. He has an extra heart sound. S4

When questioned about recent health, Jason tells the nurse that he has had chest pain off and on for
about 1 week. Jason describes the pain as a tightness or heaviness in the center of his chest under the
breastbone. Jason also mentions that the pain occurs with physical exertion and goes away with rest.

Jason is married and has two children. He is a sales executive and received a promotion 1 month ago.
Jason smokes about one pack of cigarettes per day. He has no previous medical history and does not
take any drugs. Jason says that his father died of a heart attack and his mother has hypertension.

Triage Assessment, Acuity Level IV: Chest pain, unrelieved: pain continues at rest.

Jason is taken immediately to the treatment area to rule out myocardial ischemia or injury. A 12-lead
ECG is immediately done and reveals ST segment elevation in leads I, II, III, A VF, V4, V5, and V6. T waves
are inverted in VI, V2. and 1 '3. and an abnormal R wave is present in VI. The initial creatinine
phosphokinase (CPK) is reported as 153 (0 to 225 is normal). The ED physician makes a diagnosis of
acute inferior lateral myocardial infarction (MI). True posterior MI is also considered.

Jason is given oxygen via nasal cannula at 5 liters/min and sublingual nitroglycerin with significant
reduction in his pain. After consultation with a cardiologist. Jason is deemed a candidate for
thrombolytic therapy. A lidocaine bolus is administered per protocol and a continuous infusion of
lidocaine is started at 2 mg/min. Tissue plasminogen activator (t-PA) is selected as the thrombolytic
agent for Jason. An intravenous bolus dose of 10 mg of t-PA is given by the physician, and an infusion of
t-PA is initiated at a rate of 50 mg/hr. Jason is then transferred to the coronary care unit (CCU) for
further definitive therapy and monitoring

3. How is the diagnosis of AMI determined?

Three criteria are important for the diagnosis of AMI: clinical presentation, ECG findings, and cardiac
enzyme studies. The most significant component is the clinical picture. If a person presents with
symptoms of AMI, appropriate medical evaluation and treatment should be initiated even if the ECG.
and/or cardiac enzymes are normal.

If the chest pain is associated with dyspnea. dizziness, weakness, or diaphoresis, the patient should be
observed with cardiac monitoring and have further diagnostic evaluation. If ECG changes of ischemia.
injury, or infarction (necrosis) are present and the patient has chest pain, the diagnosis of CHD is fairly
certain.
 Provocative/Palliative (What makes pain worse/better?)

Pain related to coronary heart disease is usually aggravated by exercise or increase in physical activity.
Ask patients if they noticed a pattern associated with the chest pain. Pain associated with coronary
heart-disease typically is relived by rest or stopping physical activity. Pain of AMI is not relived by
anything.

 Quality (What does the pain feel like?)

Cardiac chest pain is often described as a heaviness, tightness, dullness, aching feeling, pressure
sensation, or indigation-like. The pain of myocardial infarction is typically crushing, severe, like an
elephant or truck sitting on the chest. Patients might use a clenched fist (Levine's sign) to describe their
pain.

 Reglon/Radiation (Where is the pain and where does it move to?)

The most common location of chest pain is the center of the chest, under the breastbone (substernal) or
behind the breastbone (retrosternal). Other areas include right or left of the chest, arm (s), neck or jaw.
Pain might radiate down either arm or both arms or up into the neck and jaw.

 Severlty (How bad is the pain?)

While the initial pain of coronary heart disease might be mild, pain of myocardial infarction is usually
quite severe. Ask the patient to rate the pain on a scale such as 1-5 or 1-10. The scale is useful for the
patient to quantify their pain and the scale provides a measure for the nurse to evalute the effectiveness
of interventions to manage and relieve pain.

 Timing (What factors related to time are involved with the pain and what other symptoms are
there?)

Ask the patient when the pain started, how long does it last, how often does it occur (if intermittent)
and is there a change in the timing? Does the patient have nausea, vomitig, diaphorsis, dizziness, and or
pyspnea with the chest pain? These symptoms are often associated with myocardial infarction