CC:

73

2 hr

HT

30
5

ps 8/10

20 pack-year

V/S BP 160/100 mmHg , PR 60/min , T 36.3 C ,RR 19/min SaO2 98% room air
A Thai elderly man , good consciousness , not pale , no jaundice
HEENT : no icteric sclerae , not pale conjunctivae
Heart : JVP not engorge ,normal S1,S2 no murmur , no S3 gallop
Lung : normal breath sound , no adventitious breath sounds
Abdomen : soft , not tender , no hepatosplenomegaly
Extremities : no edema
Dx STEMI inferior wall

STEMI

PCI

120

PCI

PCI

90

prep skin site

drip SK

30

CATH

approach

PCI

PCI

LAB

refer

(*

ER

PCI )
120

bleed

mortality *)

fibrinolytic

available PCI

CATH

24

At ER
=====
-

10

ECG

chest pain

ER

ECG

STEMI

==================
-

consult

"

"Onset"

typical chestpain

, risk factor

ST

"

" ECG

STEMI"

ECG

intern, resident==> fellow ==> staff

consult
10-20
-

line

fax

ECG

line

(.)

ECG STEMI

manage

inferior wall, anterior wall , posterior wall STEMI

""

consult ECG

google

"STEMI"

(
consult)

SK

STEMI

===========

"

fibrinolytic"

"refer"

refer :

CATH

refer

90

cath

SK . )

onset

30

refer( onset 10

refer PCI

)
-

> 75

- cardiogenic shock

guideline applied

Enoxaparin 1 dose

Fibrinolytic agent :

< 75

contraindication for fibrinolytic

refer

guideline)

drip SK

contraindication for fibrinolytic ( PCI

refer

BP

PCI

PCI

120

refer

drip SK

"" ""

"" , "check list contraindication" ,"

counselling"

drip SK

Initial Management
==================

- ASA (gr V) oral

- clopidogrel 300 mg oral load

(ISIS-2)

< 75

( 75

load) (CLARITY-TIMI 28 )

( prasugrel ,ticagrelor

PCI

fibrinolytic

)
- O2

vascular resistant

- Nitrate (NTG , isordil)

O2sat > 90%

coronary

O2sat < 90%

contraindication

oxygen

Sildenafil , hypotension

,bradycardia , right ventricle infarction : inferior wall

STEMI

wall

IV

SK

PCI

pain

Morphine

on saline lock

pain

drip SK

SK

monitor ECG . BP q 15 min

defibrillator

arrhythmia

drip SK

monitor

bradycardia ( inferior wall

efficacy

jarish reflex)

signs stable

atropine

VDO

drip SK

block , second degree AV block morbitz I)

10

drip

BP

drop

sinus bradycardia , first degree AV

drip SK
ST

vagal reflex (benzold

pain

Vital

Drip SK
=======

TNK

TNK

bolus dose

refer

SK

SK

access

- monitor

drip

fine VF

, ETT

CPR trauma

bleed

CXR ( CXR

ETT

relative contraindication

Fracture ribs

central line

internal pacemaker

portable)

SK

asystole

CPR

defibrillation

asystole

STEMI)

inferior wall STEMI ==> sinus bradycardia , 1st degree AV

benzold jarish reflex

atropine

BP drop

vagal tone

external

degree AV block
-

defibrillation

fine VF

pacemaker

block , second degree AV block mobitz I

VF

drip SK

delay

post cardiac arrest > 10

pneumo thorax
-

30-60

defibrillator

ER

anterior wall STEMI ==> 2nd degree AV block mobitz II , 3rd

external pacemaker

RV infarct (V3R ,V4R elevation)

drip SK

IV fluid bolus

Cardiogenic shock

BP

, levophed

STEMI

fluid

lung crepitation

challenge

100 ml
dopamine

PVC , AIVR

, non-sustain VT (VT < 30 sec)

sustain VT (VT > 30 sec)

3-24

algorithm ACLS

m2

dose

refer

OD

discharge

drip SK

Enoxaparin 1 mg/kg SC q 12 hr
48

stent thrombosis

eGFR < 30 ml/min/1.73

drip SK

fondaparinux (OASIS-6)

=========

- ECG post SK
-

0 , 30 , 60 ,90

60%

3-24

Fail

PCI

SK

TIMI flow 3

patency TIMI flow 2-3

3-24

success

PCI

30%

SK

PCI

m2

dose

refer

OD

discharge

- ACEI

24

exclusion)

- ARB

- betablocker

stent thrombosis

24

drip SK

fondaparinux (OASIS-6)

SAVE (Captopril) ,TRACE

clinical trials Cr > 2.5

contraindication

ACEI (VALIANT)

eGFR < 30 ml/min/1.73

intolerate

48

(Trandolapril), AIRE (Ramipril))

Enoxaparin 1 mg/kg SC q 12 hr

non-inferiority trial

uncomplicated

atenolol (GUSTO-I),propranolol(BHAT)

COPD

LV dysfunction

beta1 selective betablocker (metoprolol)

betablocker

LV dysfunction

(carvedilol

(CAPRICORN) , metoprolol succinate XR , bisoprolol )

Peripheral arterial disease

contraindication

discharge

low dose

betablocker

titrate

""

- Aldosterone antagonist ( EPHESUS (eplerenone))

aldactone

(25-50 mg) OD (exclusion criteria Cr > 2.5 , K > 5 )

- Statin

guideline

High intensity Statins

20 mg/day , Atorvastatin 80 mg/day

Rosuvastatin

Simvastatin

40 mg/day ( moderate intensity)

- keep blood sugar < 180 mg%

-

steriods , NSAIDs

- lipid profile

--> 8 wks

- correct K > 4 , Mg > 2

- pain

drip SK

- Vital Signs stable

- ST

48 hr

onset

false low

consult

ER

poster

STEMI

intern

ECG