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ACUTE antero septal MI - CASE PRESENTATION RASHED 2.pdf
- 2. Objectives AT THE ENDOF THIS ACTIVITY, WE WILL BE BETTER ABLE TO: Describe the definition, pathophysiology, causes, types, symptoms and risk factors of MI. Summarize the clinical findings and differential diagnosis of MI. Review the management and complications of MI. Explain the role of the professional team in improving the management provided for better outcomes in patients with MI.
- 3. overview A HEARTATTACK (MYOCARDIAL INFARCTION) : IS A MEDICAL EMERGENCY WHERE YOUR HEART MUSCLE BEGINS TO DIE BECAUSE IT ISN'T GETTING ENOUGH BLOOD FLOW. A BLOCKAGE IN THE ARTERIES THAT SUPPLY BLOOD TO YOUR HEART USUALLY CAUSES THIS.
- 4. Definition of Myocardialinfarction (MI) : occurs when one of the arteries that supplies the heart muscle becomes blocked. Blockage may be caused by spasm of the artery or by atherosclerosis with acute clot formation. it rapidly progresses to death.. Pathophysiology of Myocardial infarction (MI) : The blockage is caused by a buildup of plaque in the arteries (atherosclerosis). Plaque is made up of deposits, cholesterol, and other substances. When a plaque breaks (ruptures), a blood clot quickly forms. The blood clot is the actual cause of the heart attack
- 5. TYPES OF HEARTATTACKS. • An acute complete blockage of a medium or large heart artery usually means you've had an ST elevation myocardial infarction (STEMI). • A partial blockage often means you've had a non-ST elevation myocardial infarction (NSTEMI). However, some people with non-ST elevation myocardial infarction (NSTEMI) have a total blockage. Not all heart attacks are caused by blocked arteries. Other causes include: • Coronary artery spasm. This is a severe squeezing of a blood vessel that's not blocked. The artery generally has cholesterol plaques or there is early hardening of the vessel due to smoking or other risk factors. Other names for coronary artery spasms are Prinz metal's angina, vasospastic angina or variant angina. • Certain infections. COVID-19 and other viral infections may cause damage to the heart muscle. • Spontaneous coronary artery dissection (SCAD). This life-threatening condition is caused by a tear inside a heart artery.
- 6. SYMPTOMS Symptoms of aheart attack vary. Some people have mild symptoms. Others have severe symptoms. Some people have no symptoms. Common heart attack symptoms include: •Chest pain that may feel like pressure, tightness, pain, squeezing or aching •Pain or discomfort that spreads to the shoulder, arm, back, neck, jaw, teeth or sometimes the upper belly •Cold sweat •Fatigue •Heartburn or indigestion •Lightheadedness or sudden dizziness •Nausea •Shortness of breath Women may have atypical symptoms such as brief or sharp pain felt in the neck, arm or back. Sometimes, the first symptom sign of a heart attack is sudden cardiac arrest. Some heart attacks strike suddenly. But many people have warning signs and symptoms hours, days or weeks in advance. Chest pain or pressure (angina) that keeps happening and doesn't go away with rest may be an early warning sign. Angina is caused by a temporary decrease in blood flow to the heart.
- 7. RISK FACTORS • Age.Men age 45 and older and women age 55 and older are more likely to have a heart attack than are younger men and women. • Tobacco use. This includes smoking and long-term exposure to secondhand smoke. If you smoke, quit. • High blood pressure. Over time, high blood pressure can damage arteries that lead to the heart. High blood pressure that occurs with other conditions, such as obesity, high cholesterol or diabetes, increases the risk even more. • High cholesterol or triglycerides. A high level of low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol) is most likely to narrow arteries. A high level of certain blood fats called triglycerides also increases heart attack risk. Your heart attack risk may drop if levels of high-density lipoprotein (HDL) cholesterol — the "good" cholesterol — are in the standard range. • Obesity. Obesity is linked with high blood pressure, diabetes, high levels of triglycerides and bad cholesterol, and low levels of good cholesterol. • Diabetes. Blood sugar rises when the body doesn't make a hormone called insulin or can't use it correctly. High blood sugar increases the risk of a heart attack. • Metabolic syndrome. This is a combination of at least three of the following things: enlarged waist (central obesity), high blood pressure, low good cholesterol, high triglycerides and high blood sugar. Having metabolic syndrome makes you twice as likely to develop heart disease than if you don't have it. • Family history of heart attacks. If a brother, sister, parent or grandparent had an early heart attack (by age 55 for males and by age 65 for females), you might be at increased risk.
- 8. • Not enoughexercise. A lack of physical activity (sedentary lifestyle) is linked to a higher risk of heart attacks. Regular exercise improves heart health. • Unhealthy diet. A diet high in sugars, animal fats, processed foods, trans fats and salt increases the risk of heart attacks. Eat plenty of fruits, vegetables, fiber and healthy oils. • Stress. Emotional stress, such as extreme anger, may increase the risk of a heart attack. • Illegal drug use. Cocaine and amphetamines are stimulants. They can trigger a coronary artery spasm that can cause a heart attack. • A history of preeclampsia. This condition causes high blood pressure during pregnancy. It increases the lifetime risk of heart disease. An autoimmune condition. Having a condition such as rheumatoid arthritis or lupus can increase the risk of a heart attack.
- 9. DIAGNOSIS Diagnosis of aheart attack includes checking blood pressure, pulse and temperature. Tests are done to see how the heart is beating and to check overall heart health. Tests to diagnose a heart attack include: Electrocardiogram (ECG or EKG). This first test done to diagnose a heart attack records electrical signals as they travel through the heart. Sticky patches (electrodes) are attached to the chest and sometimes the arms and legs. Signals are recorded as waves displayed on a monitor or printed on paper. An electrocardiogram (ECG) can show if you are having or have had a heart attack. Blood tests. Certain heart proteins slowly leak into the blood after heart damage from a heart attack. Blood tests can be done to check for these proteins (cardiac markers). Chest X-ray. A chest X-ray shows the condition and size of the heart and lungs. Echocardiogram. Sound waves (ultrasound) create images of the moving heart. This test can show how blood moves through the heart and heart valves. An echocardiogram can help identify whether an area of your heart has been damaged. Coronary catheterization (angiogram). A long, thin tube (catheter) is inserted into an artery, usually in the leg, and guided to the heart. Dye flows through the catheter to help the arteries show up more clearly on images made during the test. Cardiac computed tomography (CT) or Magnetic resonance imaging (MRI). These tests create images of the heart and chest. Cardiac CT scans use X-rays. Cardiac MRI uses a magnetic field and radio waves to create images of your heart. For both tests, you usually lie on a table that slides inside a long tubelike machine. Each test can be used to diagnose heart problems.
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- 13. NURSING MANAGEMENT Attachmonitor to the patient (Better to attach D-fib Pads). Obtain ECG Regularly as doctor order. Always make sure the patient has 2 large-bore Ivs. Monitor cardiac enzymes. Initiate treatment for acute MI. Administer morphine for pain. Start aspirin and nitroglycerin (0.4 mg sublingual). Provide oxygen if pulse oximetry is less than 94% at room air. Ensure patient seen by a cardiologist. Monitor vitals, daily weight, and urine output. Administer heparin as ordered for STEMI. If the patient has cardiac catheterization, check groin for hematoma and feel distal leg pulses. Keep Monitoring 1)ECG 2)Cardiac enzymes 3)Oxygenation-pulse oximetry 4)Vital signs 5)The intensity of chest pain 6) Palpate leg pulses 7)Auscultate chest for rales and new murmurs
- 14. TREATMENT Medications to treata heart attack might include: • Aspirin. Aspirin reduces blood clotting. It helps keep blood moving through a narrowed artery. If you called 911 or your local emergency number, you may be told to chew aspirin. Emergency medical providers may give you aspirin immediately. • Clot busters (thrombolytics or fibrinolytics). These drugs help break up any blood clots that are blocking blood flow to the heart. The earlier a thrombolytic drug is given after a heart attack, the less the heart is damaged and the greater the chance of survival. • Other blood-thinning medicines. A medicine called heparin may be given by an intravenous (IV) injection. Heparin makes the blood less sticky and less likely to form clots. • Nitroglycerin. This medication widens the blood vessels. It helps improve blood flow to the heart. Nitroglycerin is used to treat sudden chest pain (angina). It's given as a pill under the tongue, as a pill to swallow or as an injection. • Morphine. This medicine is given to relieve chest pain that doesn't go away with nitroglycerin. It also alleviates dyspnea. It produces venodilation, which reduces LV preload & oxygen requirement. It decreases systemic vascular resistance, which reduces LV afterload. It also helps redistribute blood volume in acute pulmonary edema.
- 15. TREATMENT • Beta blockers.These medications slow the heartbeat and decrease blood pressure. Beta blockers can limit the amount of heart muscle damage and prevent future heart attacks. They are given to most people who are having a heart attack. •Blood pressure medicines called angiotensin-converting enzyme (ACE) inhibitors. These drugs lower blood pressure and reduce stress on the heart. • Statins. These drugs help lower unhealthy cholesterol levels. Too much bad (low-density lipoprotein, or LDL) cholesterol can clog arteries.
- 16. Surgical and otherprocedures If you've had a heart attack, a surgery or procedure may be done to open a blocked artery. Surgeries and procedures to treat a heart attack include: • Coronary angioplasty and stenting. This procedure is done to open clogged heart arteries. It may also be called percutaneous coronary intervention (PCI). If you've had a heart attack, this procedure is often done during a procedure to find blockages (cardiac catheterization). • During angioplasty, a heart doctor (cardiologist) guides a thin, flexible tube (catheter) to the narrowed part of the heart artery. A tiny balloon is inflated to help widen the blocked artery and improve blood flow. • A small wire mesh tube (stent) may be placed in the artery during angioplasty. The stent helps keep the artery open. It lowers the risk of the artery narrowing again. Some stents are coated with a medication that helps keep the arteries open. • Coronary artery bypass grafting (CABG). This is open-heart surgery. A surgeon takes a healthy blood vessel from another part of the body to create a new path for blood in the heart. The blood then goes around the blocked or narrowed coronary artery. It may be done as an emergency surgery at the time of a heart attack. Sometimes it's done a few days later, after the heart has recovered a bit. • Cardiac rehabilitation Cardiac rehabilitation is a personalized exercise and education program that teaches ways to improve heart health after heart surgery. It focuses on exercise, a heart-healthy diet, stress management and a gradual return to usual activities. Most hospitals offer cardiac rehabilitation starting in the hospital. The program typically continues for a few weeks or months after you return home.
- 17. COMPLICATIONS Heart attack complicationsare often due to heart muscle damage. Potential complications of a heart attack include: • Irregular or atypical heart rhythms (arrhythmias). Heart attack damage can affect how electrical signals move through the heart, causing heartbeat changes. Some may be serious and can be deadly. • Cardiogenic shock. This rare condition occurs when the heart is suddenly and abruptly unable to pump blood. • Heart failure. A lot of damage to the heart muscle tissue can make the heart unable to pump blood. Heart failure can be temporary or long-lasting (chronic). • Inflammation of the saclike tissue surrounding the heart (pericarditis). Sometimes a heart attack triggers a faulty immune system response. This condition may be called Dressler syndrome, post myocardial infarction syndrome or postcardiac injury syndrome. • Cardiac arrest. Without warning, the heart stops. A sudden change in the heart's signaling causes sudden cardiac arrest. A heart attack increases the risk of this life-threatening condition. It can lead to death (sudden cardiac death) without immediate treatment.
- 18. PREVENTION It's never toolate to take steps to prevent a heart attack — even if you've already had one. Here are ways to prevent a heart attack. Follow a healthy lifestyle. Don't smoke. Maintain a healthy weight with a heart-healthy diet. Get regular exercise and manage stress. Manage other health conditions. Certain conditions, such as high blood pressure and diabetes, can increase the risk of heart attacks. Ask your health care provider how often you need checkups. Take medications as directed. Your health care provider may prescribe drugs to protect and improve your heart health. It's also a good idea to learn CPR properly so you can help someone who's having a heart attack. Consider taking an accredited first-aid training course, including CPR and how to use an automated external defibrillator (AED). Get regular health checkups. Some of the major risk factors for a heart attack — high blood cholesterol, high blood pressure and diabetes — don't cause early symptoms. Limit alcohol. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men.
- 19. CASE PRESENTATION 4 JUNE2023 (ZIRKU MEDICAL CENTRE) BRIEF OVERVIEW AND SOME RELEVANT DETAILS A 38 years old healthy looking married gentleman . He had been enjoying healthy life. He had been a smoker for last couples of years. He had no known chronic condition like Diabetes or Hypertension and not on any medication. Yesterday he was shouting with his son on mobile . Patient had completed his Periodic Medical Assessment last year in Abu Dhabi and was found FIT for Offshore.
- 20. BRIEF OVERVIEW ANDSOME RELEVANT DETAILS On this day he woke up early in the morning got ready and went to his work area. He was feeling chest pain with mild burning sensation in his throat and epigastric area. He thought it is the same issue and wanted to continue to work but one of his long-time friend encouraged him to go to clinic and see the doctor.
- 21. PATIENT ARRIVAL INTOZIRKU MEDICAL CENTER On 4 June 2023 at 08:03 hrs., he walked into Zirku Medical Center with his friend . Upon entering the EMERGENCY ROOM . ER nurse received him and as a primary triage inquired his symptoms and the reason for visiting the clinic. He reported CHEST PAIN and BURNING sensation in his head. During the triage the nurse noted: Pulse rate 89 beats/min Blood pressure 140/90 mmHg Resp rate: 18 breaths/min Oxygen saturation 96 % on room air. FBS: 137mg/dL Temperature 36.9°C
- 22. The Nurseupon noting his ECG , immediately called the Emergency Specialist. The Emergency Specialist Dr. SAMER immediately rushed to the emergency room, took over the patient and starting evaluating him. INITIAL PHYSICAL EXAMINATION Patient was conscious and oriented, Breathing normally and spontaneously, was communicating well, it was distress and sever chest pain (8)that Moment. CARDIOVASCULAR & RESPIRATORY EXAMIANTION Regular Pulse rate in sinus rhythm, Blood pressure was slightly high, JVP Not raised, No pedal Edema, No heave or thrill, Normal heart sound, No murmur no add sound, Sign of Heart Failure, No chest wall deformity, bilateral equal air entry, normal chest wall movement, normal breath sounds, no add sounds NEUROLOGICAL EXAMINATION Was conscious, oriented, normal memory, speech and hearing intact, all Cranial nerves intact, No Focal neurological deficit, Normal shape & Size Responding to light. Cranial nerve intact, tendon reflex intact, power, sensation, coordination, tone was found normal in all limbs, No signs of other neurological deficit.
- 23. EVALUATION AND MANAGEMENTHAND IN HAND 12 lead ECG ordered which revealed ST elevation in ANTERIOSEPTAL leads and STEMI IV canula 18G inserted and blood extracted and send to lab.
- 24. NEW TURN08:05 HRS. Immediately request HEMS activation from our CMO During the evaluation, the patient collapsed on VF rhythm and code blue team activated immediately.
- 25. 08:05 HRS -CPR started immediately with effective chest compression while charging defibrillator to deliver the first DC shock. 08:05 HRS - asynchronized 200J biphasic shock given (1st) with resume of chest compression, after one cycle of chest compression the patient achieved ROSC, and the patient was fully conscious, oriented with light chest heaviness. MEDICAL RECORD AUDIT TRAINING
- 26. 08:05 HRS -code blue team and CMO arrived. 08:05 HRS - airway attached(Oro-pharyngeal)/ O2 started 5L/M. 08:08 HRS - another I.V cannulation 18G inserted 08:10 HRS - aspirin 300mg & clopidogrel 300mg oral given. 08:12 HRS - morphine prepared and given 2.5 mg iv . 08:16 HRS - BP 100/70 PR: 89/min SPO2 100% HR: 80 B/M. 08:17 HRS - Pantoprazole 40mg IV ordered and given. 08:27 HRS - Metoclopramide 10 mg given iv . 09:00 HRS - Clexane 4000 IU 2 ampules prepared and given SC. LAB RESULT OUT WITH NEGATIVE TROPONIN AND SLIGHTLY ELEVATED CK-MB, OTHER INVESTIGATIONS WAS NORMAL.
- 28. 08:22 HRS -patient collapsed again on VF , started effective chest compression immediately while preparing for the defibrillator for the second DC shock. 08:22 HRS - asynchronized 200J biphasic shock given (2nd), with resume of chest compression 08:26 HRS - asynchronized 200J biphasic shock given (3rd), with resume of chest compression 08:27 HRS - patient achieved ROSC , fully conscious , talking to us. 08:35 HRS - Atorvastatin 40mg oral given. 09:00 HRS - Clexane 40 4mg IV given and 40 mg sc .. 09:31HRS - Hems team arrived 10:09 HRS - Patient ready to transfer in the ambulance.
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