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Myocardial Infarction (Primary Survey (Breathing: Assess RR and SpO2,…
Myocardial Infarction
Primary Survey
Breathing: Assess RR and SpO2, provide oxygenation, listen to breath sounds
Circulation: HR, BP, cap refill, ECG, 2x IV cannulas, Bloods (FBC, UEC, Trops, lipase, coags, LFT's), Fluid resus (1L at 500mLs/hour), listen to heart sounds
Airway: Is the airway intact? Signs of impending airway obstruction? Intubation?
Disability: AVPU/GCS, BGL, pupils
DRS
Exposure: Temp
MONA: Morphine (1-10mg IV), Oxygen, GTN (300mcg every 10 minutes x3), Aspirin (300mg)
STEMI further management
General management: Cardiac monitoring, IV nitrates, B-blockers, consider ondansetron for N & V, and pantoprazole for GI prophylaxis
Anti-thrombotic therapy: Aspirin (already given), Clopidegrol (300-600mg), Enoxaparin (300mg IV)
Confirm indications for reperfusion: evidence of STEMI on ECG, Hx suggesting MI, sx >30 minutes and <12 hours
Choose reperfusion method
Thrombolyse (Tenecteplase): If greater than 90mins to cath lab
Cath lab/Transfer to PCI site (If managing via cath lab omit enoxaparin given above)
Consult local guidelines
Consult cardiologist
Investigations
CXR
3x ECG
STEMI criteria
Greater than 2mm of ST elevation in 2 contiguous chest leads
New LBBB
Greater than 1mm of ST elevation in 2 contiguous limb leads
Other
Sx suggestive of ischaemia: ST depression, T wave inversion, Q waves
Wellens syndrome suggesting critical stenosis of LAD: deeply inverted or biphasic T waves in V2 - V3
2x Trops: Initial reading, 2nd reading at 4 hours post onset of chest pain (Rise if 4-8 hours post sx and peak at 18-20 hours)
NSTEMI further management
Stratify ACS (unstable angina --> NSTEMI) risk as per local guidelines
Intermediate risk: Clopidegrol (300-600mg) + aspirin
High risk: Same drugs as STEMI without anti-thrombotic therapy
Low risk: Aspirin
General management
Repeat trops at 8 hours if initial set negative
Repeat ECG at 8 hours +/- if sx recur
Regular vitals
Re-stratify as necessary