Clinical Scenarios, PPCI and Direct Admission of High Risk NSTE-ACS

1. Clinical Scenarios
PPCI and Direct Admission of High Risk NSTE-ACS
Beardmore Hotel
17th February 2016

5. Scenario 1

6. • SAS call to office on Sauchiehall Street
• 50 year old male
o Chest tightness for 30 mins
o “It must be the fry-up”
o Associated sweating and nausea
o Recent history of increasing exertional chest
discomfort
• Hypertension, smoker
• “On tablets for blood pressure”

7. A Talking in full sentences
B RR 18, Sp02 96% OA, chest clear
C HR 85, BP 175/95, clammy
D AVPU
E T 36.5, BM 7.9, nil else

9. What would you do next?
1. Call GJNH
2. Take to local A+E
3. Initiate medical therapy
4. Reassure and leave

10. What would you do next?
1. Call GJNH
2. Take to local A+E
3. Initiate medical therapy
4. Reassure and leave

13. 2 2 1 1 ?
6
High risk NSTEMI
✔ ✔ ✔
✔
GJNH

15. Scenario 2

16. • SAS call to Christmas party in Merchant’s City
• 40 year old male
o Chest tightness and palpitations for the past 1
hour
o “I love a free bar pal”
• Admits to frequent episodes of palpitations
recently – has been seen in clinic
• On simvastatin

17. A Talking in full sentences
B RR 18, Sats 98% OA, chest clear
C HR 160, BP 120/75, well-perfused
D AVPU
E T 37.2, BM 4.2, nil else

19. What does this ECG show?
1. Narrow complex tachycardia
2. Atrial fibrillation
3. Rate-related ischaemia
4. All of the above

20. What does this ECG show?
1. Narrow complex tachycardia
2. Atrial fibrillation
3. Rate-related ischaemia
4. All of the above

21. What further information would be
useful?
1. HEART Score
2. More detailed social history
3. Clinic letters
4. All of the above

22. What further information would be
useful?
1. HEART Score
2. More detailed social history
3. Clinic letters
4. All of the above

23. Cardiology clinic 01/12/15:
“I saw this man in clinic today. He has a
6-month history of intermittent
palpitations. These are associated with
excessive alcohol intake. I have
organised a 24 hour ECG recording and
will see him back with the results in 3
months.”

24. ?
3
0 2 0 1
PAF with rate-related ischaemia
Local A&E

25. Scenario 3

26. • SAS call to nursing home in Partick
• 89 year old female
o Gradual increase in SOB over past 2 weeks
o “I can hardly sleep”
o No chest pain
• “She’s had a heart attack before and has a
weak heart”
• On aspirin, ramipril, bisoprolol, simvastatin

27. A Broken sentences
B RR 28, Sats 85% OA, crackles bilaterally,
C HR 96, BP 110/90, cool peripherally
D AVPU
E T35.9, BM 5.5, peripheral oedema

29. What does this ECG show?
1. NSTEMI
2. STEMI
3. LBBB
4. RBBB

30. What does this ECG show?
1. NSTEMI
2. STEMI
3. LBBB
4. RBBB

31. What further information would
be most useful?
1. Lactate
2. Detailed family history
3. Medication doses
4. Old ECGs

32. What further information would
be most useful?
1. Lactate
2. Detailed family history
3. Medication doses
4. Old ECGs

34. What is the most likely diagnosis?
• NSTEMI
• Decompensated heart failure
• Pulmonary embolism
• Respiratory tract infection

35. What is the most likely diagnosis?
• NSTEMI
• Decompensated heart failure
• Pulmonary embolism
• Respiratory tract infection

36. DNACPR in place since July 2015.
Patient and family do not wish any further
invasive investigations.

37. Summary
• Rapid identification of high-risk NSTEMI
• Early discussion with GJNH
• Recognition of type 2 myocardial infarctions
• Thorough information-gathering
• Better outcomes for patients