This document presents a case study of a 70-year-old woman who presented with progressive shortness of breath over 4 hours. Upon examination, she was found to be in severe respiratory distress. Tests revealed signs of a heart attack and congestive heart failure. She was diagnosed with a ST-elevation myocardial infarction and treated with oxygen, medications, and supportive care in the intensive care unit. Her condition gradually improved and she was discharged after 6 days with a full recovery.

1. Case presentation Presented by: Louza Al-anqodi

2. outlines Case presentation Pitfalls in management Topic review Take home messages.

3. 70 yr DM and HTN since more than 10 yrs 4 hrs of progressive SOB.

4. Primary survey.

5. Generally: Was on severe respiratory distress, Using accessory muscle

6. Generally: Was on severe respiratory distress, A:patent no secretion edentulous

7. B: Dyspnic RR:14/min spo2 95% with 100% o2 poor inspiratory efforts b/l coarse crepitation Generally: Was on severe respiratory distress A: patent no secretion edentulous

8. B: Dyspnic RR:14/min spo2 95% with 100% o2 poor inspiratory efforts b/l coarse crepitation Generally: Was on severe respiratory distress A: patent no secretion edentulous C: Pr:115/min bp105/67 cold extremities

9. B: Dyspnic RR:14/min spo2 95% with 100% o2 poor inspiratory efforts b/l coarse crepitation Generally: Was on severe respiratory distress A: patent no secretion edentulous C: Pr:115/min bp105/67 cold extremities D: Reflow:12 pupils'/l reactive GCS: E3V4M6

10. B: Dyspnic RR:14/min spo2 95% with 100% o2 poor inspiratory efforts b/l coarse crepitation Generally: Was on severe respiratory distress A: patent no secretion edentulous E: Cold extremities, Temp:38.1 C: Pr:115/min bp105/67 cold extremities D: Reflow:12 pupils'/l reactive GCS: E3V4M6

11. history She was feeling unwell the same night, Took a small amount of dinner and then vomited it, She was complaining of on-off central chest discomfort, Awaked from sleeping with severe SOB, struggling to breath and profuse sweating.

12. No cough or fever No GI symptoms No h/o contact with sick person No recent travel. Never smoke or drink alcohol.

13. Examination: Exhausted, tired, not pale, JVP:not raised, no pedal edema Chest: poor air entery, b/l coarse crepitation, no wheezes. CVS: normal s1s2, no added sounds Abdomen is soft, no hepatomegaly.

14. Differential diagnosis Acute LVF secondary to ACS. Pneumonia Sepsis

15. Action taking Aspirin 300mg po Frusmide 80mg given Started on GTN 0.5mg/hr O2 via non-rebreather mask.

18. ABG: Ph:6.8, pco2:106, po2 109, HCO3:17, BE:-17 Troponin0.15

19. Refered to cardiologist and anasthetic informed. CPAP Confused and resltess Planned for intubation.

20. Bedside echo showed global hypokinesia, EF~10%,mild MR , mild TR, calcific aortic valve ,no clots, ECG repeated after one hr:

22. Hb is 14.8,hct:47.7,plt271, wbc:22.1,neutrophile 4.9,lymphocyte:15.6. Urea:5.7, creat:82, K: 4.6, Na:136.

23. Disposal Home ICU CCU ?Cath. Lab. ?thrombolysed.

24. Pt shifted to CCU Dx STEMI, presumably new LBBB. Her BP dropped Started on 3 inotropes and antibiotics,

25. CVP,arterial line , NGT inserted,urinary catheter inserted. Started on frusmide infusion ,because of copuis secretion from ETT. Bleeding from NGT suction Heparin infusion, clopedogril and aspirin

26. Remained critical for 2 days, Monitor showed tachycardia of 210 /min, BP 90/50 on 3 inotropes.

29. Started to improve with supportive care by the 3ed day Inotropes tapered and stopped Extubated Relative refused PCI. Discharge with full recovery in the 6th day.

30. STEMI

31. Spectrum of Acute Coronary Syndromes Ischemic Discomfort at Rest Presentation No ST-segment Elevation ST-segment Elevation Emergency Department Cardiac Markers + – + + In-hospital 6-24 hours Unstable Angina (UA) Non-Q-wave MI (NSTEMI) Q-wave MI (STEMI) Adapted from Braunwald E, et al. Available at: http://www.acc.org/clinical/guidelines/unstable/unstable.pdf

32. Brief Physical Exam in the Emergency Department Airway, Breathing, Circulation (ABC) Vital signs, general observation Presence or absence of jugular venous distension Pulmonary auscultation for rales Cardiac auscultation for murmurs or gallops Presence or absence of stroke Presence or absence of pulses Presence or absence of systemic hypoperfusion (cool, clammy, pale/ashen) Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed November 1, 2005.

33. Reperfusion Options for STEMI PatientsStep One: Assess Time and Risk. Risk of Fibrinolysis Time Since Symptom Onset Risk of STEMI Time Required for Transport to a Skilled PCI Lab

35. door-to- needle( time for initiation of fibrinolytic therapy) ti be achieved within 30 minutes

37. Known structural cerebral vascular lesion (e.g., arteriovenous malformation)

38. Known malignant intracranial neoplasm (primary or metastatic)

39. Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours NOTE: Age restriction for fibrinolysis has been removed compared with prior guidelines.

41. Active bleeding or bleeding diathesis (excluding menses)

43. Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg)

44. History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications

46. Noncompressible vascular punctures

47. For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior allergic reaction to these agents

48. Pregnancy

51. High Risk from STEMI Cardiogenic shock, Killip class ≥ 3

54. Primary PCI for STEMI: Specific Considerations PCI preferred if > 3 hours from symptom onset. Primary PCI should be performed in patients with severe congestive heart failure (CHF) and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.

55. Primary PCI for STEMI: Specific Considerations It is reasonable to perform primary PCI for patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following: a. Severe CHF b. Hemodynamic or electrical instability c. Persistent ischemic symptoms.

57. Maintenance and restoration of hemodynamic and/or electrical instability

59. After alteplase, reteplase, tenecteplase

61. Aspirin A daily dose of aspirin (initial dose of 162 to 325 mg orally; maintenance dose of 75 to 162 mg) should be given indefinitely after STEMI to all patients without a true aspirin allergy.

63. ≥ 3 months after sirolimus-eluting stent

64. ≥ 6 months after paclitaxel-eluting stent

66. Other Pharmacological Measures Angiotensin converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARB) Aldosterone blockers Glucose control Magnesium Calcium channel blockers

68. Pulmonary congestion

69. LVEF < 0.40An ARB should be given to ACE-intolerant patients with either clinical or radiological signs of HF or LVEF < 0.40.

70. Rescue PCI Rescue PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI It is reasonable to perform rescue PCI for patients with one or more of the following: a. Hemodynamic or electrical instability b. Persistent ischemic symptoms.