critical case

1. Critical Case Presentation

2. A 45-YEAR MAN WITH SEVERE
CENTRAL CHEST PAIN
PRESENTER
DR.MD.SAJJAD SAFI
PHASE-B,MD CARDIOLOGY
BLUE UNIT
BSMMU

3. PARTICULARS
• Name :Md.Shirajul Islam
• Age :45 years
• Address :Rahmatgonj, Chachok Bazar
• Occupation: Businessman
• Married
• Date of admission:10-12-2016 @6:10pm
• Date of examination:10-12-2016 @09:30pm

4. Chief complaints
• Severe central chest pain for 3 hrs

5. History of present illness
• Diagnosed case of Diabetes Mellitus(DM) for 2 yrs
• Chest pain:
– For 3 hrs
– Retrostenal central chest pain
– sudden onset and progressive (crescendo type)
– Very severe in nature
– Associated with excessive sweating and palpitation
– Radiating to right side of chest
– And relieved by sublingual nitroglycerine spray

6. Conti…
• No h/o :Fever,Cough, LOC or Chest trauma
• H/o DM for 2 yrs on oral medication
• H/o smoking for 10 yrs
• No h/o Hypertension(HTN)

7. On examination
• Anxious and restlessness
• 0riented and able to talk
• Mildly anemic ,no edema and not dehydrated
• All limbs are warm

8. • Pulse rate : 60 beats/min
• Blood Pressure: 180/120mmHg
• Temperature : Afebrile
• Respiration : 18/min
• Spo2 :90-92% with high flow o2
• JVP :Not raised

9. Systemic examination
• Cardiovascular :S1 and S2 audible,no murmur
• Respiratory :24/min with B/L basal crepts
present
• Other systems: Revealed no abnormality

10. INVESTIGATIONS
• ECG
• RBS
• ELECTROLYTES
• TROPONIN-I
• ECHO(2D and M-mode)

11. ECG

12. Lab Reports
10/12/2016 11/12/16
Troponin I 0.06 ng/ml 175.64 ng/mL
Sodium 140 mmol/L 139 mmol/L
Potassium 4.9 mmol/L 3.7 mmol/L
S.creatinine 0.96 mg/dl 1.13 mg/dL
RBS 23.9 mmol/L 19.40 mmol/L

13. ECHO
• Infero-septal wall hypokinetic
• Free wall:basal and mid akinetic-akinetic
• Fair LV systolic function
• Impaired RV function
• EF=58%

14. Diagnosis
• Acute STEMI(inf with RV infarction)
• Acute left ventricular failure(ALVF)
• Hypertension emergency
• Diabetes mellitus(DM)

15. Management
• Complete bed rest
• Propped up position
• O2 inhalation with 2L/min throu’ nasal cannula
• Diet diabetic with chart
• Inj. Frusomide (Lasix) 1amp iv stat then sos
• Inj. GTN 1 amp(50mg)+40mL NS @ 0.3mL/hr and
titrate
• Inj. Morphine 3mg iv stat then sos(1amp+14D/W)
• Inj. Prochlorperazine(Vergon) 1 amp iv stat

16. Streptokinase injection
• Hold till Blood pressure(BP) under controlled
with iv GTN
• Started with BP(160/95)mm Hg
• Inj.STK 1.5 IU throu’ syringe pump over
60mins

17. After STK injection

18. Conti…
• Antiplatelets: Tab.Aspirin,(75mg) &
clopidregrel (75mg)
• Statins: Tab.Atovastatin,(40mg)
• ACE inhibitor : Tab.Ramopril ,(2.5)
• PPIs: Tab.Rabeprazole,(20mg)
• Heparin :Low molecular heparin(1mg/kg)
• Insulin : Regular insulin sliding scale
• Anxiolytics: clonazepam 1mg at night

19. Next plan
• ECHO
• Sub minimal ETT
• CAG

20. Contraindications and Cautions for Fibrinolytic
Therapy in STEM
• Absolute contraindications
– Any prior ICH
– Known structural cerebral vascular lesion(e.g., AV malformation)
– Known malignant intracranial neoplasm (primary or metastatic)
– Ischemic stroke within 3 mo (EXCEPT acute ischemic stroke
within 4.5 h)
– Suspected aortic dissection
– Active bleeding or bleeding diathesis (excluding menses)
– Significant closed-head or facial trauma within 3 mo
– Intracranial or intraspinal surgery within 2 mo
– Severe uncontrolled hypertension (unresponsive to emergency
therapy)
– For streptokinase, prior treatment within the previous 6 mo

21. • Relative contraindications
– History of chronic, severe, poorly controlled hypertension
– Significant hypertension on presentation (SBP >180 mm
Hg or DBP >110 mm Hg)
– History of prior ischemic stroke >3 mo
– Dementia
– Known intracranial pathology not covered in absolute
contraindications
– Traumatic or prolonged (>10 min) CPR
– Major surgery (<3 wk)
– Recent (within 2 to 4 wk) internal bleeding
– Noncompressible vascular punctures
– Pregnancy
– Active peptic ulcer
– Oral anticoagulant therapy

22. THANK YOU