- The patient presented with symptoms of an acute myocardial infarction (MI) and should be placed in an environment with continuous ECG monitoring and defibrillation capabilities to identify any ST-elevation and provide immediate reperfusion therapy if needed. - Initial emergency treatments include oxygen, aspirin, nitroglycerin, and morphine for pain relief. - Reperfusion therapies like thrombolysis with drugs like streptokinase or percutaneous coronary intervention can be used to restore blood flow in the blocked artery and limit heart muscle damage from ongoing ischemia.

1. Emergency Management
Myocardial Infarction patient in
Emergency Room
BHAVANA RAJANNA
89A

3. Management of MI
 The implication of this early diagnosis for clinical
managementis that a patient who is considered to
have an ACS should beplaced in an environment with
continuous ECG monitoring anddefibrillation
capability, where a 12-lead ECG can be
obtainedexpeditiously and definitively interpreted,
ideally within 10min of arrival in the ED. The most
urgent priority of earlyevaluation is to identify patients
with ST-elevation MI (STEMI)who should be considered
for immediate reperfusion therapy andto recognize
other potentially catastrophic causes of
patientsymptoms, such as aortic dissection.

4. Emergency treatment
 Ambulance
 Analgesia
 Aspirin
 nitroglycerin

5. Morphine (2 to 4 mg IV), repeated q 15 min as
needed, is highly effective but can depress
respiration, can reduce myocardial contractility,
and is a potent venous vasodilator.
Hypotension and bradycardia secondary to
morphine can usually be overcome by prompt
elevation of the lower extremities.

6. Hospital: Reperfusion to restore
coronary flow in patients with acute MI
areused thrombolysis (streptokinase,
alteplase,tenecteplase) or primary
percutaneous coronaryintervention
(PCI).

7. For Stemi
1. FIBRINOLYTIC DRUGS (THROMBOLYTICS)
2. PERCUTANEOUS INTERVENTION, OR-
3. CORONARY ARTERY BYPASS GRAFT
SURGERY

8. Thrombolytic therapy improve survival rates in
patients with acute MI if administered in a
timely fashion in the appropriate group of
patients. Reperfusion using fibrinolytics is most
effective if given in the first few minutes to
hours after onset of MI. The earlier a fibrinolytic
is begun, the better. The goal is a "door-to-
needle" time of 30 to 60 min. Greatest benefit
occurs within 3 h, but the drugs may be
effective up to 12 h

9. Indications for thrombolytics:-
 - within 12 hours (opt-6 hours) of onset of typical
symptoms - patients with ST-segment elevation
greater than 0.1 mV in 2 or more contiguous ECG
leads,- new left bundle-branch block (not known to be
old), - or anterior ST depression consistent with
posterior infarction (a large R wave in V₁ andST-
segment depression in leads V-Va, confirmed with a
15-lead ECG). This finding does not meet current
criteria for fibrinolytics; ECG is repeated in 20 to 30 min
to see if ST-segment elevation has developed.The
major side-effect of thrombolytic therapy is bleeding
(the most common - cerebralhaemorrhage)

10. Contraindications for thrombolysis
 - active internal bleeding (not menses) - aortic
dissection-stroke (due to cerebral haemorrhage) in
patient's historypericarditis- severe hypertension (>
180/110 mm Hg (after initial antihypertensive
therapy).recently surgery treatment (within 4
wk)pregnancyPatients who previously received
streptokinase or anistreplase are not given that
drugSings of successful reperfusion are: relief of pain,
resolution of acute ST elevation, transient reperfusion
arrhythmia.

11.  Alteplase (human tissue plasminogen activator or tPA)
is a genetically engineered drug and is approximately 7-10
times more expensive than streptokinase; it is not antigenic
and seldom causes hypotension. Alteplaseis given in an
accelerated or front-loaded dosage over 90min.
Alteplasewith concomitant IV heparin improves patency, is
nonallergenic, has a higherrecanalization rate than other
fibrinolytics, and is expensive. The standard regimen is
given over90 minutes (bolus dose of 15 mg, followed by
0.75 mg/kg body weight, but not exceeding 50mg, over 30
minutes and then 0.5 mg/kg body weight, but not
exceeding 35 mg, over 60minutes)

12.  Tenecteplaseand reteplase are recommended most often
because tenecteplaseis given as a single bolus over 5 sec
and reteplaseas a double bolus. Administration time and
drug errors are reduced compared with other fibrinolytics,
which have a more complicated dosing regimen.
Tenecteplase, like alteplase, has an intermediate risk of
intracranial hemorrhage, has a higher rate of recanalization
than other fibrinolytics, and it is expensive. Reteplaschas the
highest risk of intracranial hemorrhage and a recanalization
rate similar to that of tenecteplase, and it is expensive.

13.  Anticoagulants - Heparin (and other anticoagulant
agents) has an established role as an adjunctive agent
in patients receiving t-PA but not with streptokinase.
Heparin is also indicated in patients undergoing
primary angioplasty and in patients not receiving
thrombolytic therapy in the setting of acute MI.

14.  Antiplatelet drugs: Aspirin, clopidogrel, ticlopidine, and
glycoprotein (GP) IIb/IIIa inhibitors are examples. All
patients are given aspirin 160 to 325 mg (not enteric-
coated), if not contraindicated, at presentation and 81
mg once/day indefinitely thereafter.

15. Beta-blockers
 Beta-blockers reduce the rates of reinfarction and
recurrent ischemia and possibly reduce the mortality
rate if administered within 12 hours after MI to all
patients with MI without contraindications.These drugs
are recommended unless contraindicated (bradycardia,
heart block, hypotension, or asthma), especially for
high-risk patients. B-Blockers reduce heart rate, arterial
pressure, and contractility, thereby reducing cardiac
workload and O: demand. IV B-blockers given within
the first few hours improve prognosis by reducing
infarct size, recurrence rate, incidence of ventricular
fibrillation, and mortality risk.

16.  Nitrates have no apparent impact on mortality rate in
patients with ischemic syndromes.Their utility is in
symptomatic relief and preload reduction. Administer
to all patients with acuteMI within the first 48 hours of
presentation, unless contraindicated (in RV infarction).

17. ACE inhibitors
 ACE inhibitors reduce mortality risk in MI patients,
especially in those with anterior infarction, heart failure, or
tachycardia. The greatest benefit occurs in the highest-
risk patients early during convalescence. Administer ACE
inhibitors as soon as possible as long as the patient has
no contraindications and remains in stable condition. ACE
inhibitors have the greatest benefit in patients with
ventricular dysfunction. Contraindications include
hypotension, renalfailure, bilateral renal artery stenosis,
and known allergy. Angiotensin II receptor blockers may
be an effective alternative for patients who cannot
tolerate ACE inhibitors (because of cough). Currently, they
are not Ist-line treatment after MI.