- A 57-year-old woman presented with acute inferior myocardial infarction with right ventricular involvement and decreased consciousness. - She was intubated after her Glasgow Coma Scale dropped during streptokinase infusion to treat the myocardial infarction. - Computed tomography of the brain was requested urgently to rule out intracranial hemorrhage from the previous ischemic stroke or as a complication of the streptokinase. - Her diagnosis was revised to rule out intracranial bleeding and she continued to be closely monitored in intensive care.

1. MORBIDITY & MORTALITY
ACUTE INFERIOR MYOCARDIAL INFARCTION WITH
RIGHT SIDED INVOLVEMENT (KILLIP IV)

2. Staff in shift:
• Medical Officer -> Dr. Deenie
-> Dr. Sakti
-> Dr. Zul (Passive)
• Medical Assistant -> MA Azraie (Triage)
-> MA Zahrah
-> MA Fitri
-> MA Jazlan
-> MA Hafiz
• Staff Nurse -> SN Liza

3. • Name: Mdm S
• Age: 57 years old
• MRN: 1031
• Date: 18th November 2020
• Time arrived from KK: 6.00am
• Time vital signs taken: 6.06am
• Sent to SARI Red Zone
• Time seen by doctor: 6.06am

4. • 57 years old, Malay lady, ADL dependent, Bedbound for 2 years (due to bilateral
knee pain, ?osteoarthritis)
• Morbidly Obese, EBW 120kg
• History of CVA 2 years ago, claimed ischaemic stroke, unable to trace record from
Radio HTAN in view of no record available, not on any follow up
• Refer from Klinik Kesihatan Palong 9, 10, 11 for Inferior MI
• Presented with:-
1) Chest pain since yesterday at 12pm, heaviness in nature, non-radiating, pain
score 8/10
2) Shortness of breath x2/7
3) Loss of consciousness at 3pm today
4) Cough x3/7
Associated with failure symptoms, reduced effort tolerance and PND, no orthopnea.
Otherwise, no fever, abdominal pain, vomiting/diarrhea, no UTI symptoms, no other
active complaint.

5. • Upon arrival at KK, initially GCS E2V1M6 (9/15), then reassess back
E4V1M6 (11/15), patient didn’t talk
• BP 105/57 PR 94 SPO2 90% under room air T 36.1 Reflo 11.0mmol/L
• Lungs clear, CVS S1S2
• ECG at KK ST elevation at lead II, III, aVF
• Right sided Q wave with ST elevation 1 box at V4R-V6R
• FBC taken Hb 14.7 WCC 12.7 Platelet 373
• No history traveling to Red Zone COVID-19 cases

6. • O/E: alert, GCS 15/15, pink, warm peripheries, crt < 2 secs, good pulse
volume, mildly tachypnoeic, RR 24, lethargic looking, obey simple
command/answer
• BP 145/81 PR 85 SPO2 90% under room air, 99% under FMO2 10L/min
T 37, Reflo: 5.5 mmol/L
• Lungs generalized crepitations
• CVS S1, S2
• P/A soft, non tender
• No pedal oedema
• Neurological examination intact
• Gag reflex present

10. • ECG: sinus rhythm, Q wave at lead III and aVF, ST elevation at lead II, III and
aVF with reciprocal changes ST depressed at lead I and aVL
• ECG right sided: ST elevation at V4R-V6R
• ECG posterior: no ST elevation
• CXR: Overload picture
• Diagnosis: Acute Inferior Myorcardial Infarction with Right Sided
Involvement (Killip III)
• Discussed with EP - For Streptokinase patient if no contraindication

11. Plan
• S/L GTN I/I
• T Aspirin 300mg
• T. Plavix 300mg
• IV Omeprazole 40mg
• IV Lasix 40mg
• IV Morphine 2mg
• Keep FMO2 10L/min
• Keep SPO2 > 95%
• Watchout for respiratory distress
• Trace all blood investigations taken
• Continous cardiac monitoring
• For Streptokinase if no
contraindication
• Start IVI Noradrenaline and titrate
accordingly if persistent hypotensive
• Monitor vital signs closely
• Issue DIL - awaiting family member
for further history of stroke
• Watchout for hypotensive/bleeding
tendencies/GCS drop/cardiac
arrhythmia
• Trace RTK Covid-19 test

12. Investigations
• FBC Hb 15.1 WCC 15.8 Plt 386
• RP Urea 6.1 Na 138 K 3.5 Creat 177
• LFT ALP 95 ALT 23 AST 126 TBIL 14.5
• CE CK 1010 LDH 419
• Ca 2.57 PO4 0.87 Mg 0.88
• ABG FMO2 10L pH 7.44 PO2 91 PCO2 36.1 HCO3 24.3 BE 0.2 SO2 97
• PT 9.9 INR 0.87
• UFEME Leucocyte 2+ Nitrite -ve Ketones 1+ Others Negative

13. @7.00pm
• BP drop 95/59 (after S/L GTN), started on IVI Noradrenaline 0.2mcg/kg/hr
(double strength)
@ 7.30pm
• Son arrived around 7.15pm but still unsure regarding his mother diagnosis
previously (unable to trace his phone number from KK)
• Trial tracing record from MO Radio HTAN after family member arrived, to
trace CT Brain claimed done previously at HTAN 2-3 years ago wether
ischaemic/haemorrhagic stroke
• However at 7.50pm, told no record available

14. @7.45pm
• BP increase up to 210/108, IVI Noradrenaline was withold
• Reconfirmed with another son (just arrived) at 7.55pm regarding status of her
stroke, he claimed it was ischaemic stroke and patient itself agreed
@ 8.00pm
• Patient was started on IVI Streptokinase 1.5MiU in 100cc NS over 1 hour with
continuous cardiac monitoring
@ 8.15pm
• 15 mins after started IVI Streptokinase, suddenly patient GCS drop
• Cardiac monitor shows no cardiac arrhythmia
• On examination GCS E2V2M5 (9/15), pupils 2mm bilaterally reactive
• BP 117/62 (not supported) PR 90 SPO2 100% under FMO2 10L

15. @8.20pm
• Proceed with intubation, withold IVI Streptokinase
• Pre-medications given IV Midazolam 1mg, IV Fentanyl 100mcg, IV Scoline
100mg
• Used ETT size 7.0, anchored at 19cm, confirmed by direct visualization,
single attempt
• Post intubation lungs equal air entry, equal chest rise, vapor seen in ETT,
SPO2 100% under ventilator
• Subsequently BP drop to 89/45, thus restarted back IVI Noradrenaline
0.1mcg/hr (double strength)
• Started sedation IVI Midafentanyl 2mls/hr

16. Plan
• Updated EP - to request CT Brain urgent
• Case referred to Medical Team
• Revised diagnosis
- To rule out ICB post Streptokinase
- Acute Inferior MI with Right Sided Involvement (Killip IV)

20. • ECG post intubation: Resolving ST elevation III, aVF (>50%), deeper
Q wave III, aVF, ST depression I, aVL, V4-V6
• ABG post intubation: pH 7.29 PO2 316.9 PCO2 44.4 HCO3 20.9 BE -
5.7
• Case discussed with Physician HTAN - for CT brain plain urgent as
planned and update CT brain later
• Monitor BP every 15 minutes, aim MAP more than 65
• To restart IVI Noradrenaline if indicated
Seen by Medical Team