A 65-year-old patient presents to your clinic with a history of chest pain for last 24 hours associated with sweating and diaphoresis. The follow ing ECG findings are seen. BP is 150/90 mm Hg. Which of the following is not given in management of this patient?
Correct Answer: Thrombolysis
Description: Ans. a. Thrombolysis (Ref: Harrison 19/e p1603-1605, 18/e p2027-2029)Symptoms and ECG findings are suggestive of ST-elevation MI. Since the patient has come to the hospital 24 hours after onset of symptoms, there will be no benefit from thrombolysis."Management of Patients with ST-segment Elevation Myocardial Infarction: In the absence of contraindications. it is reasonable to administer fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12 to 24 hours who have continuing ischemic symptoms and electrocardiographic evidence of STEMI. Fibrinolytic therapy should not be administered to asymptomatic patients whose initial symptoms of STEMI began more than 24 hours earlier nor to patients whose 12-lead ECG shows only ST-segment depression, except if a true posterior myocardial infarction (MI) is suspected. ""Aspirin is essential in the management of patients with suspected STEMI and is effective across the entire spectrum of acute coronary syndromes Rapid inhibition of cyclooxygenase-1 in platelets followed by a reduction of thromboxane A levels is achieved by buccal absorption of a chewed 160-325-mg tablet in the Emergency Department. This measure should be followed by daily oral administration of aspirin in a dose of 75-162 mg. "-- Harrison 19/e p1603"Morphine is a very effective analgesic for the pain associated with STEMI. However, it may reduce sympathetically mediated arteriolar and venous constriction, and the resulting venous pooling may reduce cardiac output and arterial pressure These hemodynamic disturbances usually respond promptly to elevation of the legs, but in some patients, volume expansion with intravenous saline is required. The patient may experience diaphoresis and nausea, but these events usually pass and are replaced by a feeling of well-being associated with the relief of pain. Morphine also has a vagotonic effect and may cause bradycardia or advanced degrees of heart block, particularly in patients with inferior infarction. These side effects usually respond to atropine (0.5 mg intravenously). Morphine is routinely administered by repetitive (every 5 min) intravenous injection of small doses (2--4 mg), rather than by the subcutaneous administration of a larger quantity; because absorption may be unpredictable by the latter route.-- Harrison 19/e p1603.Management of Patients with ST-segment Elevation Myocardial InfarctionPrehospital, emergency medical service providers should administer aspirin (162 to 325 mg) to all patients not already taking aspirin, obtain a 12-lead electrocardiogram (ECG) in patients suspected of having STEMIQ, review a reperfusion checklist, and relay this information to a medical facility.Patients with STEMI who have cardiogenic shock, those with contraindications to lytics. and those at high-risk of dying because of heart failure should be channeled immediately to a facility capable of cardiac catheterizationQ.Initial Recognition and Evaluation in the Emergency DepartmentInitial evaluation in the emergency department focuses on identification of STEMI, early therapy, and reperfusion strategySelection of reperfusion strategy' depends on hospital and patient characteristics.Time to reperfusion therapy strongly influences outcomes in STEMI.Patients presenting to a hospital with percutaneous coronary intervention (PCI) capability should undergo PCI within 90 minutes of first medical contact as a systems goalQ.Patients with STEMI presenting to a non-PCI-capable hospital should be considered for transfer to a PCI-capable hospital based on patient characteristics time from symptom onset, and time to available PCI therapySTEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should receive fibrinolytic therapy within 30 minutes of hospital presentation as a systems goat in the absence of contraindications.If pharmacologic reperfusion is selected, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hoursQ.In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12 to 24 hours who have continuing ischemic symptoms & electrocardiographic evidence of STEMIQ.Fibrinolytic therapy should not be administered to asymptomatic patients whose initial symptoms of STEMI began more than 24 hours earlier nor to patients whose 12-lead ECG show s only ST- segment depression, except if a true posterior myocardial infarction (MI) is suspectedQ.Patients should be evaluated for contraindications to fibrinolytic therapy such as a history of intracranial hemorrhage (ICH), significant closed head or facial trauma within the past 3 months, uncontrolled hypertension, or ischemic stroke within the past 3 months.STEMI patients at substantial (4%) risk of ICH should be treated with PCI rather than with fibrinolytic therapyQ.
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