Month: July 2016

Podcast: Play in new window | Download

You have 90 minutes to restore blood flow.

Step 1: Obtain EKG and Call STEMI Alert

• This activates ED resources as well as cath lab, interventional cardiology, etc

Step 2: Stop the Platelets

• Dual anti-platelet therapy
  • Aspirin 325mg chewed (or PR)
  • Plavix 600mg (not usually given in ED)
    • Complicates management if patient needs CABG

Step 3: Stop the Coagulation Cascade

• Heparin 60 units/kg (MAX 4000 units)

Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now

• If you DON’T have cath lab
  • Option 1: 30 minutes to give thrombolytics
  • Option 2: 120 minutes to get them to a different hospital with cath lab

Sgarbossa Criteria

• Left bundle branch block (LBBB)
• PLUS
• Concordant ST elevation (>1mm) in leads with positive QRS
• OR
• Concordant ST depression (>1mm) in leads with negative QRS
  • Typically V1-V3
• OR
• Severely discordant ST elevation (>5mm) in leads with negative QRS

“MONA”

• Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain
• Oxygen has been shown to worsen outcomes if given indiscriminately
  • Not ideal to be giving supplemental O2 when SaO2 is 100%
• Nitroglycerine
  • Nitroglycerine 0.4 mg SL q5min
  • OR
  • Nitroglycerin 10mcg/min drip (will need to be titrated UP)
    • For comparison…
      • 0.4 mg SL nitroglycerine releases approximately 80mcg/min
  • Contraindications
    • Inferior/Right heart infarction
      • Patients usually preload dependent
      • Nitro drops preload
    • Sildenafil (Viagra)
      • Can cause sudden/severe drop in blood pressure
    • Hypotension

Additional Reading

• Round 3 – Chest Pain (EM Clerkship)
• The Death of MONA in ACS: Part 1 – Morphine (REBEL EM)
• The Death of MONA in ACS: Part 2 – Oxygen (REBEL EM)
• The Death of MONA in ACS: Part 3 – Nitroglycerine (REBEL EM)
• The Death of MONA in ACS: Part 4 – Aspirin (REBEL EM)