 I nt er nal Medi ci ne

Ìmmediate therapy
· ÌV access
· Cardiac monitoring
· Morphine ÌV
· Oxygen with continuous
monitoring
· Nitroglycerin SL or spray
· Aspirin 325 mg, chewable
No ST elevation
Enzymes negative
Manage as unstable angina
Consider for reperfusion
therapy
Either thrombolysis or
angioplasty
Ìf neither appropriate/
available: stabilize
Thrombolysis
· No contraindication
· MÌ within 2-6 hours
· MÌ within 12 hours with
persistent chest pain and
ST elevation
· Ìf contraindicated or
cardiogenic shock,
consider angioplasty
Ìnitial stabilization
Evaluate and treat complications
of acute MÌ
Angioplasty
· Catheter lab immediately
available (<1 hour to
reperfusion) and/or
· Contraindication to lytic
therapy
· Cardiogenic shock
· Refractory ventricular
arrhythmia
· Large infarct size
Additional therapy/
hypertension
· Relieve pain
· ÌV nitroglycerin
· Beta-blockers
· ACE inhibitors
Hypovolemia
Ìnferior MÌ, right ventricle
infarction
Give rapid ÌV volume
using NS (normal saline)
Shock
Ventilation/oxygenation
Ìmmediate primary PTCA
Hemodynamic monitoring
Ìntraaortic balloon pump
Vasopressors: dopamine/
dobutamine
Mechanical problems
Papillary muscle rupture/
dysfunction
Acute severe MR
Ventricular septal rupture
Dysrhythmia/conduction disturbances
SVT (supraventricular tachycardia)
DC cardioversion if symptoms or
hemodynamic instability
Drugs: adenosine, metoprolol,
procainamide
Ventricular tachycardia/fibrillation
Defibrillate immediately
Drugs: lidocaine, procainamide,
amiodarone
No prophylactic lidocaine
Maintain K
+
> 4 mEq/L and Mg
> 2 mEq/L
Bradycardia/atrioventricular block
Atropine 0.5-1.0 mg
Standby pacemaker if risk for:
Complete heart block
New left bundle branch block
with primary atrioventricular
block
New bifascicular block
Acute surgical
Ìnitial Assessment
· Focused history and physical examination
· Evaluate peripheral perfusion
· ECG-ST elevation >1 mm in at least 2 anterior, inferior,
lateral leads; ST depression in anterior lead (post-MÌ)
· Cardiac enzymes
Consider angioplasty
Failure
Success
Negative
for MÌ
Positive
for MÌ
Iigure 1-4. Algorithm for assessment and treatment of chest pain.