CASE 1

Jason R is a 38 year old male who called the ED about 30 min prior so arrival to ask if he should come
to hospital. Jason said over the phone”my wife bugging me to come over there. I’ve got a heavy
pressure in my chest, sort of like indigestion. I’ve had it before, but it always went away. This time I
can’t get rid of it. “Jason was advised by the ED nurse to cometo the hospital, preferably by
ambulance.

Jason arrived by car and is noted to look pale and uncomfortable. He complains of pain in the center
of his chest that feels like a heavy pressure that is now going down both arms. The pain has
increased in severity since he left home. Jason rates pain as 8 on a scale of 1 to 10. Jason is assisted
to a stretcher and while lying in semi-Fowlers position has no dyspnea. His vital sign are temperature
99 F. Pulse 60 and regular, respiratory rate 22, and BP 108/60. Lung sounds are clear and heart
sounds are regular with normal S1 and S2. He has an extra heart sound S4.

When questioned about recent healt, Jason tells the nurse that he has had chest pain off and on for
about week. Jason describes the pain as a tightness or heaviness in the center of his chest under the
breastbone. Jason also mentions that the pain occurs with physical exertion and goes away with rest.

Jason is merried and has two children. He is a sales executive and received a promotion 1 month ago.
Jason smokes about one pack of cigarettes per day. He has no previous medical history and does not
take any drugs. Jason says that his father died if a herat attack and his mother has hypertension.

Triage Assessment, Acuity Level IV : Chest pain, unrelieved : pain continues at rest.

Jason is taken immediately to the treatment area to rule out myocardial ischemia or injury. A 12-lead
ECG is immediately done and reveals ST segmen elevation in leads I, II, III, A VF, V4, V5, and V6. T
waves are inverted in V1, V2, and I ‘3, and an abnormal R wave is present in V1. The initial creatine
phosphokinase (CPK) is reported as 153 (0 to 225 is normal). The ED physician makes a diagnosis of
acute inferior lateral myocardial infarction (MI). True posterior MI is also considered.

Jason is given oxygen via nasal cannula at 5 liters/min and sublingual nitroglycerin with significant
reduction in his pain. After consultation with a crdiologist. Jason is deemed a candidate for
thrombolytic therapy. A lidocaine bolus is administered per protocol and a continous infusions of
lidocaine is started at 2mg/min. Tissue plasminogen activator (t-PA) is selected as the thrombolytic
agen for Jason. An intravenous bolus dose of 10 mg of t-PA is given by the physican, and an infusion
of t-PA is initiated at a rate of 50 mg/hr. Jason is then transferred to the coronarycare unit (CCU) for
further definitive therapy and monitoring.