Case Study #5: Antero-lateral STEMI

prehospitalresearch.eu/

March 8,
2014

Patient & Apparent Chief Complaint

A 46 year old male presents to ambulance crew with central crushing chest pain,
radiating to his shoulder blades.

History
This gentleman was packing golf clubs into his car with two friends present when he
developed sudden, crushing pain in his chest, radiating to his shoulder blades. Pain 9/10
on scale. He had no previous medical history of significance, a non-smoker and non-
drinker. Ambulance was called for by one of his friends. No first aid was administered.

Initial Clinical Findings

Airway – clear
C Spine – not indicated (NOI: chest pain)
Breathing – adequate
Circulation – Pulse present, irregular; skin colour pale, cap refill normal
Disability – Patient alert and orientated, PEARRL

Clinical Impression
Cardiac chest pain, ? acute myocardial infarction

AMPLE History
A NKDA
M No medications
P Nil medical history of significance
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 L Breakfast at 0930 (fruit)
E Packing car when pain occurred

Observations
Pulse rate 100bpm
Pulse rhythm Irregular, weak and thready
ECG rate 108
ECG rhythm Sinus Tachycardia with ST elevation in antero-septal leads (V1-V4)

Resp rate 18
Resp quality Shallow and laboured in both lungs. No wheeze/crackles
SpO2% 99% on O2 @ 15lpm; 89% on room air
Cap Refill <2secs
BP 115/78
Pupils PEARRL, size 4
GCS 15/15 (E4, V5, M6)
BGL 5.8mmol/l
Temp 35.2C
Physical examination Nil of significance, nil pedal oedema. Patient diaphoretic
and anxious.

Pre-hospital care & management

O2 @15lpm via NRB commenced by Paramedic crew. GTN 800mcg administered
sublingually. Aspirin 300mg PO administered. Morphine 10mg IV administered in 2mg
doses, 3 minutes apart. Clopidogrel 300mg PO administered.

In-hospital care & management

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Patient triaged as Category 2 (Very Urgent; to be seen within 10 minutes) with central
crushing chest pain, possibly cardiac.

Troponin I 22.93 (>0.10 is indicative of AMI)

Clinical Findings
Antero-septal STEMI

Patient candidate for thrombolysis therapy.

Enoxaparin 30mg IV administered as per
thrombolysis protocol. Tenectaplase 8000ú IV
administered. Slow ST resolution evident on ECG.
Pain reduced to 4/10. At 40 mins post lysis severe
retrosternal pain re-occurred. – 10/10 on pain
scale. Morphine 10mg IV administered.
Worsening ST elevation evident on ECG. Patient
sent for rescue PCI. LAD stented – severe 3 vessel
disease.

1 day post event – ST segment resolved, Q waves

present in anterior and septal leads. Hypotensive
(86/60). For Clopidogrel/Aspirin/Lipitor for life.
Aggressive Cardiac Rehab to be commenced.
Titrate ACE-Inhibitor & beta blocker as tolerated.
Patient discharged home 4 days post event.

Identification of all interventions initiated and rationale

Pulse oximetry – to monitor oxygen saturation levels in the blood
Supplemental oxygen – to re-oxygenate patient and increase potential oxygen
supply to the myocardium
GTN – to reduce preload and in turn reduce myocardial oxygen demand.
Aspirin – to decrease the risk of further clots developing and causing further
myocardial damage
Semi-recumbent position – comfortable for patients with chest pain, allows for
relaxation of abdominal muscles, and allows for use of intercostals muscles of the
back to aid breathing
3 Lead ECG – to identify any life-threatening arrhythmias
12 Lead ECG – to identify any life-threatening arrhythmias or ECG changes
indicative of myocardial damage (secondary to hypoxia etc.)
Morphine – to relieve pain due to cardiac ischemia and to reduce anxiety
Clopidogrel – to further reduce the risk of clot formation
Thrombolysis – to dissolve any clot that may be present in the coronary arteries,
causing myocardial ischemia
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 CXR – to identify pneumonia, pneumothorax, pleural effusion etc. that may
increase morbidity
Blood tests – to identify any electrolyte imbalances, cardiac enzymes released due
to myocardial damage, clotting factors present in blood etc.

Learning Outcomes

Pre-hospital intervention
The ability of Paramedics to perform 12 Lead ECGs, and identify ST segment
elevation/depression is a vital skill that can help to rapidly identify ST elevation MI’s. The
facility to be able to transmit them to an emergency department or other facility for
cardiology review is also another important aspect of pre-hospital cardiac care.

This patient would also have been a candidate for pre-hospital thrombolysis in the event
of a delay in transport for PCI. He was conscious, coherent and would have understood
the therapy. He would have consented, was under 75 years of age, had symptoms for
less than 6 hours and had ST elevation >1mm in 2 or more contiguous leads. He had no
contraindications to thrombolysis. This would have reduced his time to receive
thrombolysis therapy by 1½ hours.

Manchester Triage Scale

The Manchester Triage Scale is a method of categorising patients for medical attention
based on their presentation, rather than their diagnosis. It is a system that triages
patients into distinct categories, based on the severity of their presentation (Mackway-
Jones, 2008). According to Cronin (2003) using a triage system “has many advantages for
the emergency department including reference to a recognised decision-making
structure and support in the form of a professionally accepted and validated system.”

There are 5 categories in the Manchester Triage Scale

Category 1 is life threatening and should be seen and assessed immediately.

Category 2 is very urgent and patients in this category should be seen within 10
minutes.
The lower categories (3, 4 and 5) have target assessment times of 60, 120 and 240
minutes respectively.

All patients have an initial set of vital signs performed on them in the Triage room, which
are then available for the nursing and medical staff in the ED. Triage is a dynamic
process, and patients may be re-evaluated and re-categorised if their condition improves
or deteriorates.

(Ganley & Gloster, 2011)

Diagnosing an AMI in the ED

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 1. Typical history:
1. central, retrosternal chest pain, may be described as crushing, squeezing,
tightness or pressure on the chest lasting > 30mins, unrelieved by nitrates.
2. May be associated with nausea, vomiting, sweating, dyspnoea
2. ECG changes:
1. ST segment elevation > 2mm in 2 or more of the precordial leads, or >1mm in
the limb leads.
2. ST segment depression in leads V1-V3 (strongly suspicious of posterior MI)
along with dominant R waves and upright tall T waves
3. Right sided ECG will show ST elevation in lead V4 – observing for right
ventricular involvement.
3. Cardiac Enzyme elevation:
1. CK (Creatnine Kinase) greater than 180U/L from 6 hours of onset of chest
pain
2. Troponin I greater than 2.5ng/ml after 8 hours of commencement of chest
pain

Immediate management of AMI in the ED

1. Soluble Aspirin 300mg PO
2. 12 lead ECG, bloods, large bore IV access obtained in case of arrest
3. Analgesia (e.g. Cyclimorph 10mg IV, divided into doses of 2.5mg)
4. Possible administration of antiemetic (e.g. Metoclopramide 10mg IV)
5. Thrombolysis if suitable candidate; Primary PCI may be considered with some
individuals
6. Oxygen, dosage based on individual basis
7. Beta-blocker

Morphine (Opioid)
Presentation: Ampoule (10mg/1ml)
Administration: Slow IV push
Dosage: 2mg IV at not <2min intervals
Effects: Reduces pain & anxiety, vasodilation, respiratory depression, reduces pre-
load to myocardium
Side-effects: Respiratory depression, drowsiness, nausea & vomiting
Additional Info: Cyclizine IV given to counteract nausea & vomiting.

Cardiac Rehabilitation
Cardiac rehabilitation is a programme which patients post MI or post any type of acute
coronary event such as angina are encouraged to undergo (Davies et al., 2010), which
aims to address many issues such as reduce their anxiety about their condition (Whalley
et al., 2011); educate them with regards to health, diet and lifestyle changes; promote
changes in exercise and diet regimes; promote independence and return to normal
activities of daily living and more (Taylor et al., 2010).
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It addresses medical, physical, psychological, social and societal issues, and aims to
reduce the morbidity of coronary events, and thus further reduce the burden on the
health services (Heran et al., 2011; Brown et al., 2011). It consists of a medical director,
nursing staff, dieticians, physiotherapists, social workers, occupational therapists,
pharmacists, community care practitioners and more.

References (non-PubMed)
Mackway-Jones K. (2008) The Manchester Triage System. Presentation to Utrecht
University School of Public Health 8th February 2008. Utrecht Public Health.

References

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PMID: 22216667.

Emergency care services in the UK are receiving increasing numbers of patients

presenting with a wide range of problems, from life-threatening conditions to minor
injury or illness. All patients seeking emergency care need to be assessed and classified
to prioritise those who have the most urgent pr […]

2.
Cronin JG. The introduction of the Manchester triage scale to an
emergency department in the Republic of Ireland. Accid Emerg Nurs.
2003 Apr;11(2):121-5. PMID: 12633631.

Triage is an integral part of the modern emergency department. The use of a recognised
triage system has many advantages for the emergency department including reference
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accepted and validated system. As part of a […]

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Heran BS1, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K,
Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for
coronary heart disease. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001800. PMID:
21735386.

The burden of coronary heart disease (CHD) worldwide is one of great concern to
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patients and healthcare agencies alike. Exercise-based cardiac rehabilitation aims to
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Davies P1, Taylor F, Beswick A, Wise F, Moxham T, Rees K, Ebrahim S.
Promoting patient uptake and adherence in cardiac rehabilitation.
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Cardiac rehabilitation is an important component of recovery from coronary events but

uptake and adherence to such programmes are below the recommended levels. This
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Whalley B1, Rees K, Davies P, Bennett P, Ebrahim S, Liu Z, West R,
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21833943.

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