antmi stair

7/25/2019 AntMI Stair

1/17

Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida

I. Case: Acute Anterior MI

II. Target Audience: 4th

year medical students, interns

III. Learning Objectives

A. Primary1. Rapid assessment of chest pain patient

2. Correct EKG interpretation

3. Initiation of therapy (ASA, NTG, beta blockers)

4. Definitive therapy (interventionalist vs. lytics and anticoagulation)

B. Secondary

1. Risk factor assessment

2. Pain scale to guide response to therapy

3. Ensure adequate access, appropriate monitoring

4. Informs patients and families

5. Seeks contraindications to lysis (if lytics used)

C. Critical Actions Checklist1. Chest Pain Evaluation

a. Rapid H+P, early EKG, CXR

b. IV access, blood for cardiac enzymes, CBC, chemistries)

c. Cardiac monitor, pulse oximeter

2. Recognition of Acute Anterior MI

a. A. EKG interpretation

b. Compare to previous EKG

3. Treatment Initiation

a. Aspirin

b. Nitroglycerin

c. Beta blockersd. Anticoagulation

e. Morphine

4. Rapid Definitive Therapy (Interventional vs. Thrombolytics)

5. Avoid Pitfalls

a. Failure to obtain or correctly interpret EKG

b. Awaiting labs for treatment

c. Delaying definitive treatment

IV. Environment

A. Simulation Lab

B. METI Set Up1. No moulage

2. 2 IV lines, normal saline

3. Aspirin

4. Nitroglycerin

5. Metoprolol

6. Morphine


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7. Oxygen

8. Thrombolytic

C. Props

1. Code cart and airway supplies

2. EKG#4showing anterior ST elevations (previous EKG [EKG#2]

without)3. Chest xray # 1 no acute disease

4. Laboratory sheet with normal initial cardiac enzymes

D. Distracters: none

V. Actors

A. ED nurse needing direction

B. Spouse played by a peer student; adds no history, but asks about status frequently


3/17


VI. Case narrative

CC

Chest pain

HPI58 year old woman presents with her husband with a chief complaint of chest pain. Shestates that she has been having a pressure sensation in her substernal area thatradiates up into her left shoulder and neck, 6/10 severity, with associated nausea ,shortness of breath, lightheadedness and sweating. She has had several episodes overthe past several months of chest pressure that resolved with Mylanta, but this time theMylanta hasnt worked.

PMH

HTN

DMGERDPUD

MEDSglyburideavandianorvascHCTZprilosec

ALLNKDA

SH+TOB 50 pack/yearsoccasional alcoholno drugs

FHno known coronary disease

ROSpressure in chest as in HPI over past few monthsincreasing fatigue


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Physical examAnxious appearing WDWN 58 yo woman in no acute distress

Vital signs T 366 P 97 R 22 BP 158/87 pOx 97%

HEENT - NCAT, unremarkableNECK - Supple, no JVDCHEST - Clear bilaterally with good air movementCARDIAC - RRR without murmurs. rubs, or gallops

ABDOMEN - Soft, NT, ND, +BS, no massesEXTREMITIES - No clubbing, cyanosis; trace nonpitting pedal edema;

2+ radial and dorsal pedal pulsesRECTAL - Normal tone, heme positive brown stoolNEURO - AAO, nonfocal, very anxious appearing

Required steps to be taken now

12 lead EKG (EKG #4)IV accessCardiac monitorBlood for CBC, chemistries, coagulation profile, cardiac enzymesCXR (CXR #1)

AspirinNitroglycerinBeta blocker

Interpretation of 12 lead EKG

(EKG #4) Acute Anterior Myocardial Infarction

Steps necessary now

Notification immediately of interventional cardiologistBeta blockers

Anticoagulation (lovenox or unfractionated permissible)Nitroglycerin if not given

Consider IIb/IIIa inhibitorClose monitoring of vital signs and symptoms


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VII. Instructors Notes (see sheet below)

VIII. DEBRIEFINGAsk performer to self evaluate performance retrospectivelyAsk peers to evaluate performance

What would you do differently?

REVIEW OF CASE CHECKLISTInitial H+P focused for cardiac history, timely

Address ABCsRapid order and interpretation of 12 lead EKG

Aspirin, nitroglycerin, beta blockerMobilization of interventional cardiologistTreatment based on syndrome and EKG, not waiting for positive enzymes

IX. Pilot Testing and Revisions

X. Author and Affiliation

Richard Stair, MD, FACEPClerkship DirectorDepartment of Emergency MedicineUniversity of Florida


6/17


STUDENT NAME______________________________ Date_____________

CASE____________________________________________________________

FACULTY REVIEWER_______________________________________________

BEGINNING SIMULATOR SETTINGS

MonitorHR 97RR 22BP 158/87pOx 97% on RA

ABCs

Airway normal swollen occluded other_______________

Breathing normal decreased on rightdiminished bilaterally decreased on leftwheezes rales

Circulation normal no peripheral pulsesno femoral pulseless

Disability normal right hemiplegia right hemiparesis

unresponsive left hemiplegia left hemiparesisother_________________

GCS motor eyes verbal

Physical findingsHEENT normalNECK normalCHEST normalCARDIAC normal

ABDOMEN normalBACK normalEXTREMITIES normalRECTAL / GU normalNEURO normalSKIN diaphoretic


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TREATMENTS AND INTERVENTIONS FOR THIS CASE

First set of treatments or interventions 5 minutes Performed

1. 12 lead EKG yes no

2. Ensure IV access yes no3. Give aspirin yes no4. Give nitroglycerin yes no5. Chest xray yes no6. Cardiac monitor yes no7. Order cardiac panel yes no8.__________________________ yes no

Second set of treatments or interventions 20 minutes Performed

1. Additional nitroglycerin yes no

2. Administer IV metoprolol yes no3. Administer lovenox or heparin yes no4. Notify interventional cardiology vs. thrombolytics yes no5. May give morphine as well yes no6.__________________________ yes no7.__________________________ yes no8.__________________________ yes no

Third set of treatments or interventions >20 minutes Performed

1. ACLS for arrest if over 20 minutes without treatment yes no

2.____________________________ yes no3.____________________________ yes no4.____________________________ yes no5.____________________________ yes no6.____________________________ yes no7.____________________________ yes no8.____________________________ yes no


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SIMULATOR RESPONSES TO INTERVENTIONS AND TREATMENTS

APPROPRIATE and TIMELY INAPPROPRIATE and/or DELAYED

#1 - treated correctly within 5 minutes #1 - incorrect or after 5 minutes

HR 85 HR 100RR 20 RR 24BP 145/82 BP 165/90pOx 97% pOx 97%

Changes Changesnone none


HR 70 HR 0 (V fib)RR 18 RR 0BP 120/80 BP 0pOx 97% pOx 50%

Changes Changesnone no pulse, no respirations

COMMENTS


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DATA

CBC ABGWBC 9.7 pHHGB 12.0 pCO2

HCT 37.1 pO2PLT 220 HCO3

satBMP base ex

Na 137K

+ 3.9 UA

Cl 105 spec gravHCO3 27 leuk estBUN 15 nitriteCr 1.1 bloodGlu 192 protein

glucoseLFT ketones

TP WBCAlb RBCT bili bacteriaD bili epithelial

ASTALTAlk Ph hCG

CPK

Total 245MB 4.5Index 1.83

Troponin


10/17


11/17

Richard W. Stair, MD, FACEP

University of Florida

DATA

CBC ABGWBC 9.7 pH

HGB 12.0 pCO2HCT 37.1 pO2PLT 220 HCO3

satBMP base ex

Na 137K+ 3.9 UACl 105 spec gravHCO3 27 leuk estBUN 15 nitriteCr 1.1 blood

Glu 192 proteinglucose

LFT ketonesTP WBC

Alb RBCT bili bacteriaD bili epithelial

ASTALTAlk Ph hCG

CPKTotal 245MB 4.5Index 1.83

Troponin


12/17


13/17


14/17


15/17

Simulator Preparation - Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida

STUDENT NAME______________________________ Date_____________

CASE____________________________________________________________

FACULTY REVIEWER_______________________________________________

BEGINNING SIMULATOR SETTINGS

MonitorHR 97RR 22BP 158/87pOx 97% on RA

ABCs

Airway normal swollen occluded other_______________

Breathing normal decreased on rightdiminished bilaterally decreased on leftwheezes rales

Circulation normal no peripheral pulsesno femoral pulseless

Disability normal right hemiplegia right hemiparesisunresponsive left hemiplegia left hemiparesis

other_________________

GCS motor eyes verbal

Physical findings

HEENT normalNECK normalCHEST normalCARDIAC normal

ABDOMEN normalBACK normalEXTREMITIES normalRECTAL / GU normalNEURO normalSKIN diaphoretic


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TREATMENTS AND INTERVENTIONS FOR THIS CASE

First set of treatments or interventions 5 minutes Performed

1. 12 lead EKG yes no2. Ensure IV access yes no

3. Give aspirin yes no4. Give nitroglycerin yes no5. Chest xray yes no6. Cardiac monitor yes no7. Order cardiac panel yes no8.__________________________ yes no

Second set of treatments or interventions 20 minutes Performed

1. Additional nitroglycerin yes no2. Administer IV metoprolol yes no

3. Administer lovenox or heparin yes no4. Notify interventional cardiology vs. thrombolytics yes no5. May give morphine as well yes no6.__________________________ yes no7.__________________________ yes no8.__________________________ yes no

Third set of treatments or interventions >20 minutes Performed

1. ACLS for arrest if over 20 minutes without treatment yes no2.____________________________ yes no

3.____________________________ yes no4.____________________________ yes no5.____________________________ yes no6.____________________________ yes no7.____________________________ yes no8.____________________________ yes no


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SIMULATOR RESPONSES TO INTERVENTIONS AND TREATMENTS

APPROPRIATE and TIMELY INAPPROPRIATE and/or DELAYED


HR 85 HR 100RR 20 RR 24BP 145/82 BP 165/90pOx 97% pOx 97%

Changes Changesnone none


HR 70 HR 0 (V fib)RR 18 RR 0BP 120/80 BP 0pOx 97% pOx 50%

Changes Changes

none no pulse, no respirations

COMMENTS

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