45 years old gentleman who is a
chronic smoker and underlying hypertension presented with typical chest pain 1
hour prior to presentation associated with diaphoresis, nausea and vomiting and
one episode of fainting at workplace.
Vital sign upon arrival as follow;
RR 18/min, PR 74/min, Temp 36.4 degree Celsius, SpO2 100% under room air, BP
198/131, repeated 193/132. CSS is full.
On examination, patient is fully
conscious and alert, in severe pain (pain score 10/10), pink, Hydration and
perfusion status is good, not tachypnoeic and not tachycardic. Examination of
Respiratory, Cardiovascular and Gastrointestinal system are unremarkable.
Initial ECG taken at triage shows
sinus rhythm with rate of 75, ST elevation at lead II, III, aVF, V4-V6 and
reciprocal ST depression with T inversion in lead V1-V3.
 |
| Initial ECG |
Patient was triage at red zone.
100% oxygen was delivered via non rebreather high flow mask. Two large bore IV
line was set up. Sublingual GTN was given for two times but the pain was not
resolving. Therefore, IV Fentanyl 100 mcg stat was given together with IV metaclopromide 10 mg. Pain score was reduce
to 5/10.
Repeated ECG after 5 minutes of
presentation shows similar finding. Right sided ECG was done and did not reveal any right wall involvement. A diagnosis of Inferolateral MI with
involvement of posterior wall and hypertensive emergency was made.
 |
| 5 minutes later |
 |
| Right sided ECG shows normal V4-V6 indicating no right wall involvement |
IV GTN infusion 50mg diluted in 50
cc NS was started at the rate of 0.3 mcg and titrated accordingly to control
the blood pressure. Tab Captopril 25 mg stat was served as well. However, BP
was remained in a higher side 180/130. Therefore, IV hydrallazine infusion was
added and BP was managed to be reduced to 140/106.
Pain score was persistently 5/10
and patient was given IV morphine 2.5 mg stat.
After evaluation, patient is found
to be suitable for thrombolytic therapy. However, in view of persistently high
BP, the duration of thrombolytic therapy was extended from 1 hour to two hours.
IV streptokinase 1.5 Million IU was diluted in 100 ml of normal saline and
infuse over 2 hours.
Throughout infusion, patient was
complicated with hypotensive episode of 70/64 and borderline bradycardia of 60
b.p.m. Antihypertensive agent was off and IV streptokinase was withhold. A
fluid challenge of 250 cc NS was infuse as rapid bolus and BP pick up to
100/70. IV streptokinase was then continued and completed after two hours and
15 minutes.
Post thrombolytic ECG was taken and
it shows return of ST elevation to the baseline. Patient was disposed to
Coronary Care Unit for further management
Love to ask, in what basis, Iv streptokinase need to be started in this patient?
ReplyDeleteLee - Ortho
streptokinase is a thrombolytic.. it used to dissolve the clog inside the coronary artery.. thrombolytic therapy is for ST elevation myocardial infarction
ReplyDelete