STEMI
Patient presentation:
Z.P., a 58 year old male patient arrived to a local ER via EMS with chest pain, shortness of breath, nausea, vomiting, and dizziness. Chest pain is described as “an elephant sitting on my chest” and located mostly to left chest with radiation to left arm and neck. Vital signs are as follows: blood pressure: 100/50, heart rate: 60, and respirations: 24. EMS established an 18 gauge IV in right ACV with one liter of normal saline running and placed a nasal cannula with 2 liters oxygen. EMS gave the patient 81mg of aspirin and morphine 4 mg IV push which lowered pt’s pain from 10/10 to 5/10. Pt has a history of previous myocardial infarction with 2 stents placed. Pt also has type 2 diabetes mellitus, hyperlipidemia, hypertension, is overweight and just quit his 15 year, 2 packs a day smoking habit one year prior.
On arrival patient is alert and oriented, the skin is pale and diaphoretic, pt is hyperventilating slightly, still complains of chest pain 5/10, shortness of breath, and lightheadedness. Lung sounds are clear bilaterally. Vital signs remain 98/52, heart rate 62, respirations 21, temperature 98.7 Fahrenheit, and 98% on 2 liters oxygen via nasal cannula. There is evidence of jugular vein distention (JVD) when patient inhales deeply (Kussmaul’s sign). Abdomen is soft and non-tender with no pulsatile masses.
Possible diagnosis:
STEMI, Non-STEMI, or angina.
Tests:
ECG show ST elevation in leads II, III, and AVF.
iStat Troponin level 4.0 ng/mL (elevated).
CPK/CPK-MB, PT, INR, CBC, CMP, and Type and Screen were ordered, drawn and sent to lab.
Chest XR shows no acute changes
2nd 18 Gauge IV was established and 2nd liter normal saline wide open started
Diagnosis:
Inferior wall Myocardial infarction (occlusion of the right coronary artery) which affects the right ventricle, part of the left ventricle, and SA node. Nitroglycerin was not given because this would drop his blood pressure even more and cause more ischemia to the heart.
Treatment:
The catheterization team was activated. The patient was rushed to the Cath Lab for heart catheterization and possible stent placement under 30 minutes from time of arrival to ER. The patient received a cardiac artery catheterization and had 2 more stents placed.
Outcome:
The patient was discharged from the hospital several days later with strict guidelines of medications, diet, and exercise.
Case created by Zina Potorac, 2010.