{ Challenging Case Presentations From South Texas Methodist Hospital REGIONAL SYSTEMS OF CARE DEMONSTRATION PROJECT: MISSION: LIFELINE™ STEMI SYSTEMS ACCELERATOR

Case 2 58 y/o male with no prior known medical history presented to outside ED at 2 am with severe substernal crushing chest pain starting at 1am. Pain started 3 days prior but had been stuttering Initial pain started at his son’s wedding ER physician dx acute inferior MI ER physician concerned about significant hypertension and hyperthyroid by history obtained from the family Pt had been seen in Mexico for several months but for unknown reason

Classic ST changes suggestive of Inferior STEMI

Treatment decision. Pt 2-3 hours by EMS or 1.5 hours by Helicopter Pt vitals HR 50-60, BP 170/90, RR18. no obvious signs of CHF ED physician calls Cardio- hospitalist who instructed to give lytics. Helicopter arrived and pt was pain free with resolution of ECG changes Pt admitted to the CICU.

Pt taken to the cath lab for recurrent pain however with transient ECG changes the next afternoon. PCI to RCA without complication Hospital Course and outcome

Cardiac Cath

Points of discussion 1.Should pt have been transported without lytics? 2.Should there have been any concern about giving lytics? 3.Should the patient been taken directly to the cath lab on arrival?

RETAVASE THROMBOLYTIC PROTOCOL/ORDER SHEET FOR ACUTE MI Methodist Healthcare System Prior to initiating Retavase determine the following: Any major surgery in the past 10 days( ) YES( ) NO Any trauma in the past 10 days( ) YES( ) NO History of Stroke( ) YES( ) NO Bleeding disorders (Haemophilia, Coumadin use, etc)( ) YES( ) NO Gastrointestinal bleeding( ) YES( ) NO Systolic BP greater than 180( ) YES( ) NO Diastolic BP greater than 110( ) YES( ) NO IF YES TO ANY OF THE ABOVE NOTIFY THE PHYSICIAN BEFORE PROCEDING Obtain Consent to Administer Thrombolytic Agent Normal Saline to large bore IV at KVO. Start Twincath IV or 2 nd and 3 rd IV. Obtain blood from IV site and order STAT (if not already done): CBC, PT, PTT, Cardiac Enzymes, Se Creat Administer Retavase bolus of 10 units IV over 2 minutes x 1 dose. Repeat in 30 minutes 1 st Dose given: ______ 2 nd dose may be given by EMS – send medication with patient DO NOT ADMINISTER RETAVASE AND HEPARIN IN SAME LINE Begin vital sign and neuro checks every 15 minutes, notifying MD of any bleeding or changes in vital signs or neuro status. HEPARIN If not already started: Give Heparin 60 Units/Kg IV (maximum of 5,000 Units) Follow with Heparin continuous infusion of 12 Units/Kg per hour (maximum of 1000 Units per hour). DO NOT ADMINISTER RETAVASE AND HEPARIN IN SAME LINE **** OR *** LOVENOX If not already started and Se Creatinine is <2.5 (male) or <2.0 (female) give Lovenox as follows: Pt < 75 years of age give Lovenox 30 mg IV bolus now plus 1mg/kilogram subcutaneous (Max dose 100 mg) Pt > 75 years of age give Lovenox 0.75 mg/Kg subcutaneous now (Max dose 75 mg) 9. STAT ECG 60 minutes after thrombolytic therapy initiated and notify MD of result. ECG DUE AT______. Notify MD if: * recurrent chest discomfort * hematoma or bleeding at any site * new sustained arrhythmias * syncope * systolic BP 165* HR 120 * dyspnea or O2 SAT < 90%* severe headache or mental status change