Question

Brief Patient History

Mrs. G is a 54-year-old African American woman who has been having intermittent indigestion for the past month. She has a history of hypertension and hyperlipidemia. She was admitted as an inpatient on a medical floor for management of her blood pressure and is scheduled to undergo endoscopy tomorrow. Mrs. G suddenly becomes diaphoretic and complains of nausea and epigastric pain.

Clinical Assessment

The rapid response team is called to evaluate Mrs. G. When the team arrives at her bedside, she continues to complain of pain, which now radiates to her neck and back. She has some slight shortness of breath and is vomiting.

Diagnostic Procedures

The admission electrocardiogram (ECG) shows ST-segment elevation in II, III, and AVF.

Baseline vital signs include the following: blood pressure of 160/90 mm Hg, heart rate of 98 beats/min (sinus rhythm), respiratory rate of 18 breaths/min, temperature of 99° F, and O2 saturation of 94%.

Medical Diagnosis

Inferior myocardial infarction is diagnosed

What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

Answer 1

BASICALLY this question is dealt with the prompt management of IWMI (Inferior wall myocardial infarction)..

as u start treating the IWMI...the symptoms will be relived ....

so we devided our treatment protocol in to few parts

1. first aid...2. Specific therapy...3.Symptomatic treatment..4.Treatment of complications..5. regular monitering with periodic Review....

so

1...First aid :
a) Bed rest. Give reassurance. Moist O2 inhalation at the rate of 4–6 litres/minute.

b) Start I.V drip NS as IN IWMI patient is prone for hypotension an emergency I.V channel.

c) Tab isosorbide dinitrate (5 mg/tab) or tab glycerol trinitrate (0.5 mg/tab)—1 tab to be kept under tongue immediately and to be repeated every 5 minutes till relief of chest pain. Discontinue if hypotension develops.
d) Inj. morphine sulphate (to combat excruciating chest pain)—10 mg, I.V stat, may be repeated (5 mg, I.V) if necessary.
e) Acetyl salicylic acid (aspirin; 150-300 mg/tab)—1 tab stat to be chewed and clopidogrel 300 mg given
orally.
f) Carry out 12 lead ECG. Take blood for cardiac enzymes (CK, CK-MB, AST, LDH, troponin T and troponin I), blood count, ESR, electrolytes (Na+, K+, Mg++), glucose and lipid profile. Repeat after enzymes study at 12 hrs and 24.

2. Specific therapy :

If the patient comes within 8 hours (preferably within 4 hours) of the onset of symptoms,
Thrombolysis by inj. streptokinase—1.5 million units dissolved in 100 ml of normal saline and infused by I.V route over 1 hour. It is a widely used drug must be but with in 4 hour...others are ...Anistreplase, alteplase, reteplase
(r-PA) and tenecteplase (TNK-t-PA).

Inj heparin, S.C, 5000 units twice daily may prevent deep vein thrombosis and left ventricular thrombus formation. After successful thrombolysis, inj. heparin 5000 units, S.C, twice daily may be continued for 7 days (in addition to daily oral aspirin). Enoxaparin, a LMWH may be used 1 mg/kg twice daily, subcutaneously instead.

3. Symptomatic treatment :
a) Constipation—Isapgol husk 2-4 tsf in tepid water at bed time.
b) Restlessness—Diazepam (5 mg/tab), 1 tablet twice daily may be given

4. Treatment of complications :

a) treatment of LVF and CCF accordingly
b) Sinus bradycardia—Elevation of the legs and/or foot end of the bed; inj. atropine 0.6 mg, I.V stat.
c) Atrial fibrillation or flutter—Digoxin 0.25 mg I.V stat; synchronised DC shock
d) Ventricular fibrillation—DC shock, cardiopulmonary resuscitation (CPR).
e) Cardiac asystole—CPR; if fails, temporary pacemaker.
f) Heart block—Inj. atropine 0.6 mg, I.V stat, repeated if necessary; pacemaker.
g) Cardiogenic shock—O2 (8-10 litres/min), normal saline drip, dopamine infusion (2-20 μg/kg/min), inj. hydrocortisone. Arrhythmias should be carefully dealt with.

5. regular monitering with periodic Review....

a) Record vital signs regularly.
b) Low calorie diet; multiple small feeds from the 2nd day onwards (liquid diet on the 1st day). Diet should contain fibres. Stop smoking.

c) Continue,

(i) Tab aspirin (75-150 mg/tab) or clopidogrel (75 mg-150 mg/tab)
(ii) Tab isosorbide-5 mononitrate (20 mg/tab or  Tab isosorbide dinitrate (5 mg/tab)—1 tab to be placed sublingually, sos at the onset of chest pain.

(iii) Statins—Atorvastatin (5–20 mg) or simvastatin (5–20 mg) orally daily given at bedtime to control hyperlipidaemia.

d) Review :
a) Usually at 1 month.
b) Carry out exercise test.
c) Review secondary prevention (avoid smoking, control hypertension and diabetes, taking regular
exercise, control weight gain, lower lipid level by diet control and statins) and screening of the family.