ACUTE ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

Initial management

  • Continue ECG monitoring
  • Oxygen 6L/min face mask
  • IV access x 2 - bloods for FBC, EUC, CK, lipids, coags, G+S
  • Administer 150mg soluble aspirin P.O.
  • IV heparin (80 U/kg loading, 18 U/kg/hr infusion)1
  • GIIb/IIIa inhibitor (discuss with cardiology registrar)
  • If BP < 100 (see below - Hypotension)
  • If in cardiogenic shock proceed to urgent balloon pump/PTCA
  • If normotensive
    • Administer 600mcg anginine S/L
    • IV GTN 5-10mcg/min and titrate to pain and BP

Reperfusion options

(if ECG criteria for Reperfusion therapy and most recent episode of chest pain < 12 hrs since onset )

Meanwhile

  • Contact cardiology registrar
  • Contact coronary care unit
  • Consider immediate angioplasty and notify cardiac catheter lab
  • Make arrangements for immediate transfer to either catheter lab or coronary care unit with defibrillator and resuscitative equipment

COMPLICATIONS

Hypotension

  • Treat arrhythmias
  • RV infarction - IV fluids up to 3L Normal saline, careful with GTN

Cardiogenic shock (hypotension with acute heart failure)

  • Anterior infarction with Cardiogenic shock (aim for SBP > 100)
    • 200 ml aliquots of Haemacell if chest is clear
    • Bolus metaraminol 1-2mg IV @ 3min or adrenaline 10-20 mcg @ 1 min
    • Adrenaline infusion 1-10mcg/min
    • Urgent intra-aortic balloon pump/angioplasty
    • CPAP/mechanical ventilation if refractory hypoxaemia with high flow oxygen

Acute pulmonary oedema

Arrhythmias (treat as usual)

Cardiac arrest

 

  1. RA Raschke. The Weight-based Heparin Dosing Nomogram Compared with a "Standard Care" Nomogram - A Randomized Controlled Trial.  Annals of Internal Medicine. 1 November 1993; 119(9):874-81