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7/25/2019 AntMI Stair
1/17
Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
I. Case: Acute Anterior MI
II. Target Audience: 4th
year medical students, interns
III. Learning Objectives
A. Primary1. Rapid assessment of chest pain patient
2. Correct EKG interpretation
3. Initiation of therapy (ASA, NTG, beta blockers)
4. Definitive therapy (interventionalist vs. lytics and anticoagulation)
B. Secondary
1. Risk factor assessment
2. Pain scale to guide response to therapy
3. Ensure adequate access, appropriate monitoring
4. Informs patients and families
5. Seeks contraindications to lysis (if lytics used)
C. Critical Actions Checklist1. Chest Pain Evaluation
a. Rapid H+P, early EKG, CXR
b. IV access, blood for cardiac enzymes, CBC, chemistries)
c. Cardiac monitor, pulse oximeter
2. Recognition of Acute Anterior MI
a. A. EKG interpretation
b. Compare to previous EKG
3. Treatment Initiation
a. Aspirin
b. Nitroglycerin
c. Beta blockersd. Anticoagulation
e. Morphine
4. Rapid Definitive Therapy (Interventional vs. Thrombolytics)
5. Avoid Pitfalls
a. Failure to obtain or correctly interpret EKG
b. Awaiting labs for treatment
c. Delaying definitive treatment
IV. Environment
A. Simulation Lab
B. METI Set Up1. No moulage
2. 2 IV lines, normal saline
3. Aspirin
4. Nitroglycerin
5. Metoprolol
6. Morphine
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
7. Oxygen
8. Thrombolytic
C. Props
1. Code cart and airway supplies
2. EKG#4showing anterior ST elevations (previous EKG [EKG#2]
without)3. Chest xray # 1 no acute disease
4. Laboratory sheet with normal initial cardiac enzymes
D. Distracters: none
V. Actors
A. ED nurse needing direction
B. Spouse played by a peer student; adds no history, but asks about status frequently
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
VI. Case narrative
CC
Chest pain
HPI58 year old woman presents with her husband with a chief complaint of chest pain. Shestates that she has been having a pressure sensation in her substernal area thatradiates up into her left shoulder and neck, 6/10 severity, with associated nausea ,shortness of breath, lightheadedness and sweating. She has had several episodes overthe past several months of chest pressure that resolved with Mylanta, but this time theMylanta hasnt worked.
PMH
HTN
DMGERDPUD
MEDSglyburideavandianorvascHCTZprilosec
ALLNKDA
SH+TOB 50 pack/yearsoccasional alcoholno drugs
FHno known coronary disease
ROSpressure in chest as in HPI over past few monthsincreasing fatigue
7/25/2019 AntMI Stair
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
Physical examAnxious appearing WDWN 58 yo woman in no acute distress
Vital signs T 366 P 97 R 22 BP 158/87 pOx 97%
HEENT - NCAT, unremarkableNECK - Supple, no JVDCHEST - Clear bilaterally with good air movementCARDIAC - RRR without murmurs. rubs, or gallops
ABDOMEN - Soft, NT, ND, +BS, no massesEXTREMITIES - No clubbing, cyanosis; trace nonpitting pedal edema;
2+ radial and dorsal pedal pulsesRECTAL - Normal tone, heme positive brown stoolNEURO - AAO, nonfocal, very anxious appearing
Required steps to be taken now
12 lead EKG (EKG #4)IV accessCardiac monitorBlood for CBC, chemistries, coagulation profile, cardiac enzymesCXR (CXR #1)
AspirinNitroglycerinBeta blocker
Interpretation of 12 lead EKG
(EKG #4) Acute Anterior Myocardial Infarction
Steps necessary now
Notification immediately of interventional cardiologistBeta blockers
Anticoagulation (lovenox or unfractionated permissible)Nitroglycerin if not given
Consider IIb/IIIa inhibitorClose monitoring of vital signs and symptoms
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
VII. Instructors Notes (see sheet below)
VIII. DEBRIEFINGAsk performer to self evaluate performance retrospectivelyAsk peers to evaluate performance
What would you do differently?
REVIEW OF CASE CHECKLISTInitial H+P focused for cardiac history, timely
Address ABCsRapid order and interpretation of 12 lead EKG
Aspirin, nitroglycerin, beta blockerMobilization of interventional cardiologistTreatment based on syndrome and EKG, not waiting for positive enzymes
IX. Pilot Testing and Revisions
X. Author and Affiliation
Richard Stair, MD, FACEPClerkship DirectorDepartment of Emergency MedicineUniversity of Florida
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
STUDENT NAME______________________________ Date_____________
CASE____________________________________________________________
FACULTY REVIEWER_______________________________________________
BEGINNING SIMULATOR SETTINGS
MonitorHR 97RR 22BP 158/87pOx 97% on RA
ABCs
Airway normal swollen occluded other_______________
Breathing normal decreased on rightdiminished bilaterally decreased on leftwheezes rales
Circulation normal no peripheral pulsesno femoral pulseless
Disability normal right hemiplegia right hemiparesis
unresponsive left hemiplegia left hemiparesisother_________________
GCS motor eyes verbal
Physical findingsHEENT normalNECK normalCHEST normalCARDIAC normal
ABDOMEN normalBACK normalEXTREMITIES normalRECTAL / GU normalNEURO normalSKIN diaphoretic
7/25/2019 AntMI Stair
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
TREATMENTS AND INTERVENTIONS FOR THIS CASE
First set of treatments or interventions 5 minutes Performed
1. 12 lead EKG yes no
2. Ensure IV access yes no3. Give aspirin yes no4. Give nitroglycerin yes no5. Chest xray yes no6. Cardiac monitor yes no7. Order cardiac panel yes no8.__________________________ yes no
Second set of treatments or interventions 20 minutes Performed
1. Additional nitroglycerin yes no
2. Administer IV metoprolol yes no3. Administer lovenox or heparin yes no4. Notify interventional cardiology vs. thrombolytics yes no5. May give morphine as well yes no6.__________________________ yes no7.__________________________ yes no8.__________________________ yes no
Third set of treatments or interventions >20 minutes Performed
1. ACLS for arrest if over 20 minutes without treatment yes no
2.____________________________ yes no3.____________________________ yes no4.____________________________ yes no5.____________________________ yes no6.____________________________ yes no7.____________________________ yes no8.____________________________ yes no
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
SIMULATOR RESPONSES TO INTERVENTIONS AND TREATMENTS
APPROPRIATE and TIMELY INAPPROPRIATE and/or DELAYED
#1 - treated correctly within 5 minutes #1 - incorrect or after 5 minutes
HR 85 HR 100RR 20 RR 24BP 145/82 BP 165/90pOx 97% pOx 97%
Changes Changesnone none
#2 - treated correctly within 20 minutes #2 - incorrect or after 20 minutes
HR 70 HR 0 (V fib)RR 18 RR 0BP 120/80 BP 0pOx 97% pOx 50%
Changes Changesnone no pulse, no respirations
COMMENTS
7/25/2019 AntMI Stair
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Acute Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
DATA
CBC ABGWBC 9.7 pHHGB 12.0 pCO2
HCT 37.1 pO2PLT 220 HCO3
satBMP base ex
Na 137K
+ 3.9 UA
Cl 105 spec gravHCO3 27 leuk estBUN 15 nitriteCr 1.1 bloodGlu 192 protein
glucoseLFT ketones
TP WBCAlb RBCT bili bacteriaD bili epithelial
ASTALTAlk Ph hCG
CPK
Total 245MB 4.5Index 1.83
Troponin
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7/25/2019 AntMI Stair
11/17
Richard W. Stair, MD, FACEP
University of Florida
DATA
CBC ABGWBC 9.7 pH
HGB 12.0 pCO2HCT 37.1 pO2PLT 220 HCO3
satBMP base ex
Na 137K+ 3.9 UACl 105 spec gravHCO3 27 leuk estBUN 15 nitriteCr 1.1 blood
Glu 192 proteinglucose
LFT ketonesTP WBC
Alb RBCT bili bacteriaD bili epithelial
ASTALTAlk Ph hCG
CPKTotal 245MB 4.5Index 1.83
Troponin
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Simulator Preparation - Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
STUDENT NAME______________________________ Date_____________
CASE____________________________________________________________
FACULTY REVIEWER_______________________________________________
BEGINNING SIMULATOR SETTINGS
MonitorHR 97RR 22BP 158/87pOx 97% on RA
ABCs
Airway normal swollen occluded other_______________
Breathing normal decreased on rightdiminished bilaterally decreased on leftwheezes rales
Circulation normal no peripheral pulsesno femoral pulseless
Disability normal right hemiplegia right hemiparesisunresponsive left hemiplegia left hemiparesis
other_________________
GCS motor eyes verbal
Physical findings
HEENT normalNECK normalCHEST normalCARDIAC normal
ABDOMEN normalBACK normalEXTREMITIES normalRECTAL / GU normalNEURO normalSKIN diaphoretic
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Simulator Preparation - Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
TREATMENTS AND INTERVENTIONS FOR THIS CASE
First set of treatments or interventions 5 minutes Performed
1. 12 lead EKG yes no2. Ensure IV access yes no
3. Give aspirin yes no4. Give nitroglycerin yes no5. Chest xray yes no6. Cardiac monitor yes no7. Order cardiac panel yes no8.__________________________ yes no
Second set of treatments or interventions 20 minutes Performed
1. Additional nitroglycerin yes no2. Administer IV metoprolol yes no
3. Administer lovenox or heparin yes no4. Notify interventional cardiology vs. thrombolytics yes no5. May give morphine as well yes no6.__________________________ yes no7.__________________________ yes no8.__________________________ yes no
Third set of treatments or interventions >20 minutes Performed
1. ACLS for arrest if over 20 minutes without treatment yes no2.____________________________ yes no
3.____________________________ yes no4.____________________________ yes no5.____________________________ yes no6.____________________________ yes no7.____________________________ yes no8.____________________________ yes no
7/25/2019 AntMI Stair
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Simulator Preparation - Anterior MI Richard W. Stair, MD, FACEPUniversity of Florida
SIMULATOR RESPONSES TO INTERVENTIONS AND TREATMENTS
APPROPRIATE and TIMELY INAPPROPRIATE and/or DELAYED
#1 - treated correctly within 5 minutes #1 - incorrect or after 5 minutes
HR 85 HR 100RR 20 RR 24BP 145/82 BP 165/90pOx 97% pOx 97%
Changes Changesnone none
#2 - treated correctly within 20 minutes #2 - incorrect or after 20 minutes
HR 70 HR 0 (V fib)RR 18 RR 0BP 120/80 BP 0pOx 97% pOx 50%
Changes Changes
none no pulse, no respirations
COMMENTS
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