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 )

• PTCA if available within 90 min
• Otherwise consider thrombolysis - check for contraindications

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