Critical case presentation1

critical case

1. Critical Case Presentation

2. A 45-YEAR MAN WITH SEVERE CENTRAL CHEST PAIN PRESENTER DR.MD.SAJJAD SAFI PHASE-B,MD CARDIOLOGY BLUE UNIT BSMMU

3. PARTICULARS Name : Md.Shirajul Islam Age :45 years Address : Rahmatgonj , Chachok Bazar Occupation: Businessman Married Date of admission:10-12-2016 @6:10pm Date of examination:10-12-2016 @09:30pm

4. Chief complaints Severe central chest pain for 3 hrs

5. History of present illness Diagnosed case of Diabetes Mellitus(DM) for 2 yrs Chest pain: For 3 hrs Retrostenal central chest pain sudden onset and progressive (crescendo type) Very severe in nature Associated with excessive sweating and palpitation Radiating to right side of chest And relieved by sublingual nitroglycerine spray

6. Conti… No h/o : Fever,Cough , LOC or Chest trauma H/o DM for 2 yrs on oral medication H/o smoking for 10 yrs No h/o Hypertension(HTN)

7. On examination Anxious and restlessness riented and able to talk Mildly anemic ,no edema and not dehydrated All limbs are warm

8. Pulse rate : 60 beats/min Blood Pressure: 180/120mmHg Temperature : A febrile Respiration : 18/min Spo2 :90-92% with high flow o 2 JVP : N ot raised

9. Systemic examination Cardiovascular :S1 and S2 audible,no murmur Respiratory :24/min with B/L basal crepts present Other systems : Revealed no abnormality

10. INVESTIGATIONS ECG RBS ELECTROLYTES TROPONIN-I ECHO(2D and M-mode)

11. ECG

12. Lab Reports 10/12/2016 11/12/16 Troponin I 0.06 ng /ml 175.64 ng /mL Sodium 140 mmol /L 139 mmol /L Potassium 4.9 mmol /L 3.7 mmol /L S.creatinine 0.96 mg/dl 1.13 mg/ dL RBS 23.9 mmol /L 19.40 mmol /L

13. ECHO Infero-septal wall hypokinetic Free wall:basal and mid akinetic-akinetic Fair LV systolic function Impaired RV function EF=58%

14. Diagnosis Acute STEMI( inf with RV infarction) Acute left ventricular failure(ALVF) Hypertension emergency Diabetes mellitus(DM)

15. Management Complete bed rest Propped up position O2 inhalation with 2L/min throu ’ nasal cannula Diet diabetic with chart Inj. Frusomide (Lasix) 1amp iv stat then sos Inj. GTN 1 amp(50mg)+40mL NS @ 0.3mL/ hr and titrate Inj. Morphine 3mg iv stat then sos (1amp+14D/W) Inj. Prochlorperazine ( Vergon ) 1 amp iv stat

16. Streptokinase injection Hold till Blood pressure(BP) under controlled with iv GTN Started with BP(160/95)mm Hg Inj.STK 1.5 IU throu ’ syringe pump over 60mins

17. After STK injection

18. Conti… Antiplatelets : Tab.Aspirin ,(75mg) & clopidregrel (75mg) Statins: Tab.Atovastatin ,(40mg) ACE inhibitor : Tab.Ramopril ,(2.5) PPIs: Tab.Rabeprazole ,(20mg) Heparin :Low molecular heparin(1mg/kg) Insulin : R egular insulin sliding scale Anxiolytics: clonazepam 1mg at night

19. Next plan ECHO Sub minimal ETT CAG

20. Contraindications and Cautions for Fibrinolytic Therapy in STEM Absolute contraindications Any prior ICH Known structural cerebral vascular lesion(e.g ., AV malformation ) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 mo (EXCEPT acute ischemic stroke within 4.5 h) Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 mo Intracranial or intraspinal surgery within 2 mo Severe uncontrolled hypertension (unresponsive to emergency therapy ) For streptokinase, prior treatment within the previous 6 mo

21. Relative contraindications History of chronic, severe, poorly controlled hypertension Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) History of prior ischemic stroke >3 mo Dementia Known intracranial pathology not covered in absolute contraindications Traumatic or prolonged (>10 min) CPR Major surgery (<3 wk ) Recent (within 2 to 4 wk ) internal bleeding Noncompressible vascular punctures Pregnancy Active peptic ulcer Oral anticoagulant therapy

22. THANK YOU