emergency treatment of MI.pptx

emergency treatment of mi

1. Emergency Management Myocardial Infarction patient in Emergency Room BHAVANA RAJANNA 89A

2. Management of MI The implication of this early diagnosis for clinical managementis that a patient who is considered to have an ACS should beplaced in an environment with continuous ECG monitoring anddefibrillation capability, where a 12-lead ECG can be obtainedexpeditiously and definitively interpreted, ideally within 10min of arrival in the ED. The most urgent priority of earlyevaluation is to identify patients with ST-elevation MI (STEMI)who should be considered for immediate reperfusion therapy andto recognize other potentially catastrophic causes of patientsymptoms , such as aortic dissection.

3. Emergency treatment Ambulance Analgesia Aspirin nitroglycerin

4. Morphine (2 to 4 mg IV), repeated q 15 min as needed, is highly effective but can depress respiration, can reduce myocardial contractility, and is a potent venous vasodilator. Hypotension and bradycardia secondary to morphine can usually be overcome by prompt elevation of the lower extremities.

5. Hospital: Reperfusion to restore coronary flow in patients with acute MI areused thrombolysis (streptokinase, alteplase,tenecteplase ) or primary percutaneous coronaryintervention (PCI).

6. For Stemi fibrinolytic drugs (thrombolytics) percutaneous intervention, or- coronary artery bypass graft surgery

7. Thrombolytic therapy improve survival rates in patients with acute MI if administered in a timely fashion in the appropriate group of patients. Reperfusion using fibrinolytics is most effective if given in the first few minutes to hours after onset of MI. The earlier a fibrinolytic is begun, the better. The goal is a "door-to-needle" time of 30 to 60 min. Greatest benefit occurs within 3 h, but the drugs may be effective up to 12 h

8. Indications for thrombolytics:- - within 12 hours (opt-6 hours) of onset of typical symptoms - patients with ST-segment elevation greater than 0.1 mV in 2 or more contiguous ECG leads,- new left bundle-branch block (not known to be old), - or anterior ST depression consistent with posterior infarction (a large R wave in V₁ andST -segment depression in leads V- Va , confirmed with a 15-lead ECG). This finding does not meet current criteria for fibrinolytics; ECG is repeated in 20 to 30 min to see if ST-segment elevation has developed.The major side-effect of thrombolytic therapy is bleeding (the most common - cerebralhaemorrhage )

9. Contraindications for thrombolysis - active internal bleeding (not menses) - aortic dissection-stroke (due to cerebral haemorrhage) in patient's historypericarditis - severe hypertension (> 180/110 mm Hg (after initial antihypertensive therapy).recently surgery treatment (within 4 wk ) pregnancyPatients who previously received streptokinase or anistreplase are not given that drugSings of successful reperfusion are: relief of pain, resolution of acute ST elevation, transient reperfusion arrhythmia.

10. Alteplase (human tissue plasminogen activator or tPA) is a genetically engineered drug and is approximately 7-10 times more expensive than streptokinase; it is not antigenic and seldom causes hypotension. Alteplaseis given in an accelerated or front-loaded dosage over 90min. Alteplasewith concomitant IV heparin improves patency, is nonallergenic, has a higherrecanalization rate than other fibrinolytics, and is expensive. The standard regimen is given over90 minutes (bolus dose of 15 mg, followed by 0.75 mg/kg body weight, but not exceeding 50mg, over 30 minutes and then 0.5 mg/kg body weight, but not exceeding 35 mg, over 60minutes)

11. Tenecteplaseand reteplase are recommended most often because tenecteplaseis given as a single bolus over 5 sec and reteplaseas a double bolus. Administration time and drug errors are reduced compared with other fibrinolytics, which have a more complicated dosing regimen. Tenecteplase, like alteplase, has an intermediate risk of intracranial hemorrhage, has a higher rate of recanalization than other fibrinolytics, and it is expensive. Reteplaschas the highest risk of intracranial hemorrhage and a recanalization rate similar to that of tenecteplase , and it is expensive.

12. Anticoagulants - Heparin (and other anticoagulant agents) has an established role as an adjunctive agent in patients receiving t-PA but not with streptokinase. Heparin is also indicated in patients undergoing primary angioplasty and in patients not receiving thrombolytic therapy in the setting of acute MI.

13. Antiplatelet drugs: Aspirin, clopidogrel, ticlopidine, and glycoprotein (GP) IIb/IIIa inhibitors are examples. All patients are given aspirin 160 to 325 mg (not enteric-coated), if not contraindicated, at presentation and 81 mg once/day indefinitely thereafter.

14. Beta-blockers Beta-blockers reduce the rates of reinfarction and recurrent ischemia and possibly reduce the mortality rate if administered within 12 hours after MI to all patients with MI without contraindications.These drugs are recommended unless contraindicated (bradycardia, heart block, hypotension, or asthma), especially for high-risk patients. B-Blockers reduce heart rate, arterial pressure, and contractility, thereby reducing cardiac workload and O: demand. IV B-blockers given within the first few hours improve prognosis by reducing infarct size, recurrence rate, incidence of ventricular fibrillation, and mortality risk.

15. Nitrates have no apparent impact on mortality rate in patients with ischemic syndromes.Their utility is in symptomatic relief and preload reduction. Administer to all patients with acuteMI within the first 48 hours of presentation, unless contraindicated (in RV infarction).

16. ACE inhibitors ACE inhibitors reduce mortality risk in MI patients, especially in those with anterior infarction, heart failure, or tachycardia. The greatest benefit occurs in the highest-risk patients early during convalescence. Administer ACE inhibitors as soon as possible as long as the patient has no contraindications and remains in stable condition. ACE inhibitors have the greatest benefit in patients with ventricular dysfunction. Contraindications include hypotension, renalfailure , bilateral renal artery stenosis, and known allergy. Angiotensin II receptor blockers may be an effective alternative for patients who cannot tolerate ACE inhibitors (because of cough). Currently, they are not Ist -line treatment after MI.