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STEMI Stuff

59 y/o WM presents to (non-PCI capable) ED Intense substernal heaviness - radiation dyspnea - N/V - diaphoresisOnset 45 min PTA while watching TVAin't never had nuttin like this before?. Couch Potato. PMH: NoneMeds: NoneAllergies: NoneFH: Neg for CADSH: 1 ppd X yearsPhysical ExamVS

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STEMI Stuff

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    1. STEMI Stuff Friday, February 13, 2009

    2. 59 y/o WM presents to (non-PCI capable) ED Intense substernal heaviness - radiation + dyspnea - N/V - diaphoresis Onset 45 min PTA while watching TV Ain’t never had nuttin like this before… Couch Potato MRN: 4157045, DOS 1/20. Pt: JHMRN: 4157045, DOS 1/20. Pt: JH

    3. PMH: None Meds: None Allergies: None FH: Neg for CAD SH: 1 ppd X years Physical Exam VS: 97/62, 86, 18, 96% on 2 lpm Chest: RRR w/o murmur BS CTA w/o crackles No JVD or edema Couch Tater cont’d

    4. Tater Tracing

    5. Discussion Interpret 12-lead Likely anatomy? Immediate interventions?

    6. ED Interventions Rapid ECG ASA NTG Plavix 600 mg po Heparin bolus Lopressor IV

    7. Outcome 90% mid LAD, 100% LCx, 40% & 80% RCA Balloon and thrombectomy of LAD IABP placed CABG X 6 D/C on day 11 doing well.

    8. Tater Time Symptom onset: 1800 Arrival at First Hospital 1837 1st ECG: 1838 Cath lab activation: 1843 Arrival ED: 1913 Vessel open: 1933 D2B (total): 56 minutes D2B (SW): 20 minutes

    9. Just Dying for a Stent 51 y/o WM presents to OSH ED Ventricular Fibrillation x 1 Flown in for emergent PCI Transported directly to lab 0548726, 1/24, DR0548726, 1/24, DR

    10. 12-lead Not pt’s real ECG - their’s wasn’t available so I pulled one from my stash of ECGs Not pt’s real ECG - their’s wasn’t available so I pulled one from my stash of ECGs

    11. Intubated, PEA arrest, ROSC 90% lesion to entire LAD Stent placed, flow resumed IABP placed PEA -> asystole w/o ROSC

    12. Symptom onset: 0500 EMS Contact: 0615 EMS ECG: 0620 OSH ED arrival: 0641 Cath lab activation: 0725 Arrival S&W: 0750 Arrival Lab: 0755 Vessel Open: 0825 From First Medical Contact 130 minutes D2B (Total): 104 minutes D2B (SW) 35 min Including arrest X 2! Chronology

    13. 67 y/o WM Sharp, intense, substernal CP Radiation to left arm and neck. +nausea and diaphoresis Initial ECG non-diagnostic, subsequent ECG = STEMI. Transferred from nearby facility Waiting to Rise 5211946, 1/21, FR5211946, 1/21, FR

    14. Repeat 12-lead Not pt’s real ECG - their’s wasn’t available so I pulled one from my stash of ECGs Not pt’s real ECG - their’s wasn’t available so I pulled one from my stash of ECGs

    15. What Happened Next… 90% LAD with multiple lesions throughout LAD system. PCI aborted in favor of CABG X 3 Required IABP, pressors but was weaned successfully. D/C day 7

    16. Times Symptom Onset: 0545 Initial Arrival: 0640 Initial ECG: 0641 Subsequent ECG: 0645 Cath Lab Activation: 0716 Arrival PCI Facility: 0740 Arrival Lab: 0747 Vessel Open: 0801 D2B (total): 76 min D2B (SW): 21 min (D2B from ECG showing STEMI) 1120425 & 5213194, 1/23, DH1120425 & 5213194, 1/23, DH

    17. Those Medics Were Right! 47 y/o WM contacted EMS Midsternal, crushing CP + nausea + diaphoresis + SOB EMS requests cath lab activation MRN 1120425/5213194, 1/23/09. DHMRN 1120425/5213194, 1/23/09. DH

    18. EMS 12-lead

    19. No significant PMH, Meds, etc Risk factors: smoking, hyperlipidemia VS unstable in ED VF arrest in ED. ROSC, taken to lab

    20. 12 lead

    21. Outcome ROSC in ED, hemodynamically stable PCI w/ stent to mid LCX for 100% occlusion Post arrest echo: 55% EF D/C day 2, doing well

    22. Right Times Symptom onset: 0700 EMS Contact: 1217 Initial ECG: 1223 Lab activation: 1231 Arrival PCI Facility: 1245 Arrival Lab: 1300 Vessel open: 1318 D2B (total): 61 minutes D2B (SW): 33 minutes

    23. Take Me to Town 48 y/o M in Rural Area Substernal chest pain + pale + diaphoretic Pain “just like my past heart attack….” MRN 4861360, 1/28/09, MKMRN 4861360, 1/28/09, MK

    24. Let’s Go PMH: CAD, stented X 4 ASA, NTG and ECG by EMS. Air Medical Transport Utilized VS reportedly stable Pain improved with NTG and fentanyl

    25. 12 lead

    26. It’s Good To Be Here Given Plavix, heparin enroute Directly to cath lab Occlusion of RCA Bare metal stent with restoration of flow D/C on hospital day 3, doing well

    27. 12-lead, Post PCI

    28. Travel Times Onset of symptoms: 1200 EMS Contact: 1305 EMS ECG: 1308 Lab activation: 1354 Arrival SW: 1411 Arrival Lab: 1421 Vessel open: 1431 D2B (Total): 86 minutes D2B (SW): 20 minutes

    29. Not Our Finest 5 Hours 50 y/o M sees PCP in office for 2 days of intermittent chest heaviness radiating to left arm, worse with exertion. + nausea and diaphoresis. No prior episodes. MRN 0395827, 1/29/09, GDMRN 0395827, 1/29/09, GD

    30. 5 x PMH: Hyperlipidemia, GERD PE in clinic unremarkeable. ECG there reportedly shows STEMI. Sent to local ED STEMI confirmed, flown to cath lab by Helicopter.

    31. 12 lead

    32. Outcome Bare metal stent to RCA Thrombectomy of LAD lesion Preserved LVF, symptom free D/C on day 3, doing well

    33. 5 x Times Symptom onset: 2000 prior day Initial PCP Contact: 1100 Initial ECG: 1110 ED Arrival: 1341 Lab Activated: 1711 Arrival SW: 1822 Arrival Lab: 1830 Vessel Open: 1859 D2B (Total): 318 minutes D2B (SW): 37 minutes Initial ECG done in clinic. Pt instructed to go to ED.

    34. Way Out Yonder 61 y/o F in Rural Texas Substernal, severe, crushing CP for 2 hrs PMH: CAD s/p PCI w/ stents X 2, diabetes Noncompliant with her medications “I felt so good, I didn’t think I needed them” PE: Essentially unremarkable. MRN: 1177417, 2/4/08. DTMRN: 1177417, 2/4/08. DT

    35. Way Out Yonder (cont’d) Prehospital Care ASA NTG ECG reveals inferior injury Transported to local ED Hospital Care Thrombolytics administered Cath lab activated at tertiary center Flown to Tertiary Center

    36. Initial 12-lead Not pt’s real ECG - their’s wasn’t available so I pulled one from my stash of ECGs Not pt’s real ECG - their’s wasn’t available so I pulled one from my stash of ECGs

    37. Way Out Yonder Chronology Symptom Onset: 2000 Initial Medical Contact: 2150 Initial EKG: 2158 Initial Presentation: 2230 Lytics Given: 2233 Helicopter Requested: 2230 Cath Lab Activation: 2241 Arrival S&W: 2358 Arrival Cath Lab: 0008 Vessel Open: 0035 D2N Time* 3 minutes D2B Time (Total): 125 minutes D2B Time (S&W): 37 minutes

    38. After Lysis & PCI

    39. Way Outcome Suspicion of in-stent thrombosis 100% occlusion of RCA stent, multiple additional arteries Restored RCA flow with balloon only CABG X 4

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