ACLS come to life!

Another post from our senior residents in EM - Dr Koh Shao Hui.


It is a quiet Monday morning in the resus room. Suddenly the VHF radio crackles to life: “48, yr old, Indian male. Standby for AMI. ETA 10 mins”


A 12 lead ECG is faxed over by the paramedics


What does the pre-hospital ECG show? The team prepares for the arrival of the patient.


Patient arrives with rhythm strip on board ambulance. (Together with strip done at OPS)

2 3
Additional history: Chest pain radiating to left arm since last night. Worse this morning occurring even at rest. A/w diaphoresis. Went to OPS, conveyed here by SCDF. PO aspirin 300mg loaded en route.
O/e: Alert, Diaphoretic, cold and clammy peripheries. L: clear. H: dual heart sounds, no murmurs. Pulses equal. Calves supple. No pedal oedema
Vitals: BP 160/74 HR 70 spo2 98% on RA
Defib pads put on stat with continuous cardiac monitoring.


Standard and right-sided ECG leads

What do the above ECGs show?

Diagnosis: Inferior-right sided STEMI


Consent taken. Cath Lab activated. Patient loaded with PO ticagrelor. IV cannulation performed and bloods sent off.  Given IV morphine and maxolon.


Cath lab calls for patient. Ready to move out.


Change in cardiac rhythm noted on monitoring and patient becomes unresponsive.

1 x DC shock 150J delivered stat. Rhythm changes to NSR transiently and patient transiently regains consciousness. Goes back into VF shortly after. 2nd shock delivered. Goes back into NSR transiently but goes back into VF shortly after. Still spontaneously (agonally) breathing. Decision made to secure away via RSI. (Etomidate and Sux) Intubation performed. CPR commenced with manual bagging. Patient remains in VF. Further shock given. Given IV adrenaline 1mg. CPR continued. Further 4 shocks given. Further bolus doses of adrenaline given. IV boluses of amiodarone, lignocaine and MgSo4 given (As patient noted to have runs of polymorphic VT in between).


First semblance of a perfusing rhythm seen

Pulse present! BP 150/80. Total downtime (Time from collapse to first sustained ROSC) - 19 mins.
Patient connected to ventilator and started on IV fentanyl infusion 50mg/H. Maintained on amiodarone infusion.


Leaves ED for cath lab. Reaches cath lab. (Door to balloon time approx 1Hr)
Cardiac catheterisation performed with angioplasty done.

100% stenosis noted in p-mRCA (accounting for ST elevation in Right sided leads)

85% stenosis noted in dRCA extending into RPAV (accounting for ST elevation in inferior leads)
Thrombectomy performed and Drug eluting stents put into RCA and RPAV.

Patient is subsequently transferred to MICU (under cardiology) for further monitoring
He is extubated the next day with neurology fully intact.

2 days after:


Learning points:
1) Time is myocardium in STEMIs. The pre-hospital Emergency Medical System is an integral part of the chain of ensuring that the patient gets to the Cath lab ASAP (goal of 90mins door to balloon time). Do not disregard Pre-hospital ECGs and vitals as they provide important information.
2) Put on the defib pads onto the patient ASAP on STEMI cases. You may have to shock earlier than you think!
3) Take consent and active the CATH lab stat after (during office hours only).
4) Load the patient with PO ticagrelor 180mg and PO aspirin 300mg (if not given earlier) ASAP
5) Routine oxygen is out for normoxic patients.
6) Do Right sided +/- posterior leads in patients with ST elevation in inferior leads
7) Avoid nitrates in patients with Right sided infarcts.
8) If patient collapses, to resuscitate as per ACLS, with early intubation (RSI needed if patient is still spontaneously breathing) ensuring high quality chest compressions with minimal interruptions in between (Switch rescuers doing CPR frequently)
9) Consider therapeutic hypothermia.
10) If no ROSC, ECMO CPR may be beneficial if available.

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