Another post from our senior residents in EM - Dr Koh Shao Hui.0830H:
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)
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: