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ST-segment elevation myocardial infarction

2012-04-07T01:05:55Z

Fink22:

== Background ==
*RV infarction accompanies ~25% of inferior STEMIs
**Hemodynamically significant only 10% of the time
*Posterior infarction is rarely isolated (~3-8% of all AMIs)
**Usually will see changes in V6 OR II, III, aVF

==Diagnosis==
#ST-segment elevation ≥ 1-mm (0.1mV) in at least 2 anatomically contiguous limb leads (aVL to III, including -aVR)
#ST-segment elevation ≥ 2-mm (0.2mV) in V1 through V3
#ST-segment elevation ≥ 1-mm in V4 through V6
#New LBBB
##See [[Sgarbossa's Criteria]] for management in pts w/ preexisting LBBB

==Anatomical Correlation==
*See [[ACS - Anatomical Correlation]]

==DDx==
#Myocardial ischemia or infarction
#Noninfarction, transmural ischemia (Prinzmetal's angina pattern or acute takotsubo cardiomyopathy)
#Post-MI (ventricular aneurysm pattern)
#Previous MI with recurrent ischemia in same area
#[[Pericarditis]]
#Early repolarization
#LVH or LBBB (only V1-V2 or V3)
#[[Myocarditis]] (may look like myocardial infarction or pericarditis)
#[[Brugada Syndrome]]
#Myocardial tumor
#Myocardial trauma
#[[Hyperkalemia]] (only leads V1 and V2)
#[[Hypothermia]] (J wave/Osborn wave)

*See also: [[ST Segment Elevation (DDX)]]

==Treatment==
=== Adjunctive ===
#O2
##Esp for SpO2 <90%
#ASA 162-325mg chewable or 600mg PR
#Clopidogrel
##Loading dose
###300mg
###600mg if PCI anticipated
###No loading dose if >75yr receiving fibrinolytics
#NTG
#Morphine
#Beta-Blocker:
##PO within 24 hours
##IV beta-blocker is reasonable for patients who are hypertensive in the absence of:
###Heart failure
###Low cardiac output state
###Cardiogenic shock risk factors
####Age > 70yr, sys BP < 120, HR > 110 or <60,
###Conduction block (PR interval > 0.24s, 2nd or 3rd block
###Active asthma

===Anticoagulation===
#[[Heparin]] (UFH)
##Bolus 60U/kg (max: 4000U) followed by 12U/kg/h (max: 1000U/h)
##Titrate to PTT 1.5-2.5 x control
#LMWH
##<75yo with serum Cr < 2.5 mg/dL (men) or < 2.0 mg/dL (women):
###30mg IV bolus followed by 1mg/kg SC q12h
##≥ 75yo
###0.75mg/kg SC q12h
##CrCl < 30 mL/min
###1mg/kg SC qd
#Fondaparinux
##Cr < 3.0 mg/dL:
###2.5mg IV bolus then 2.5mg SC qd started 24hr after bolus
##Monitor anti-Xa levels
#Bivalirudin
##0.75mg/kg IV bolus followed by 1.75 mg/kg/h
##CrCl < 30 mL/min
###0.75mg/kg IV bolus followed by 1.0 mg/kg/h

===Antiplatelets===
#GPIIB/IIIa Inhibitors (Abciximab, Eptifibatide)
##Defer to cardiologist
##Given right before PCI
#Clopidogrel
##300mg po x1
##600mg po x1 (if PCI is anticipated)

===Definitive===
#Fibrinolytics
##Goal: Give within 30min
##If receive fibrinolytics also give anticoagulants for minimum of 48hr
##Fibrinolytic tx w/in 3hr resulted in >30 lives saved per 1000 pts
##0.5-1% of pts suffer ICH
#PCI
##Goal: Give within 90min (acceptable delay may be up to 120min)

== Fibrinolysis ==

=== Indications ===

#<12hr from onset of CP AND:
##ST elevation of ≥1mm in 2 contiguous limb or precordial leads OR new LBBB

=== Contraindications ===

#Absolute contraindications
##Any prior ICH
##Known structural cerebral vascular lesion (AVM)
##Known intracranial neoplasm
##Ischemic stroke w/in 3 mo
##Active internal bleeding (excluding menses)
##Suspected aortic dissection or pericarditis
#Relative contraindications
##Severe uncontrolled BP (>180/100)
##History of chronic severe poorly controlled HTN
##History of prior ischemic stroke >3 mo
##Known intracranial pathology not covered in absolute contraindications
##Current use of anticoagulants with known INR >2–3
##Known bleeding diathesis
##Recent trauma (past 2 wk)
##Prolonged CPR (>10 min)
##Major surgery (<3 wk)
##Noncompressible vascular punctures (e.g. IJ, subclavian)
##Recent internal bleeding (within 2–4 wk)
##Pts treated previously with streptokinase should not receive streptokinase a 2nd time
##Pregnancy
##Active peptic ulcer disease
##Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc) 

=== Dosing (Alteplase) ===

*>67kg pt:
*Infuse 15mg IV over 1-2min; then 50mg over 30min; then 35mg over next hr
**Total dose: 100 mg over 1.5hr
*≤67kg pt:
**Infuse 15mg IV over 1-2min; then 0.75 mg/kg (not to exceed 50 mg) over 30 min; then 0.5 mg/kg over 60min (not to exceed 35 mg)

=== Dosing (Tenecteplase-TNKase) ===

*Reconstitute 50 mg vial in 10 mL sterile water (5 mg/mL)
*< 60 kg = 30 mg IV push over 5 seconds
*60-69 kg = 35 mg IV push over 5 seconds
*70-79 kg = 40 mg IV push over 5 seconds
*80-89 kg = 45 mg IV push over 5 seconds
*> 90 kg = 50 mg IV push over 5 seconds

=== Rescue PCI ===

*Failed reperfusion: consider if repeat EKG 90 minutes after infusion fails to show reduction of elevated ST segments by 50%
*Recurrent significant ST elevation following successful lysis
*Persistent hemodynamically unstable arrythmias, persistent ischemic symptoms, or worsened cardiogenic shock

==See Also==
*[[Acute Coronary Syndrome (Main)]]
*[[ST Segment Elevation (DDX)]]

==Source ==
*ACC/AHA Practice Guidelines 2004/5
*EBM 6/09
*Electrocardiography in Emergency Medicine. ACEP Textbook

[[Category:Cards]]

NIH Stroke Scale

2012-04-07T00:35:22Z

Fink22:

'''1a. Level of consciousness'''

Alert = 0 

Not alert, arousable to mild stimulation = 1

Not alert, arousable to significant stimulation = 2

Not alert; reflexic, autonomic or no response = 3

'''1b. Level of Consc. Questions:''' Month and DOB

Both correct = 0

One correct = 1

Zero correct = 2

'''1c. Level of Consc. Command:''' Open/close eyes & squeeze/release hand

Both correct = 0

One correct = 1

Zero correct = 2

'''2. Best Gaze:''' Horizontal voluntary or oculocephalic reflex

Normal = 0

Partial gaze palsy = 1

Forced deviation or total gaze palsy = 2

'''3. Visual Fields'''

Normal = 0

Partial hemianopia = 1

Complete hemianopia = 2

Bilateral hemianopia or cortical blindness = 3

'''4. Facial Paralysis'''

Normal = 0

Minor, flat nasolabial fold = 1

Partial or total uni lower paralysis= 2

Complete paralysis 1 or both sides (upper & lower) = 3

'''5. Motor Arm''' (10 seconds)

No drift = 0

Some drift = 1

Falls, effort against gravity = 2

Falls, No effort against gravity = 3

No movement = 4

'''6. Motor Leg''' (5 seconds)

No drift = 0

Some drift = 1

Falls, effort against gravity = 2

Falls, No effort against gravity = 3

No movement = 4

'''7. Limb ataxia'''

Absent = 0

One limb = 1

Two limb = 2

'''8. Sensory Loss''' (arms, legs, trunk)

Normal = 0

Present but altered = 1

Absent = 2

'''9. Best Language:''' identification (picture or tactile), repetition, comprehension

No aphasia = 0

Mild to moderate = 1

Severe = 2

Mute/Global aphasia =3

'''10. Dysarthria'''

None = 0

Mild to moderate = 1

Severe = 2

1'''1. Extinction/Inattention '''(neglect)

None = 0

Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1

Profound hemi-inattention or more than 1 modality = 2

*Intubation or limb pathology making categories not testable should be considered and potentially not scored.

*tPA candidate generally with NIHSS 4 - 22

Source: National Institute of Neurologic Disorders and Stroke

Fink 04/06/2012

NIH Stroke Scale

2012-04-07T00:33:35Z

Fink22: Created page with "'''1a. Level of consciousness''' Alert = 0 Not alert, arousable to mild stimulation = 1 Not alert, arousable to significant stimulation = 2 Not alert; reflexic, autonomic..."