A 81 year old male presents to a regional ED with chest pain for the last 4 hours. Below is the patients ECG:
Describe and Interpret the ECG
How would you manage this patient?
Answer
Rate: 60 beats/min
Rhythm: Normal Sinus
Axis: Normal Axis
Intervals:
PR: 240ms
QRS: 100ms
QT: 440ms
Additional:
STE II, III, aVF, V4-5 (STE III>II), reciprocal ST depression I and aVL, TWI V2-3
This ECG shows an inferolateral STEMI with likely right sided involvement. The patient is border line bradycardic and has a first degree heart block
The 2 main challenges in treatment of this patient is that he is in a regional area with no access to cath lab and the patients age which puts him at higher risk complications for thrombolysis.
Management would include
- O2 to maintain sats 94-98%
- Aspirin 300mg po and Clopidogrel 300mg po
- Fentanyl 25-100mcg to control pain
- Avoid GTN, 250ml normal saline bolus as right sided STEMI preload dependent
- Exclude contraindications for thrombolysis and appropriateness to thrombolyse patient given his age
- Obtain consent for thrombolysis
- Tenecteplase weight based dosage – half dose recommended in patients > 75 years old
- Heparin bolus followed by infusion
- Prepare for possible complications from thrombolysis – bleeding, hypotension
- Arrange transfer to tertiary centre
Referrence:
Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. The Medical journal of Australia. 205(3):128-33. 2016