Non-STEMI that need Cath Lab NOW!; Smith at SMACC.
-
Upload
oliver-flower -
Category
Health & Medicine
-
view
7.415 -
download
1
description
Transcript of Non-STEMI that need Cath Lab NOW!; Smith at SMACC.
NON-STEMI THAT NEED THE CATH LAB NOW
Stephen W. SmithAssociate Professor of EM
Hennepin County Med CenterUniversity of MN
4 days ago
4 days ago presenting ECG - pain free
46 yo male
2.5, 420 ,2 = 27.11
25 min later
Side by Side
Missed, ruled in with max trop I = 130 ng/ml. Cath next day.
Proximal LAD occlusion, convalescent anterior WMA
42 yo with chest pain
Computerized QTc = 388
QTc = 388, STE60V3 = 4 mm, RAV4 = 32 mm: formula = 17.24 (<< 23.4)
Lateral AMI confirmed by reciprocal depression in lead IIIFirst Diagonal occlusion — NOT “inferior ischemia”
47 yo woman with CP
RCA occlusion, but not STEMI
60 yo woman with Chest Pain
Prehospital ECG: STE at 60 ms after the J-point in lead V3 = 2.0 mm, QTc = 422 ms, R-wave amplitude in lead V4 = 4mm: formula = 25.99 (> 23.4)
Referred for STEMI from clinic
First is outside ECG, 2nd is ED: QTc = 392. 392, 2, 12 = 21.61
390, 2, 11 = 21.8
Male in 60s with chest pain
Chest pain, resolved
Still no chest pain, but trop slightly positive, repeat ECG
Young woman, crushing and stabbing CP
Initial trop 6.1 (+), serial ecgs unchanged, no WMA, dx myocarditis. No MRI, no rub, no effusion, so diagnosis not certain
24 yo woman, heavy EtOH and vomiting night before, now CP
After Cath
Saw this in a pile of ECGs
First trop neg. 2nd trop I returns at 4 hours = 3.8 ng/ml. Repeat ECG:
Formula = 24.5, peak trop 100, 40% LVEF
“Heartburn”
25 yo male with chest pain
Texted to me during meeting
50 yo male with refractory chest pressure
Down-Up T-waves
K = 2.3
61 yo with chest pain
Right sided ECG: (V1-V6 are really V1R through V6R, on the right chest):
Chest pain
Isolated Posterior STEMI
51 yo woman with 1 hr of typical Chest Pain.
Old ECG
No emergent PCINext day Troponin 72, CK 3200. Cath next day: culprit lesion 2nd OM. Stented. Convalescent echo: posterior akinesis, 55%
65 year-old with 2 hours of CP. No h/o MI.
previous
V3
V6
V5
V4
RVLVRA
A
RVLV
ADIAPHRAGM
V9 V8V7
5th intercostal space
56 yo male with 2 hours of typical CP
Given tPA. Reperfused, troponin 5.4, posterior WMA. Later angio with 99%
OM-1, stented.
50 yo m with chest pain
Formula, with QTc 418, = 25.85. 4 hours later:
Becoming hypotensive. To cath lab. Proximal LAD occlusion. Much myocardial loss, but survived.
Elderly woman with CP
Elderly woman with chest pain--12 min later
Chest Pain
75 yo with chest pain
60 yo with chest pain uncontrolled by medical Rx
First trop I 0.063. Repeat unchanged, but pain not controlled. Taken for immediate PCI: 95% LAD proximal to large D1 with
thrombus/TIMI-II
Contrast
Chest Pain
Early repol, 2.5, 401, 21 = 19.8
Woman in 40’s with chest pain
Formula (but Q wave V3): 2, 442, 8.5 = 25.64
Previous 2 cases, compare and contrast
58 yo with 1 hour of Chest pain
SyncopeCath lab activated
Subtle Inferior MI?
40 yo diagnosed with GERD 5d ago
ClinicECG
Bedside Ultrasound
32 yo male with CP, cough, ST (cont’d next slide)
37 minutes
1st ECG that you just saw
After Cath and PCI
Same case: 24 hour ECG