nstemi clinical scenarios
TRANSCRIPT
![Page 1: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/1.jpg)
Clinical Scenarios
PPCI and Direct Admission of High Risk NSTE-ACSBeardmore Hotel
17th February 2016
![Page 2: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/2.jpg)
![Page 3: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/3.jpg)
![Page 4: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/4.jpg)
![Page 5: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/5.jpg)
Scenario 1
![Page 6: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/6.jpg)
• SAS call to office on Sauchiehall Street• 50 year old male
o Chest tightness for 30 minso “It must be the fry-up”o Associated sweating and nauseao Recent history of increasing exertional chest
discomfort• Hypertension, smoker• “On tablets for blood pressure”
![Page 7: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/7.jpg)
A Talking in full sentencesB RR 18, Sp02 96% OA, chest clearC HR 85, BP 175/95, clammyD AVPUE T 36.5, BM 7.9, nil else
![Page 8: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/8.jpg)
![Page 9: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/9.jpg)
What would you do next?
1. Call GJNH2. Take to local A+E3. Initiate medical therapy4. Reassure and leave
![Page 10: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/10.jpg)
What would you do next?
1. Call GJNH2. Take to local A+E3. Initiate medical therapy4. Reassure and leave
![Page 11: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/11.jpg)
![Page 12: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/12.jpg)
![Page 13: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/13.jpg)
2 2 1 1 ?6High risk NSTEMI
✔ ✔ ✔✔
GJNH
![Page 14: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/14.jpg)
![Page 15: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/15.jpg)
Scenario 2
![Page 16: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/16.jpg)
• SAS call to Christmas party in Merchant’s City• 40 year old male
o Chest tightness and palpitations for the past 1 hour
o “I love a free bar pal”• Admits to frequent episodes of palpitations
recently – has been seen in clinic• On simvastatin
![Page 17: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/17.jpg)
A Talking in full sentencesB RR 18, Sats 98% OA, chest clearC HR 160, BP 120/75, well-perfusedD AVPUE T 37.2, BM 4.2, nil else
![Page 18: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/18.jpg)
![Page 19: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/19.jpg)
What does this ECG show?
1. Narrow complex tachycardia2. Atrial fibrillation3. Rate-related ischaemia4. All of the above
![Page 20: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/20.jpg)
What does this ECG show?
1. Narrow complex tachycardia2. Atrial fibrillation3. Rate-related ischaemia4. All of the above
![Page 21: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/21.jpg)
What further information would be useful?
1. HEART Score2. More detailed social history3. Clinic letters4. All of the above
![Page 22: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/22.jpg)
What further information would be useful?
1. HEART Score2. More detailed social history3. Clinic letters4. All of the above
![Page 23: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/23.jpg)
Cardiology clinic 01/12/15:
“I saw this man in clinic today. He has a 6-month history of intermittent palpitations. These are associated with excessive alcohol intake. I have organised a 24 hour ECG recording and will see him back with the results in 3 months.”
![Page 24: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/24.jpg)
?3
0 2 0 1
PAF with rate-related ischaemia
Local A&E
![Page 25: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/25.jpg)
Scenario 3
![Page 26: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/26.jpg)
• SAS call to nursing home in Partick• 89 year old female
o Gradual increase in SOB over past 2 weekso “I can hardly sleep”o No chest pain
• “She’s had a heart attack before and has a weak heart”
• On aspirin, ramipril, bisoprolol, simvastatin
![Page 27: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/27.jpg)
A Broken sentencesB RR 28, Sats 85% OA, crackles bilaterally, C HR 96, BP 110/90, cool peripherallyD AVPUE T35.9, BM 5.5, peripheral oedema
![Page 28: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/28.jpg)
![Page 29: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/29.jpg)
What does this ECG show?
1. NSTEMI2. STEMI3. LBBB4. RBBB
![Page 30: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/30.jpg)
What does this ECG show?
1. NSTEMI2. STEMI3. LBBB4. RBBB
![Page 31: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/31.jpg)
What further information would be most useful?
1. Lactate2. Detailed family history3. Medication doses4. Old ECGs
![Page 32: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/32.jpg)
What further information would be most useful?
1. Lactate2. Detailed family history3. Medication doses4. Old ECGs
![Page 33: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/33.jpg)
![Page 34: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/34.jpg)
What is the most likely diagnosis?
• NSTEMI• Decompensated heart failure• Pulmonary embolism• Respiratory tract infection
![Page 35: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/35.jpg)
What is the most likely diagnosis?
• NSTEMI• Decompensated heart failure• Pulmonary embolism• Respiratory tract infection
![Page 36: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/36.jpg)
DNACPR in place since July 2015. Patient and family do not wish any further invasive investigations.
![Page 37: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/37.jpg)
Summary
• Rapid identification of high-risk NSTEMI• Early discussion with GJNH• Recognition of type 2 myocardial infarctions• Thorough information-gathering• Better outcomes for patients
![Page 38: Nstemi clinical scenarios](https://reader035.vdocuments.site/reader035/viewer/2022062400/5877f9521a28ab91178b5497/html5/thumbnails/38.jpg)