Accident & Emergency OSCE
Medical Emergency
Answer
a) The ECG shows
- ST elevation in lead II, III and aVF
- Reciprocal ST depression in lead I, aVL
- Reciprocal T inversion in lead V1 and V2
- Normal sinus rhythm
b) Inferior myocardial infarction
c) Risk factor
- Male sex
- Age more than 55 years old
- Smokers
d) Management in the Emergency department
i. Triage the patient to the red zone with cardiac monitoring
ii. Secure the airway, breathing and circulation
iii. If ABC is not compromised, give oxygen via nasal prong 3L/min
iv. Sublingual GTN 0.3- 0.5 mg (can be repeated every 5 minutes for 3 times if no HPT)
v. Aspirin 300 mg stat
vi. Clopidogrel 300 mg stat
vii. Analgesic 10-15 mg IV slow bolus with IV metoclopromide 10 mg. if patient still in pain, put patient on IV infusion morphine 1mg/kg in 50 ml water for injection.
viii. Blood investigation; Cardiac enzyme (CK, Troponin T), FBC
ix. Fluid resuscitation (crucial in inferior MI)
x. Consider giving thrombolytic agent, particularly streptokinase (1.5 millions unit in 100 ml normal saline infused over 60 minutes). Ask further history to the patient to elicit any contraindication to streptokinase.
xi. Right sided ECG to exclude RV involvement.
xii. Refer to cardiologist or internal medicine team.