Answer
1) Non ST Elevation Myocardial Infarction with Hyperglycaemia and underlying Hypertension and diabetes mellitus.
2) Principle of management
- Triage the patient to the red zone with cardiac monitoring and present of resuscitation trolley
- Prop up the patient 45 degree
-Secure the airway, breathing and circulation (remove any dentures)
- Oxygen 3L via nasal prong
-Sublingual GTN
- Tab Aspirin 300 mg stat
- Tab. Clopidogrel 300 mg stat
- UFH Heparin 5000u bolus followed with IV infusion 12500U (1000U per hour) (refer here for dilution: link)
- BP every 15-30 minutes
- Serial ECG and cardiac enzyme
- IV Morphine 2-mg bolus with IV Maxalon 10 mg stat if pain severe or persistent
- Start Beta blocker if not contraindicated.
-Admit the patient to the CCU
- Start subcutaneous insulin injection and monitor the capillary blood sugar.
- add another anti hypertensive drug to control the blood pressure.
3) Reduce myocardial oxygen demands by inhibiting increase in heart rate and myocardial contractility.
4) Contraindication to Beta blocker
- Bradycardia (HR less than 60 minutes)
- Systolic Blood pressure < 100mmHg
- Pulmonary congestion with crepitition beyond the lung bases
- signs of peripheral hypoperfusion
- Second or third degree AV block
- Asthma or COPD
- Severe peripheral vascular disease.