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Pulmonary
Pleuritis
Pulmonary embolism
Pneumothorax
Musculosceletal
Costochondritis
Gastro-intestinal
Oesophagitis
Hiatus hernia
Oesophageal spasm
Peptic ulcer
Goals of Treatment
1. Pain relief
2. Limit size of infarction
3. Prevent complications
4. Treat complications
5. Rehabilitation (Long term)
1. Aspirin
Antiplatelet drug
All patients with UAP or AMI
300 mg stat
150 mg daily thereafter
2. Heparin
Anti-thrombin agent
All patients who did not receive thrombolytic therapy
5000 U IV stat (All patients)
25 000 U in 200 ml Normal Saline IV over 24 hours at 8 ml/hour (check PTT daily)
or
12 500 U subcutaneously 2 times per day
3. Anti-ischaemic drugs
Nitrates
Isordil 5 mg sublingual PRN for pain
and/or
Tridil IV (for sustained pain) – 50 mg in 200 ml fluid, titrate against blood pressure and
pulse rate, start at 10 ml/hour
β-blockers
Improve myocardial oxygen supply to demand ratio
pain
infarct size
incidence of ventricular arrhythmia
Ensure a good blood pressure before initiation
Indications
Within 12 hours of pain if:
1. Typical retrosternal chest pain
2. 2 mm ST-segment elevation in 2 consecutive ECG leads
or
NEW left bundle branch block
Contra-indications
Previous cerebrovascular bleed
CVA within last year
Severe hypertension (Systole 180 or diastole 110 mmHg)
Active internal bleeding
Streptokinase within last year
Relative contra-indications
Current use of anticoagulant
Invasive surgery within preceding 2 weeks
Prolonged CPR within preceding 2 weeks
Known bleeding tendency
Pregnancy
Active peptic ulcer disease
Complications
Allergic reactions
Bleeding
Administration
1,5 million U in 200 ml Normal Saline over one hour
Follow-up ECG one hour after administration
5. Morphine
Pain relief
2 mg IV as needed
6. ACE-inhibitors
Cardiac remodeling
Blood pressure allowing, use cautiously within first 24 hours
7. Revascularisation
PTCA (Percutaneous transluminal coronary angioplasty)
Coronary bypass
If ongoing pain on maximal medical therapy
If candidate for thrombolysis, but Streptokinase contra-indicated
Management
Aspirin
Heparin / Streptokinase
IV fluids (LOTS !!!)
Avoid nitrates! – Not orally either
Cautious use of β-blockers
Dysrhythmias
1. Atrial fibrillation
If blood pressure stable and pulse rate 100 observe
Electric cardioversion – If haemodynamically unstable
2. Ventricular fibrillation
Electric cardioversion
3. Ventricular tachycardia
Electric cardioversion if haemodynamically unstable
Lignocaine 80 mg IV stat,
followed by 800 mg in 200 ml Normal Saline over 24 hours as maintenance
4. Bradydysrhythmias
Atropine
Pacemaker
Bradycardia 50
Mobitz II AV block
3o AV block
Bifascicular block (RBBB and LBBB)
5
Internal Medicine – Paarl Hospital
Indications
6 h pain
2mm ST-segment elevation in 2 contiguous leads and persistent pain
or
new left bundle branch block and persistent pain
Contraindications
Previous cerebral bleed
CVA within last year
Severe hypertension (Systole >180 or diastole > 110)
Active internal bleeding
Streptokinase within the last year
5. Pain control
Morphine 2mg IVI as needed, monitor blood pressure
(Morphine 10mg diluted in 9 ml of water give 2 ml boluses)
Isordil 5 mg S/L stat (Not with right ventricular infarct)
Nitroglycerine (Tridil) IVI – if persistent pain (Not with right ventricular infarct)
(50 mg in 200 ml fluid , titrate against blood pressure and pulse rate)
6
Internal Medicine – Paarl Hospital