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Inpatient Management of the MI Patient – CRASH! Medical Review Series



okay now so you've got a patient who's had an ally and you've treated them and you've admitted to them to the hospitals what are you going to do with them now so after the emergency management is all done all my patients are going to be initially admitted to a coronary care unit they should be placed and closely observed on house telemetry we want to know if they go into v-fib this is very important the ventricular fibrillation is the number one killer of mi patients in this period so we we need to make sure that they're on close monitoring they're going to be on daily aspirin they're going to be on IV beta blockers they're going to be on heparin we're going to anticoagulate them to Aniyah to 1.5 to 2.5 we're going to be giving them nitroglycerin for their pain and we are going to start these patients on statins why are we going to start these patients on statins well the fact of the matter is the majority of patients who have Mis have high cholesterol they have their allies because they've developed cholesterol plaques and now they get a thrombosis so we're going to put these patients on statins right away so aspirin IV beta blockers heparin getting them anticoagulate the 1.5 to 2.5 nitroglycerine and statin therapy these patients need to be on strict bed rest for 24 to 48 hours and the reason for that is that we do not want their heart rate to go up the higher the heart rate goes up the more oxygen it's going to need and the more likely they are going to be to have further damage we want these patients on 100% oxygen and that's just to keep their oxygen saturation of their blood at 100% and after that 24 to 48 hours of strict bed rest then we can gradually start getting them back into activity these patients need to be frequently monitored we need to have enzymes drawn on these patients we need to do every three to four hour every three to four hours we need to be doing need to be checking on these patients lungs and hearts and hearing how they sound because we need to monitor them for for complications so these patients need to be in coronary care unit or they need to be on the mick you all patients with an MI either non STEMI or STEMI are going to get an echocardiogram and that's done for two reasons it's done to see if there are any geographical problems with the heart or and it's also done to check for left ventricular function so if you get an infarct and a lot of them are left-sided if you get an infarct and it reduces your left ventricular function well now you're not going to have your ejection fractions going to go down and you're not going to be getting as much blood out to the rest of your body and so that's a problem and so we want to know if that's happening so all patients after they've had an mi are going to get an echocardiogram and any angina during the post mi hospitalisation period need to be sent off for cabbage so if you've admitted this patients been admitted to you they're in the hospital and you've done all your workup on them and now all of a sudden and they're on nitrates they're on aspirin they're on IV beta blockers they're on heparin all that and now they develop angina just sending them off to the surgeon for cabbage so let's recap here we are going to admit them to a CCU we're going to observe them on house telemetry we're going to give them aspirin IV beta blockers heparin those three things increase survival we're going to give them nitroglycerine we're going to give them statin therapy to get their cholesterol down and we're also going to give them morphine too for their pain strict bed rest for 24 to 48 hours we got to make sure that they're on 100% oxygen and keep that keep that saturation up and after the 24 to 48 hours we can gradually rehabilitate them into activity we want to frequently monitor these patients for complications and we want to get an idea of their left ventricular function and any geographical damage that's been done to the heart with an echocardiogram a post mi echocardiogram in any angina after the hospital FFF after the during the post mi hospitalization period so wider while they're in the hospital for that mi ne and you know they get off to the surgeon for for bypass so the reason I stress that left ventricular ejection fraction with the echo so much is because left ventricular ejection fraction is highly correlated with one-year cardiac mortality so the better ejection fraction you have the more likely you are to be alive when you're after your heart attack so this just shows that relation so the complications I we've got a whole set of slides devoted to the complications but just to go over these are the things are going to be looking for when you check on these patients every few hours and that's going to be arrhythmia which is the number one complication and ventricular fibrillation is the number one cause of sudden death arrhythmias ninety percent of patients will develop these it can be any kind of arrhythmia under the Sun and usually they come in within the first couple days the ones you need to look out for are bradycardia and AV block contractile dysfunctions you'll look for with echo and these are not going to be things that we can really treat but we want to know if they're there because we can treat the symptoms left ventricular dysfunction right ventricular dysfunction any of these will be slow to develop symptoms but you'll start to get congestive heart failure symptoms in a patient that hasn't had congestive heart failure symptoms before and you'll also hear a new murmur mechanical dysfunctions are also something we look for with echo that's going to include papillary rupture ventricular septal ruff free wall rupture and these are going to be more of a sudden decompensation and a new murmur and then of course we always want to look out for reinforce and while the patients in the hospital and the way we do that is just by continuing to draw cardiac enzymes on these patients if you have a rebound on your ck-mb then you need to think about a possible reaction

Glenn Chapman

6 Comments

  1. You said heparin isn’t given to stemi patients, only thrombolytics

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