Residents do not know how to take care of an MI in the ED these days because acute MI patients are commonly whisked to the cath lab,
There should always be a backup plan.
This patient is having an acute, anterior-wall STEMI. The story of an acute MI is always the same – the patient remembers exactly when it started, and the pain never goes away.
Anterior-wall STEMI are killers. Emergent cardiac cath is life-saving and heart-saving. What do you do when there’s no answer from Cardiology?
Plan B and Plan C are thrombolysis or refer the patient to another hospital for emergent cath.
In the mean time, treat the patient. Beta-blockers are life-saving despite the recent bad rap against BB in MI. For some people, it’s a controversial topic. For me, it’s not controversial at all. This reference is one of many re BB in acute MI (https://uk.cochrane.org/news/beta-blocker-use-acute-myocardial-infarction-cochrane-systematic-review-which-affirms-routine).
In a patient that is tachycardic and having a big anterior wall MI, beta-blockers should be given.
BB hurts patient in acute MI when the patient is already bradycardic or in heart failure (typically systolic). People forget these contraindications for some reason.
Put pads on the patient, these patients go into vfib arrest. Paddles are not available anymore and this will cut down on defibrillation time.
In addition, NTG, IV heparin should be given. Morphine helps with the pain and anxiety, though it’s another drug under attack (https://www.ahajournals.org/doi/10.1161/JAHA.117.006833), Oxygen should be given to anyone that’s hypoxic (usually from acute heart failure, https://www.nejm.org/doi/full/10.1056/nejmoa1706222), but oxygen is not life-saving in all comers.
TNK or tPA should be given if there’s no cath option. TNK is simpler to administer (single bolus dose) and may be better.
When I finally reached a fellow, his answer was “I’m at Weiler with two STEMIs, call me back unless this is important”. Sometimes, we send our STEMIs to Bellevue or Moses but that’s not easy to do.
I was planning to thrombolyze the guy and send him to the CCU. Eventually, someone from Cards answered (courtesy of the efforts of MDV and LL) and the patient went to the cath lab.
Whew.