I've had a patient in resus recently who posed a bit of a problem and I'd be
interested to hear other peoples views on his management.
This chap was a known arteriopath who had gone to a local community hospital
for ongoing eye follow-up and whilst there he had a routine ECG. It showed
ST elevation 4mm in V2 and 3. He was then sent to A&E. He had the tiniest
niggle of discomfort in his chest an hour before that had lasted five
minutes but in A&E he had no pain and was sitting there happy as a sand
boy!. Nor had he had any significant episode of relevant symptoms within
the last 48hrs.
Question: Would you have thrombolysed him purely on the ECG as he had no
contraindications?
Repeat ECGs showed that his STs came down over the course of an hour but
even then were approx 2mm above baseline. Anyway, what did I do.
Thankfully I'm in a teaching hospital at the moment and so I referred him to
a cardiologist who arranged angiography which showed 95, 90 and 90% stenoses
and he's had a CABG 4 days later!. Good for him that he didn't pitch up at
a local DGH without these facilities.
My question is how rigidly do people stick to the thrombolysis criteria?
Another lady I saw had Acute LVF but no chest pain but had a thrombolysable
ECG and we dithered until her second ECG showed hyperacute changes (when her
first one just had 2mm and 3mm elevation anteroseptally) that we gave her
rTPA.
If someone has a thrombolysable ECG but not a classical history but your gut
feeling is that they are infarcting would you thrombolyse?. My last job was
in a DGH and I'm not sure he would have had the same treatment there.
Anyway, I'll leave it there and await any comments. Sorry I've rambled so
much but I'm a 'first time caller' and got a bit carried away!
And by the way 'Hello' to anyone that knows me!
Sunil Dasan, SpR, South West Thames
________________________________________________________________________
Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
|