Potential Acute Coronary Syndrome - Case Study Example

Potential Acute Coronary Syndrome Name Instructor Institution Date Table of Contents Introduction 3 The Case 3 Clinical Assessment 3 Diagnosis 4 Electrocardiography 5 Pathophysiology 6 Management 7 Paramedic Management 7 Hospital Emergency Management (The first 24 hours) 7 Conclusion 8 Potential Acute Coronary Syndrome Introduction Acute Coronary Syndrome (ACS) is a health and economic burden for many countries. A quick and thorough assessment of the patient’s history, ECG examination, and physical examination allows one to make accurate diagnosis as well as determine the right management intervention. Paramedics need to have the ability to quickly and accurately assess patients to up with an accurate prognoses and ensure good outcomes. The Case I was called to a factory where I found Bob, a 35 year old man, experiencing central chest pain radiating into his jaw. He looked pale, cool clammy and obviously distressed. The patient background indicated that he has not had previous complains of chest pain. His medical history indicated the patient has had hypertension, Asthma, GORD, and Type II diabetes that is diet controlled. The medication he was taking include; Atenolol, salbutamol Inhaler, Breo inhaler, omeprazole, and paracetamol PRN. He has Penicillin allergy. Bob has no known communicable disease and is up to date with vaccinations. His social history indicates that he lives with a partner. Family history shows that his father died of a heart disease aged 41 and his mother died of breast cancer. He takes alcohol socially and smokes 30 cigarettes per day. Clinical Assessment The patient looked pale, cool, clammy and obviously distressed. Vital signs assessment indicate increased heart rate, mostly cause by high sympathoadrenal discharge (Ansari et al, 2012). The patient’s pulse was irregular, often caused by peripheral arterial vasoconstriction (Roy et al, 2013). In addition, respiratory rate was high. The patient indicated feeling central chest pain radiating in the jaw. The pain was intense and unremitting for 30-60 minutes, he described the pain as burning, aching and squeezing. Libby & Theroux (2005) explain that chest pain that radiates to the jaw is mostly indicative of ACS. His chest produced a wheezing sound. The patient appeared shocked which was exemplified by a fast weak pulse, paleness and low blood pressure. The patient also appeared to have breathing difficulty. Other signs and symptoms recorded included nausea, shortness of breath and light-headedness (Davis et al, 2012). Diagnosis The patient’s medical history and general assessment indicated a case of potential acute coronary syndrome (ACS). Bobs medical history indicated risk factors including being male, hypertension, type II diabetes mellitus, smoking, history of heart disease in the family (his father died at 41 due to heart disease). These are among risk factors that have been identified for ACS (Van de Werf, 2008; Makki et al, 2015). Again, the pain which Bob describes as squeezing or pressure that radiated to the shoulder and jaw was indicative of ACS (Duan et al, 2015). The patient’s pulse was irregular, often caused by peripheral arterial vasoconstriction (Kumar et al, 2009). In addition, hypotension is indicative of myocardial infarction (Hahn & Chandler, 2006). Although Kumar & Cannon (2009) indicate that these are weak indicators of acute ischemia, they say that the physical examination can indicate precipitating causes of myocardial ischemia. In the case of Bob, hypotension, pale cool skin direct to ischemia. According to Kumar and Cannon (2009), ST-segment elevation myocardial infarction (STEMI) can be diagnosed if the ischemia causes myocardial damage. Other symptoms like nausea, light-headedness and shortness were also considered in making the diagnosis. Although Kumar & Cannon (2009) indicate that these are weak indicators of acute ischemia, they say that the physical examination can indicate precipitating causes of myocardial ischemia. In the case of Bob, hypotension, pale cool skin direct to ischemia. According to Kumar and Cannon (2009), ST-segment elevation myocardial infarction (STEMI) can be diagnosed if the ischemia causes myocardial damage. According to SAAS (2013) guidelines, chest pain that radiates to the jaw should be considered cardiac ischaemia unless an alternative cause is obvious. Other tests that would help in making accurate diagnosis include; the heart rate, mean arterial pressure, blood pressure (systolic and diastolic) and ECG posture and rhythms (Thygesen et al, 2007). To determine the kind of presentation of the ACS, the patient was transported to the hospital and a 12-lead ECG examination was carried out. ECG assessment indicated a case of inferior myocardial infarction due to occlusion of right coronary artery. Electrocardiography As Kumar & Cannon (2009) say differentiating between different presentations of ACS, requires 12-lead ECG. Similarly, Ferraro et al (2013) say ECG is the only clinical tool that is able to show the main difference pathological differences in different myocardial infarctions. The SAAS guidelines (2013) state that the 12-lead ECG should be performed upon arrival if the patient has risk factors and other symptoms indicative of ACS. Performing ECG helps in supporting the diagnosis and also in risks assessment. Makki et al (2013) call 12-lead ECG as the single most important test performed in the initial stages of ACS evaluation. They recommend that the test should be performed within 10 minutes upon arrival of the patient to the hospital. ECG examination indicated ST-segment elevation and T-wave inversion. Makki et al (2013) indicate that ST-elevation, ST-depression and T-wave inversions indicate a likelihood of ACS. 12- Lead ECG indicating rhythm at Q waves and ST-segment elevation in leads II, III, and aVF and reciprocal ST-segment depression in leads I and aVL are indicative of inferior myocardial infarction (Kumar & Cannon, 2009). ST elevation in lead II and III indicate occlusion in the right coronary artery. In addition, ST elevation in V4R also indicate the RCA occlusion. Pathophysiology Pathophysiology of Acute Coronary Syndrome (ACS) involves formation of plaques in a person’s arteries. The risk factors for this condition are; a history of hypertension, type II diabetes, smoking and belonging to the male gender (Martinez-Selles et al, 2005). The risk factors were present with the patient. According to Kumar & Cannon (2009), the risk factors damage the endothelium thereby initiating atherosclerosis. Dysfunctional endothelium provides the atmosphere for the formation of plaques. Pathophysiology of ACS comprises the interplay of the inflammatory cells, the endothelium and thrombosis of the blood (Kumar & Cannon 2009). Patients with ACS have shown many plaque ruptures. There is acute imbalance demand of myocardial oxygen and its supply. This is potentially cause by narrowing of the coronary artery and thrombosis. Makki et al (2013, p. 1) add that rupture of the plaque that results “partial or complete occlusion of an epicardial coronary artery” characterises the mechanism for ACS. Plaque disruption results in platelets activation which results in thrombus formation. Coronary occlusion leads to reduction in blood flow and presence of thrombus result in ischemic discomfort in the chest. Complete occlusion of the right coronary artery normally have STEM. Other patient factors like smoking leads to transient hypercoagulability. Kim et al (2010) say that occlusion of the RCA can cause may indicate right ventricular ischemia or infarction of the inferior wall. Occlusion of the artery and reduction of coronary blood flow take place as a result of occluding thrombus (Van der Werf, 2008). Management Paramedic Management Queensland Ambulance Service (2012) guidelines outline three primary roles for paramedics. First the paramedics have the role to assess and prioritize the patient’s immediate and definitive needs. Secondly, they are supposed to deliver immediate care. Finally, paramedics have the role of providing definitive care in a time efficient manner. The priority in management is to stabilize the patient and alleviate pain. South Australian Ambulance Service (SAAS) (2013) guidelines for ischaemic chest pain recommend vasodilators and oxygen as the primary treatments. Management include giving resuscitation as required. The guidelines also recommend GTN 400 micrograms if the blood pressure is appropriate – repeated every 5 minutes. However, this can only be given if the patient has not used erectile dysfunction agents within 24 hours and if the rhythm and rate are appropriate. Additionally, Aspirin 300mg should be given orally because there are no indications of allergies (SAAS, 2013. Oxygen is also given if saturation is less than 94%. Immediate transfer to the hospital should be arranged (Nicholaos, 2010). Hospital Emergency Management (The first 24 hours) The first contact with a patient like Bob call for the medical practitioner to make a working diagnosis mainly based on the kind of chest pain, risk factors and history of coronary artery disease (Van de Werf et al, 2008). Additionally, it is important for an ECG to be taken as fast as possible. According to Van de Werf (2008) reperfusion therapy should be performed in patient with chest pain and ST-segment elevation. Reperfusion therapy allows flow in the infarcterated artery and is known to reduce the size of the infarct in STEMI patients (Makki et al, 2013). To achieve reperfusion, one may use mechanical or pharmaceutical means. Early percutaneous coronary intervention (PCI) will lead to improvement of patient outcomes and reduce the risk of ST elevation myocardial injury. Adjunctive antithrombotic therapy like the use of aspirin, and thrombin inhibitors can be used to avoid further thrombosis (Gelfand & Cannon, 2007). In addition, antiplatelet therapy is initiated to prevent recurrence of thrombosis as well as avoid further occlusion of the coronary artery. The patient should be taught how to recognize signs of ACS and call for help in case of such symptoms Makki et al (2013) say that using PCI is more effective than thrombolytics to restore blood flow. However, they note that many hospitals do not have PCI. Primary PCI is said to be more effective in reducing mortality rate. Apart from availability, the other limiting factor for this option include patient factors like delay in presentation and age. It is recommended that this option be carried out on-site for patients who are eligible especially where patient transfer cannot be achieved within 90 minutes. At the same time, there are complications with thrombolytic therapy in regards to intracranial haemorrhage. Therefore, individual risks should be assessed. Bobadila (2016) says that most recommendations contain a class of recommendation and an estimate has to be made before applying it. Conclusion Bob’s case present the importance of patient history, accurate clinical assessment and ECG examination in the diagnosis of ACS. The patient’s history is important in the initial presentation of myocardial infarction. Carrying out initial evaluation of health and family history will indicate the likelihood of ACS symptoms. ECG is important in making an accurate diagnosis. Making the right diagnosis quickly determines patient outcomes. Although there are different management practices, to determine the most suitable intervention, it is important to consider patient factors, time of response and availability of resources. References Ansari, M, Javadi, H, Pourbehi, M, Mogharrabi, M, Rayzan, M, Semnani, S, Jallalat, S, Amini, A, Abbaszadeh, M, Barekat, M, Nabipour, I, & Assadi, M 2012, 'The association of rate pressure product (RPP) and myocardial perfusion imaging (MPI) findings: a preliminary study', Perfusion, 27, 3, pp. 207-213 Basra, S, Virani, S, Paniagua, D, Kar, B & Jneid, H 2016, Acute Coronary Syndromes. Heart Failure Clinics, 12, 1, pp.31-48. Bobadilla, RV 2016, 'Acute Coronary Syndrome: Focus on Antiplatelet Therapy. 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