Sandbox:Mitra

❑ Order ECG ❑ Order serial cardiac biomarkers (troponins) and CK MB ❑ Perform a bedside echocardiography (if available)

Does the patient fulfill the criteria of myocardial infarction? ❑ Rise and/or fall of cardiac biomarker, preferably troponin, with at least one of the measurements >99th percentile of the upper limit of normal PLUS at least one of the following ❑ Symptoms of ischemia ❑ New ST-T wave changes ST-T wave changes in STEMI: ❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, OR ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI), OR ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery) ST-T wave changes in NSTEMI: ❑ No changes ❑ Non specific ST- T wave changes ❑ T wave inversion ❑ ST depression in at least 2 contiguous leads ❑ New LBBB ❑ New Q wave ❑ New regional wall abnormality or new myocardial loss

Yes

No

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Rule out the following life-threatening conditions

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

Look for supportive symptoms and signs: ❑ Sudden onset of chest pain radiating to the back or interscapular pain ❑ Acute heart failure ❑ Syncope ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space ❑ Asymmetric blood pressure in the upper extremities ❑ Coma ❑ Diminution or absence of pulse ❑ Altered mental status ❑ Evidence of ischemia ❑ Splanchnic ischemia ❑ Renal insufficiency ❑ Lower extremity ischemia ❑ Focal neurologic deficits

Look for supportive symptoms and signs: ❑ Pleuritic chest pain ❑ Dyspnea ❑ Anxiety ❑ History of: ❑ DVT ❑ Recent surgery ❑ Malignancy ❑ Immobility

Look for supportive symptoms and signs: ❑ Sudden onset of shortness of breath ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Recent medical procedure ❑ Patient on mechanical ventilation ❑ Tracheal deviation towards the unaffected side ❑ Absent heart sound on the affected side ❑ Hyperresonance on the affected side

Look for supportive symptoms and signs: ❑ Vomiting ❑ Lower chest pain ❑ Hematemesis ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Do's

• Right ventricular myocardial infarction (RVMI) should be ruled out in all patients presenting with acute inferior wall myocardial infarction, in particular in patients with hypotension.

• In patients presenting with chest pain and clinical findings of hypotension, elevated JVP and clear lung fields, consider the differential diagnoses of RVMI. These include:
  • Pulmonary embolism
  • Pericarditis with pericardial tamponade

• Systemic or pulmonary vasodilators may be considered in selected patients to reduce RV afterload, thereby improving cardiac output.

• In patients with severe tricuspid regurgitation due to RVMI, replacement of tricuspid valve or repair of the valve with annuloplasty rings may be considered.

• In patients with RVMI who have unexplained hypoxemia despite administration of 100% oxygen, right-to-left shunting -through a patent foramen ovale or atrial septal defect-, caused by the disproportionate elevation in right-sided filling pressures compared to the normal or slightly increased left-sided filling pressures should be considered.

• Patients with extensive necrosis due to RVMI may be at higher risk of right ventricular perforation during interventional procedures. Right ventricular catheterization or pacemaker insertion should be performed with great care in these patients.

Don'ts

• In patients with RVMI, avoid preload-reducing agents such as nitrates, diuretics, morphine, beta-blockers, and calcium channel blockers.