#ᑕᗩᖇᗪIOᒪOGY_74 🫀#ACS_2 #STEMI
Source : ESC ,BMJ ,Dynamed

حالات ال STEMI زي ما شفنا سابقاا بيكون صار Complete Obstruction لل Aretry وال Infarction بياخد ال Whole Thickness

هدف العلاج لمريض ال STEMI انه نرجعله ال Coronary perfusion ونمنع ال
Further Cardiac tissue Necrosis & MI complications
وكل ما اجا المريض بدري وهو بال Acute phase كل ما كان أفضل

⭐ Each Minute equal Muscle ⭐

The established cornerstone of STEMI management is a combined strategy of:

🅰Coronary reperfusion therapy – either primary percutaneous coronary intervention ( PCI) or fibrinolysis
ال Reperfusion إما بيصير بالقسطرة PCI والأولويه لل PCI 🥇
او بمذيبات الجلطة Fibrinolysin
وهنشوف لاحقا كيف نحدد طريقه ال Reperfusion

AND

🅱Antithrombotic therapy – with dual antiplatelet therapy and anticoagulation.

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Initial Management Step :

1⃣ Give all patients with suspected STEMI a single loading dose of aspirin as soon as possible, unless they have aspirin hypersensitivity

أي مريض ACS سواء STEMI او NSTEMI او Unstable angia لازم ياخد Single loading Dose aspirin ما لم يكن عنده aspirin hypersensitivity

aspirin: 300 mg orally (chewed or dispersed in water) as a loading dose

2⃣Start treatment for STEMI immediately after making a clinical diagnosis - do not wait for cardiac troponin levels to confirm it
Make a clinical diagnosis of STEMI based on a combination of:
Signs and symptoms of myocardial ischaemia, plus
Persistent or increasing ST elevation on the ECG.

⭐First medical contact to ECG and STEMI diagnosis should take ≤10 minutes ⭐

3⃣Immediately assess the patient’s eligibility for coronary reperfusion therapy

بنحدد هل المريض هيعمل PCI ولا هياخد Fibrinolysin

4⃣Gain intravenous access and start continuous haemodynamic monitoring and pulse oximetry

When placing an intravenous cannula, avoid placing it in the right hand or right wrist area as the right radial artery is the usual route used to perform primary percutaneous coronary intervention

5⃣ Give pain relief
🔸حسب ال ESC المريض هياخد morphine sulfate او diamorphine
عشان يقلل ال pain ويثبط ال Sympathetic

🔹morphine sulfate2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)

🔹diamorphine: 2.5 to 5 mg intravenously initially, followed by 1.25 to 5 mg if required (at a rate of 1-2 mg/minute)

🔸 أما ال American ما بيفضلو ال Routine use of morphine

In patients with STEMI, we only use morphine to treat chest symptoms refractory to nitrates and other medical therapy; we suggest not to routinely administer morphine to all patients with STEMI.

لان المورفين ما بيقلل ال Mortality وبيقلل ال effect لل
Antiplatelet ( P2Y12 Inhibitor )

6⃣Give an anti-emetic concomitantly with the opioid analgesic to prevent the patient vomiting the oral loading dose of dual antiplatelet therapy.

🔸ondansetron: 4-8 mg intravenously as a single dose

Or

🔸metoclopramidebody weight <60 kg: up to 500 micrograms/kg/day intravenously given in 3 divided doses; body weight ≥60 kg: 10 mg intravenously up to three times daily

Or
🔸cyclizine50 mg intravenously three times daily

7⃣Give oxygen therapy only if saturations are <90% on pulse oximetry
Routine supplemental oxygen is not indicated if arterial oxygen saturation (SaO2) ≥90%.

8⃣ Routine use of an intravenous nitrate in STEMI is not recommended as there is no evidence to support its benefits.
In practice, a sublingual (or buccal) dose is often given after a STEMI diagnosis has been made (and sometimes before the patient arrives at hospital).

المريض اللي هيستفيد على ال Nitrate I.V
🔹لو المريض اخد sublingual nitrate ولسه عنده Pain
🔹 في حالات ال Sustained HTN
🔹 لو كان مريض Heart Fauiler


🔸glyceryl trinitrate : 15-20 micrograms/minute intravenous infusion initially, adjust dose according to response, maximum 400 micrograms/minute

🔸isosorbide dinitrate: 2-10 mg/hour intravenous infusion initially, adjust dose according to response, maximum 20 mg/hour

⛔Do not give an intravenous nitrate when there is:

🔹Hypotension secondary to right ventricular infarction (usually complicating an inferior or extensive anterior STEMI)

🔹Hypotension secondary to severe aortic stenosis or left ventricular outflow tract obstruction

🔹Hypotension secondary to pre-existing cardiomyopathy

🔹Persistent hypotension secondary to other causes
Use of a phosphodiesterase-5 inhibitor (e.g., avanafil, sildenafil, tadalafil, vardenafil) for erectile dysfunction within the last 48 hours.
#لعلي_أفيدك ❤

#ᑕᗩᖇᗪIOᒪOGY_75🫀#ACS_3 #STEMI

لو تم تشخيص مريض ال ACS على إنه STEMI هيكون قدامه احتمالين لل Reperfusion:

1⃣ إما يدخل قسطرة Primary PCI strategy

أو

2⃣ ياخد مذيب للجلطة " Thrombolytic" مبدئيا وبعدها يعمل PCI ...
فعالية ال Thrombolytic لحد 12hr من ال Pain onset

⛔After 12hr There's No Role to Thrombolytic

According to ESC : After 3 hours (and up to 12 hours) of symptoms onset, the later the patient presents, the more consideration should be given to a primary PCI strategy as opposed to administering fibrinolytic therapy.

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بشكل عام الأولويه لل Reperfusion هي ال PCI

🔸A primary PCI strategy is recommended over fibrinolysis within indicated timeframes.

🔸If timely primary PCI cannot be performed timely after STEMI diagnosis, fibrinolytic therapy is recommended within 12 hours of symptom onset in patients without contraindications.

لاختيار طريقة ال Reperfusion عنا اربع سيناريوهات ...

1⃣ مريض اتشخص STEMI بمستشفى متاح فيه primary PCI center
فالأولوية لل PCI خلال أقل من 60 دقيقة

🌸Maximum time from STEMI diagnosis to wire crossing in patients presenting at primary PCI hospitals.

2⃣مريض وصل لمستشفى مفيهاش Primary PCI Center
وعشان أنقله لمكان فيه primary PCI هيحتاج اقل من 120 دقيقة
فالخيار هيكون
Refer to primary PCI
ويفضل خلال أقل من 90 دقيقة يتقسطر

🌸Maximum time from STEMI diagnosis to wire crossing in transferred patients.=<90 min

3⃣مريض وصل لمستشفى ما فيها primary PCI center وعشان يتنقل لمكان فيه primary PCI هيحتاج اكتر من 120 دقيقة
فالخيار هو ال Thrombolytic خلال 10 دقائق
من التشخيص لو لسه معداش 12hr على ال Symptom

🌸Maximum time from STEMI diagnosis to bolus or infusion start of fibrinolysis in patients unable to meet primary PCI target times =<10 min

4⃣ لو المريض اجا متأخر 12-48hr ولسه فيه pain
فالحل هو PCI

🌸A routine primary PCI strategy should be considered in patients presenting late (12-48 hours) after symptom onset.

اما لو اجا بعد 48hr بدون وجود symptoms فال PCI هنا Not Indicated
🌸In asymptomatic patients, routine PCI of an occluded IRA >48 hours after onset of STEMI is not indicated.

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ليش بعد ال Thrombolytic لازم يعمل المريض PCI ؟؟

لأن ال Thrombolytic بيذوب جزء من ال Thrombous وبيضل
Residual thrombus
الجزء اللي بيضل بيعمل Thrombotic media وبيزود ال Tendency لتكبر ال thrombous , فممكن يرجع يدخل المريض ب
Re- Elevated ST

⭐هادي الميكانزم بنسميها Thrombolytic milieu

عشان هيك بعد ال Thrombolytic Therapy(60-90min) بينعمل assess للمريض هل ال Thrombolytic Therapy كان Successful ولا لأ

✅ لو صار Resolution لل ST Segment elevation بمقدار 50% او اكتر ،، معناها ال Thrombolytic كان successful
وبنتقل المريض لعمل Routine PCI خلال 2-24 ساعه

❎ لو ال Resolution لل ST segment elevation كان اقل من 50% معناها ال Thrombolytic Failed ولازم ينتقل المريض لعمل
🔴Rescue PCI as soon as possible

Source : ESC ,BMJ
#لعلي_أفيدك ❤

تحتوي الرئتان على ما يقرب من 3000 كيلومتر من الممرات الهوائية .

وفي 1.5 ثانية فقط، يقوم القلب بتسريع الدم في كامل مساحة الحويصلات الهوائية في الرئتين، والتي تساوي مساحة ملعب التنس، ويعيده إلى مجرى الدم.

ويحدث هذا تلقائيًا 100000 مرة يوميًا، بشكل تلقائي تمامًا.
@Dr_haron

من افضل البوتات الطبية للتحضير ل usmle ⬆️🔥