Approach to a patient with chest pain in the emergency room || Unstable Angina || #aetcm||

Added: 2026-05-31

[00:00:05]Welcome to ATM the emergency medicine center. Okay.

[00:00:08]>> 65 year old male non-case of type2 diabetes hypertension presented to ER with complaints of chest pain or last 30 minutes.

[00:00:16]>> Uh a patient also gives history of similar episode for the past 2 days. So uh on initial 10 seconds assessment airway was patent with no secretion no horarsseness of voice or strider.

[00:00:27]Breathing wise saturation was 94 percentage in room air with bilateral air entry present. Uh uh uh respiratory rate of 20 per minute. Pulse rate uh uh h like heart rate of 84 per minute with a BP of 130 80 uh with by S1 S2 hertz.

[00:00:46]>> So all these chips are important in MI.

[00:00:48]>> Yes sir.

[00:00:48]>> Why?

[00:00:49]>> Uh so in from >> A B C D all are important. So when a patient with a chest pain came to uh an ER first we have to we have to make the patient sit in our bed and attach the monitors when then we have >> patient has to be comfortable sitting in a bed or lying down in you should not make patient more like exception or stress should be relieved okay >> then we'll attach the monitor we'll look for airway airway we have to look for any secretions because in case of MI with acute pulmonary there will be secretions and airway won't be patent So we have to uh if if pulmonary edma is there airway is not we have to manage accordingly.

[00:01:29]>> Then breathing wise saturation is the one we have to look for. In uh in acute pulmonary edma there may be desaturation. Uh if desaturation is there we have to first prop up the patient and see whether saturation is improving. If not we can start on low do uh uh low flow oxygen.

[00:01:47]>> Uh and to keep the >> flow is not mentioned. If desaturation is there you start oxygen depending on the clinical scenario you can set the flow. Okay. Suppose the patient is having severe desaturation you have to directly put on patient on BPAP or CPAP.

[00:02:01]>> So we have to keep the uh saturation more than 94%. Then we uh in >> when the saturation is good you should never start oxygen that is because to prevent >> myio free radical injury to myioard.

[00:02:15]>> So we should never start oxygen unnecessarily.

[00:02:18]So then bilateral air entry we have to look any any basal crepitations or any early features of alkalin is there or not we have to look for. Then circulation wise we have to uh we we have to both treat bradicardia as well as tachicardia. Tachicardia has to be the heart rate should be controlled within uh within uh range. So to prevent any further exertion of heart and uh and >> so what is a drug to be given when there is teicard in MI >> uh beta blocker >> beta blockers are the ideal drug when there were IBP teard all those things beta blockers are the drug of choice >> except in young MI where if the MI is caused by amphetamines like cocaine induced MI beta blocker is avoided >> there drug alpha blockers alpha blockers can Because if you give only beta blocker an opposite action can act and patient can have more sympto symptoms symptoms.

[00:03:15]>> Then heart heart rate then BP both hypotension and hypertension should be prevented. Hypertension we have if pain is there with hypertension we can start on NTG. If it is hypotension uh in right ventricle MA we can give fluid otherwise we can start on noral or other sort of drops like dominate.

[00:03:33]>> Okay. So no vitamin alone should not be started start then additamin once the BP is stabilized >> stabilized then disability >> why it is like that why do low vitamin alone should not be started in hypotension what is the reason what is the reason >> what is the reason >> initially when we start dobbetamin there will be a hypotension can cause then patient >> due to >> due to initial vaso dilotation >> so doamin action is peripheral vaso dilation then only it comes to heart and cardiac pumping increases so immediately there'll be BP fall okay so never do that start normal make the systolic BP at least above 100 then start domin >> then disability wise uh GRBS we have to both hypo glycemia and hypoglycemia it's not good for heart so we have to uh manage accordingly then exposure wise hypothermia as well as hyper hyperyexia have to treated.

[00:04:34]>> So so much you have to do before starting the actual treatment. So these all things will simultaneously taken care but if you don't take care all these things patient will deteriorate very fast.

[00:04:46]>> Uh then uh in then for our patient airway circulation we managed then adjance to primary survey we did an ECG ECG showing T inversion from V_sub1 to V6.

[00:04:57]>> So uh ST depression >> ST depression with T inversion. So we have uh then uh uh C uh CBC uh like uh we also did the CBC point of care if to rule out any anemia anemia can cause also this uh heart chain heart uh heart contraction >> anemia can aggravate cardiac diseases that's all any disease if you take any disease coronary artery disease cardiac failure valular heart disease all can be aggravated by anemia >> then uh we will do a uh VBG point of care to see any hypercalemia uh changes okay is there >> uh then uh we uh we uh since ECG showing ST uh depression ECG change ST changes are there we go for cardiac enzymes and uh for our patients cardiac enzymes uh was in the IR range first set cardiac was positive so now we have a case of ACS N STEMI where uh which is a no ST XT elevation MI uh since patient was having uh still like uh as the management first we have to uh give the pain should be relieved and ancillitis can be uh started. So since the patient's BP is okay as well as pain we given as orbitrate sublingual and uh we have monitored the BP and patients pain also reduced then other uh an other painkillers include we can start on morphine plus uh anti-imetics along with morphine.

[00:06:24]>> What is the dose of morphine? uh 1 mg >> one or two mig we can give >> then if morphin is contraindicated we can go go for fentinel >> then after uh ancillitis we'll give uh loading dose of uh loading dose we we have to give loading dose include antiplatelets aspirin that is 160 to 325 mg for along with clidog which is uh 300 mg >> so we have only unrecoated aspirin now so what to be done >> we have to crush it and crush You have to break it, crush it, then only you can give it and recorded will if you give directly it will release after long time like maybe half an hour, 1 hour. So it will not be useful. So you have to crush it. Okay. along with we we have to give atro stat we have to give uh along along with antiplatelet we can also say anti-coagulant >> anti-coagulation is the uh actually the goal of MI is anti-thrombotic therapy which is a combination of anticoagulant and antiplatlet therapy it is to prevent the clot extension as well as to reformation >> what does this clot consist of what is the what is the like uh component of this clot >> fibbrin platelet and fibbrin platelet and one more thing >> cholesterol. So three important things cholesterol lipid fibbrins platelets. So that's why we are giving three important drugs anticolibbrin and antiplatelet.

[00:07:52]So anticoagulation should begin immediately after the diagnosis of ACTI based on trials it shows that reduction in combined outcome of recurrent MI and as well as death with anticoagulation is compared with no anti-coagulation. So uh so if uh it's if there is in >> what is propagation of thrombus >> uh extension of thrombus like >> thrombus it is breaking know that clo is breaking and opened up.

[00:08:18]>> So again platelets fibbrin can come and attach there that's why actually we are giving and it will rupture sometimes and block completely the artery. So that's why we are giving heperin platelets antiplatelets statins. Statin what is the role of statin here? What Saturn is going to do?

[00:08:38]>> Plague stabilization.

[00:08:40]>> Plague stabilization. This is the action of Saturn is plague stabilization. So you have to give Saturn.

[00:08:46]>> So uh then uh depending on the institute we are in if we are going for an invasive approach for within 48 hours we can start initiate the patient on unfrainated heparin. So if the intra procedure anticoagulation also we can use eparin and fractionated is IV ball of 60 unit per kg maximum of 5,000 unit followed by 12 unit per kg per hour maximum of 1,000 unit per hour we can start to achieve an apt of 50 to 75 >> then uh >> you know our a normal value >> 40 30 to 40 is normal values so double at least 2.5 times of that is 75 up to 75 >> then if uh if PC is there intra catheterization also we can give an additional sort of uh additional dose of UFH as well after catheterization we can discontin heparent then uh other than we can also give bial rubin which is used during PCR immediately afterwards it doses IV of 0.75 mg per kg ball followed by 1.75 mg per kg per hour infusion which is also to be stopped immediately after PCA or continue up to 4 hours following free PCA. Then Noxiparin also we can give but Noxiparin there is no loading dose. We can we have to give a 1 mg per kg subq every 12 hour only or and continue up to 48 hours >> where it is contraindicated >> an oxiparin failure >> renal failure we give regular >> apparent otherwise you can almost all cases you can actually go for uh if it is renal clearance is less than 30 we can give but od do upg >> then uh like if there we are not talking for taking for any non-inversive approach we can get started on fondoparinx fondoparinx is not it's it's not used during PCI >> fondar hop >> factor 10 inhibitor >> fondarex is not uh not used during PCA because of higher risk of catheter related blockage >> so fondarness 2.5 mg >> where will you prefer fondarox Then >> if in noninvasive method if we are not uh it hit we have like hit >> only a parent is there >> then you can go for fond otherwise normally doctors don't prefer fondanets as a first line drug >> uh fondanos is only can like if there is no likely to be taking for PCA for for 48 hours we can start on fondanet then uh also the same uh uf like unfacted heparin also can be used in non-inversive approach. That's the same dosage like 60 unit per kg maximum up to 5,000 followed by 12 unit per kg per hour uh IV we have to give and stop if we are going for any stress test we have to stop that apparent prior to it then an oxiparan also we can give >> uh if the pat we are uh taking for we the patient is to be converted to an inversive pro procedure we can convert if the patient is on phoxipan or enoxipan or fondopanex we can convert to uh heparin prior to the procedure.

[00:12:10]Then uh if anticoagulant of choice if we are saying if there is a history of epan induced trombosis is there we can go for uh arival rubin or fondar if not there we will if inversive is there we our choice is apparent if non-inversive apparent or fondar we can >> what are the drugs we continue after immediate care >> immediate care so after immediate care uh we we can uh start on uh beta blockers to prevent >> actually beta blocker starts from the first day itself. Okay. So that should be continued.

[00:12:45]>> There is no features of heart failure.

[00:12:46]We can start on beta blocker then spolactone.

[00:12:50]>> If there is heart failure features then what you do cannot >> 24 hours we >> what is his opinion your opinion can can we give beta blockers in heart failure?

[00:13:00]>> So up to like grade two grade what is that nyhi classification >> grade 1 2 3. So you can actually start even if the patient is having cardiac failure mild moderate and all you can start but should be started with a very low dose and build up the dose slowly.

[00:13:16]Okay. What is the action of beta purpose on heart?

[00:13:19]>> Uh uh first to prevent heart arithmas heart rate control and >> heart rate control is a very important action because once you control the heart rate oxygen consumption of the myioardial muscles will come down that is advantage then long-term it will be beneficial. Second trick is >> AC inhibitor. AC emitter ARB ARB.

[00:13:38]>> Okay, that should be started within first 24 hours of the >> MI. Okay, but if there is a strong contra indication like renal failure, >> you cannot start that. Okay, then >> then spinal lactone.

[00:13:50]>> Spinal lactone. Okay, if you cannot start AC inhibitors, which can prevent ventricular remodeling?

[00:13:56]>> Calcium.

[00:13:57]>> Calcium blockers.

[00:13:58]>> So that can be tried but calcium blocker can be tried. Okay.

[00:14:02]>> Then aspirin what is the dose to be continued? 75 mg. So now it is 75 mg per day. Okay.

[00:14:10]Also we have to 75 mg. Okay.

[00:14:15]180 >> initial for 30 days it is like that then it is 90 90 m.

[00:14:21]>> Okay. So what happened to the patient now? uh after we started on heparent as well as we started on loading dose aspirin and operate continued along with beta blockers we started patient still >> during your treatment after fourth day or fifth day patient develops chest pain what investigation you do >> ckmi >> tropy so CKMB after 70 after 24 hours it's a downturn if it is either elevating we have to suspect a recurren >> reinfection >> then we manage accordingly and after he apparently given we have to continue up to 5 days minimum of 48 hours we have to give a parent. So we continue up to 5 days and we with with uh with aspir and cop discharge.

[00:15:04]>> Okay.

[00:15:06]>> Plan c later and cardio.

[00:15:09]>> Okay.

[00:15:10]>> Thank you.