ST elevation myocardial infarction with atypical main complaint
O.V., male, 56 years old has brought by ambulance in Emergency Department for seizures 30' ago wich cause a minor head trauma. At the admission was sleepy, appear alcohol intoxicated, recent bruising on his face. RR=18/min, HR=82/min, BP=110/70 mmHg, SaO2=97%. ECG reveal ST elevation myocardial infarction, CK-MB=5ng/ml, Troponin I=0,3 ng/ml, WBC=14.300/mcL. The treatment was : Aspirine 325 mg p.o., Nitrogliceryn sl 0.5 mg, Fentanyl 50mcg i.v. In the next 5' the patients becomes unconscious and the heart rythm was ventricular fibrillation. He received 150 J and he was converted to sinusal rythm. After heart sonographic examination, the decision was to initiate trombolysis and transfer the patient to another clinic for invasive procedure. Resuming history, we have a smoker, alcoholing patient with not treated high blood pressure with mild chest pain for about 2 weeks and onset of severe chest pain 2 hours ago lasting 30'. Has trombolysis become not recommended ? Is it a stroke possible simultaneously with coronary event? CT scan result : cortical atrophy, no signs of cerebral hemorrhage or cerebral ischemia. The patient received Clopidogrel 600 mg p.o., Clexane 30 mg i.v. and Metalyse 6000 u i.v. In a few minutes, the blood pressure decrease until 75/51 mmHg and the patient received Normal Saline 500 ml and Dopamine 7 mcg/Kg/min with good results. ECG recordings every 15' does not show elements of reperfusion, but the hemodynamic status of the patient until the helicopter transfer was improving. The final step of the management was the medical transport by helicopter to a higher level hospital in order to make coronary angiography and baloon dilatation or stent placement. In conclusion, sometimes, ST elevation myocardial infarction patients are present in emergency department with atypical symptoms, but this situation should not delay the diagnosis and the proper application of the treatment.
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