Myocardial infarction
Anterior wall myocardial infarction is a severe condition that results due to the restricted blood supply to the heart muscle. Given the patient’s age, smoking history, and related health conditions, such as diabetes, the risk of complications is high. Low blood pressure, difficulty breathing, nausea, and sweating are common symptoms for myocardial infarction, but they can also signify the development of complications, such as congestive heart failure or cardiogenic shock (Bajaj et al., 2014). Moreover, these complications can be followed by acute kidney injury in the case of this patient.
Heart failure, or congestive cardiac failure, is when the heart is weakened or stiff, and pumping chambers cannot be adequately filled. Although this condition develops slowly, it can be life-threatening for the patients. Myocardial infarction is a significant predictor of heart failure, but the risks increase along with such factors as age, diabetes, or smoking history. Low blood pressure, nausea, and confusion can signify the dangers of cardiac failure for this patient.
Cardiogenic shock is a dangerous condition defined as “a state in which ineffective cardiac output caused by a primary cardiac disorder results in both clinical and biochemical manifestations of inadequate tissue perfusion” (Van Diepen et al., 2017, p. e2). The symptoms that include rapid breathing, tachycardia, low blood pressure, and limited urination are present in this patient’s case. This complication is of a higher priority not only because of its feasibility but also because of its severity and rapid development. According to Puerto et al. (2018), it is “the main mechanism for early death after AMI in elderly patients… causing roughly one-half of initial deaths, followed by mechanical complications” (p. 960). That is why this condition can be predicted, and immediate treatment practice should be conducted to prevent a lethal outcome.
Cardiac shock
When the cardiac shock is caused by STEMI, as in the case with this patient, the guidelines published by Queensland Ambulance Service (2020) recommend the same treatment procedures as for acute coronary syndrome (ACS). The primary purpose of this practice is to “ensure adequate circulatory and respiratory support” (Queensland Ambulance Service, 2020). In the case of this condition, early revascularization is a significant predictor of survival rate (Reddy, Khaliq, and Henning, 2015). According to Chew et al. (2016), “primary percutaneous coronary intervention (PCI) or fibrinolytic therapy is recommended” (p. 130). The use of IABP (intra-aortic balloon pump) is recommended before primary PCI to decrease mortality risk (Yuan and Nie, 2016). Primary PCI is the best solution for this patient, but it should be done within the first 90 minutes of treatment. Therefore, it is of the highest priority to transfer the patient to the tertiary hospital as soon as possible.
Immediate pharmacological treatment for the patient with cardiogenic shock caused by STEMI includes aspirin, P2Y inhibitors, and inotropes to maintain blood pressure. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand recommend immediate use of Aspirin “300 mg orally, followed by 100-150 mg/day” (Chew et al. 2016, p. 130). The use of P2Y inhibitors should include “ticagrelor 180 mg orally, then 90 mg twice a day; or prasugrel 60 mg orally, then 10 mg daily; or clopidogrel 300e600 mg orally, then 75 mg daily” (Chew et al. 2016, p. 130). Lastly, Dobutamine infusion is necessary “to maintain mean arterial pressure to prevent end-organ damage” (Bajaj et al., 2015). Van Diepen et al. (2017) suggest using 2.5 µg/kg/min dosage for cardiogenic shock treatment. Lastly, the treatment should include long-term anticoagulant medication in the following days.
The nursing care plan for the patient developing cardiogenic shock includes assessment and proper documentation of health parameters, as well as the adjustment and management of therapies and medication. Health parameters should be assessed directly after the admission, and then they should be closely monitored with the documentation of all changes. Patient data for this client should include:
- Vital signs: Heart rate, breathing rate, pulse pressure, and blood pressure;
- Cardiac rhythm and rate monitored with ECG;
- Monitoring of oxygen saturation and ABG with pulse oximeter;
- Control and assessment of renal output;
- Evaluation of client’s consciousness level, check for signs of anxiety, pain assessment.
The management of the prescribed therapies and medication, as well as communication and reassuring, are essential parts of a nursing care plan that include the following:
- Management of IV sites, keeping fluid balance chart, reducing swelling with ice if needed;
- Manage oxygen if to keep blood saturation;
- Administration of the prescribed medication according to the treatment plan;
- Administration of pain medications when needed;
- Continuous communication with the patient and his wife to reassure and answer the questions.
The process of patient transfer
As the process of patient transfer bears significant health risks, it should be done only when health benefits are significantly higher. In the case of the discussed patient, the decision is justified by the need for PCI intervention in case of cardiogenic shock. As logistic arrangements must ensure safety and time-efficiency of transportation, it is essential to use the advanced life-support ambulance with “cardiac monitoring, defibrillation, administration of intravenous fluids” (Kulshrestha and Singh, 2016, p. 451). Kulshrestha and Singh (2016) also claim that the patient should be accompanied by an emergency team of at least two people. Communication with the receiving hospital is a necessary procedure that ensures preparedness and safe handover.
The vehicle should be provided with all the necessary equipment, including respiratory support, circulatory support (monitor, defibrillator, pulse oximeter, infusion pumps, and intravenous fluids set), and with the required pharmacological set (ANZCA, 2015, p. 9). Additionally, the ambulance must contain all the necessary documentation to provide accurate handover history. The recommendations state that “the patient must be reassessed before transport begins, especially after being placed on monitoring equipment and the transport ventilator” (ANZCA, 2015, p. 8). During transportation, the medical officer should monitor and document basic parameters for respiration, circulation, and oxygenation.
Symptoms of AKI
If the patient is developing cardiogenic shock, low or absent urine output are common symptoms of the condition. The feasibility of AKI is increased due to the previously observed low renal function reported by the patient. Additionally, there are significant risks of AKI (acute kidney injury) development among patients with STEMI. Schmucker et al. (2017) claim that a decline in renal function is commonly observed among patients with such conditions. More precisely, one-center study evidence provides the 18% ratio of AKI among patients with STEMI (Schmucker et al., 2017). AKI is a severe condition that negatively influences health outcomes. That is why the patient will be diagnosed on the subject of acute kidney injury to identify the problem and develop an appropriate care plan in case of complication.
Nevertheless, it cannot be precisely stated that the patient is suffering from AKI until the necessary assessment is conducted. According to Van Diepen et al. (2017), urinary output reduction is a symptom of AKI among patients with myocardial infarction or cardiogenic shock. Still, serum creatinine levels should also be evaluated to indicate renal hypoperfusion. According to Prowle et al. (2015), the levels of Hepcidin and NGAL (neutrophil gelatinase-associated lipocalin) are informative methods of AKI diagnosis. That is why the biomarkers assessment will be conducted for this patient due to the feasible acute kidney injury. Furthermore, the treatment will be designed to reduce support patient’s renal function.
References
Australian and New Zealand College of Anaesthetists (ANZCA). (2015). Guidelines for transport of critically ill patients. Web.
Bajaj, A., Sethi, A., Rathor, P., Suppogu, N., & Sethi, A. (2015). Acute complications of myocardial infarction in the current era. Journal of Investigative Medicine, 63(7), 844-855.
Chew, D. P., Scott, I. A., Cullen, L., French, J. K., Briffa, T. G., Tideman, P. A., … Aylward, P. E. (2016). National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Medical Journal of Australia, 205(3), 128-133.
Kulshrestha, A., & Singh, J. (2016). Inter-hospital and intra-hospital patient transfer: Recent concepts. Indian Journal of Anaesthesia, 60(7), 451.
Prowle, J. R., Calzavacca, P., Licari, E., Ligabo, E. V., Echeverri, J. E., Bagshaw, S. M., … Bellomo, R. (2015). Combination of biomarkers for diagnosis of acute kidney injury after cardiopulmonary bypass. Renal Failure, 37(3), 408-416.
Puerto, E., Viana-Tejedor, A., Martínez-Sellés, M., Domínguez-Pérez, L., Moreno, G., Martín-Asenjo, R., & Bueno, H. (2018). Temporal trends in mechanical complications of acute myocardial infarction in the elderly. Journal of the American College of Cardiology, 72(9), 959-966.
Queensland Ambulance Service. (2020). Clinical practice guidelines: Cardiac/cardiogenic shock.
Reddy, K., A., Khaliq., & Henning, R. J. (2015). Recent advances in the diagnosis and treatment of acute myocardial infarction. World Journal of Cardiology, 7(5), 243-276.
Schmucker, J., Fach, A., Becker, M., Seide, S., Bünger, S., Zabrocki, R., … Wienbergen, H. (2017). Predictors of acute kidney injury in patients admitted with ST-elevation myocardial infarction – results from the Bremen STEMI-Registry. European Heart Journal: Acute Cardiovascular Care, 7(8), 710-722.
Van Diepen, S., Katz, J. N., Albert, N. M., Henry, T. D., Jacobs, A. K., Kapur, N. K., … Cohen, M. G. (2017). Contemporary management of cardiogenic shock: A scientific statement from the American Heart Association. Circulation, 136(16), e1-e24.
Yuan, L., & Nie, S.-P. (2016). Efficacy of intra-aortic balloon pump before versus after primary percutaneous coronary intervention in patients with cardiogenic shock from ST-elevation myocardial infarction. Chinese Medical Journal, 129(12), 1400-1405.