Critical CAD with difficult Coronary Intervention

1. 29/10/2015 -THR
Presented by
Dr. Mohammed Mushfiqur Rahman
Dr.Rushdi Gazal

2. 01/06/2015 – 12:10
66 yrs male transferred as life
saving case to KSMC from
Aleman Hospital by
ambulance.

3.  01/06/2015-12:10
 ER doctor note:
chief complain; chest pain started yesterday night
k/c of DM on insulin , IHD, S/P Cath 5 yrs ago . Pain
started yesterday went to Aleman Hospital two hrs
ago where he received thrombolytic therapy
BP: 117/67 , HR :90/min, RR:20, sO2 : 90% ,
temp:36.8 , glucocheck:110mg/dl , pain score 3/10
Alert , conscious , oriented, no neurological deficit
Chest clear equal air entry
Abdomen soft lax
CVS: S1+S2+0, no Lower limb edema
Initial impression : ACS
Requested labs and chest X-ray

4.  01/06/2015- 17:25
Pt referred to cardio
66yrs old male pt k/c of DM,IHD
Come with referral from Aleman Hospital after
receiving thrombolytic therapy
ECG: LBBB, +ve tropoine
For your kind care.

5.  01/06/2015- 19:30
Cardiologist note: this 66 yrs old male non-
smoker K/C of DM, dyslipidaemia , IHD S/P Cath
5yrs back with stent.
Presented with chest pain for 9-10 hrs duration
came from other Hospital S/P streptokinase, pain
was radiating to neck and associated with
sweating and SOB.
BP:104/36 , HR : 97/min, So2: 97% with O2
Head neck normal
Chest clear
CVS S1+S2+0
Abdomen soft lax
CNS intact

11.  Impression: Acute MI S/P streptokinase from another
hospital
LBBB , DM, HTN, IHD.
Plan: Admission to CCU
Pls see the order sheet .
 Consultant impression:
Transient LBBB, anterior wall MI, old IHD post PCI DM,
dyslipidaemia.

12.  Treatment given:
 Inj Clexan 60 mg subcut BID
 Tab Aspirin 81 mg po once daily
 Tab Plavix 75 mg po once daily
 Tab Atrovastatin 40 mg PO once daily
 Tab Concor 2.5 mg po once daily
 Tab Capoten 6.25 mg po once daily
 Tab Isordil 5 mg subligual PRN
 Tab Zantac 150 mg po bid
 Inj Regular Insulin subcut in sliding scale with
glucocheck 6 hrly

13.  Pt transferred to CCU 01/06/2015- 21:00
Pt seen by CCU doctor at 21:30- 01/06/2015.
66yrs old male non smoker k/c of Dm , Dyslipidaemia, IHD post Cath twice
2yrs and 5yrs back.
Presented to another Hospital with history of chest pain for 9 hrs treated as
Acute MI post SK.
On Ex : conscious oriented, No chest pain or SOB.
HR :80/min, BP: 104/47mm Hg
Chest: clear
CVS: S1+S+2+0
Abdomen: soft and lax
ECG: SR, LBBB transient
Lab: CK 1452, CK-MB 129, trponin : 6.75
Impression : DM, dyslipidaemia ,IHD post Cath , LBBB (treated as acute
MI)
 Plan:
Pls see the order sheet
Fax to PSCC.

14.  Inj Clexan 60 mg subcut BID
 Tab Aspirin 81 mg po once daily
 Tab Plavix 75 mg po once daily
 Tab Atrovastatin 40 mg PO once daily
 Tab Concor 2.5 mg po once daily
 Tab Capoten 6.25 mg po once daily
 Tab Isordil 5 mg subligual PRN
 Tab Zantac 150 mg po bid
 Inj Regular Insulin subcut in sliding scale with glucocheck 6
hrly

15.  Day two in CCU 02/06/2015, 10:00.
CCU doctor note:
Pt is stable no new complain BP 109/68, HR 90/min
Labs:
Plan:
Detailed Echo
Trace fax result
D/c concor
Start metaprolol 25mg BID

19. 02/06/2015-11:30
Consultant note:
 Old IHD, post PCI
 Transient LBBB
 Acute MI post SK
 EF 35%
Stable no complain
BP 107/80, HR 90/min, sO2 100
Chest: clear
CVS: S1+S2+0
Plan:
Fax to PSCC
Medical referral for DM and peripheral neuropathy

20.  02/06/2015 11:30
 Echo study by consultant:
Upper normal LV dimension
Thinned akynatic apex & apico septal wall
Hypokynesia of inferior wall , anterior wall , apico medial , lateral and
mid septum
EF 30-35%
Diastolic dysfunction I/IV with moderate MR
LA 3.8cm
Mild aortic sclerosis with normal aortic flow
Normal tricuspid valve morphology and function
Normal RV size and function
No Pericardial effusion No intra-cavity mass

21.  Day three CCU no note
 Day four CCU 04/06/2015 at 00:05
CCU doctor note:
Stable no new complain BP 106/50 , HR 90/min
Chest: B/L basal creps
CVS: S1+S2+0
ECG SR , old infero posterior MI
Plan :
See the order sheet
Lasix 20mg IV stat
04/10/2015 -09:45 Patient left KSMC to PSCC for Cath.

23.  04/06/2015- 09:45, Pt went PSCC, PCI done at 12:21

24.  04/06/2015
Pt came from PSCC to CCU,KSMC at 22:30
 05/06/2015,- 02:00
CCU doctor note:
Pt suddenly develop dyspnoea
Pt is tachypnic and tachycardic
HR 138/min, BP 110/70
Chest B/L creps
CVS S1+S2+S3 gallop
ECG Sinus tachycardia
Labs: BUN 9.4, Cr 118
Plan:
IV lasix 40mg stat
Foley’s cath

25. 05/06/2015 -4:00
Foley’s cath inserted

27.  05/06/2015- 8:20
Consultant note:
 IHD, ischemic CMP
 Severe LV systolic dysfunction
 Diastolic dysfunction III/IV
 Sever MR
 3 vessels disease
 Calcified vessels total occluded + S/P PCI in RCA and LAD
with DES
 Acute pulmonary edema
Crackles up to med chest
BP 70/50

29.  Bedside Echo:
Dilated LV with EF 25-30%
Dilated LA 47*60mm
Diastolic dysfunction, restrictive patter III/IV
LVEOP> 20mmHg
WMA akynetic apical septum + hypokynatic of basal mid lateral wall
and anterior wall
Sever MR III-IV/IV, need qualify by ERO RV RF departmental Echo
(PISA)
Moderate TR
No clots
No pericardial effusion
 Plan:
IV intrope dopamine +dobutamine + IV lasix infusion
Medical to R/o DKA
Start IV insulin
Hold capoten and metoprolol
Resume metoprolol 25mg BID if BP >90/60
Fax to PSCC

30.  05/06/2015-9:50AM
CCU doctor note:
Pt is in setting position no chest pain
BP 90/49 Hr 121/min
On dopamine , dobutamin and lasix
Plan: central line
I/O chart
Urgent fax
05/06/2015-11:30
pt is dysphonic, on ionotrope, BP: 92/45, HR: 130/ MIN
Chest: bilat crackles.
 Case discussed with Intervention Cardiologist of PSCC for possible
intervention but he advise to continue conservative treatment.

33.  05/06/2015-21:50
Pt become more dysphonic , desaturating
Pt was intubated, connected to mechanical
ventilator.
BP: 87/42 on ionotrope. HR: 125/MIN
Chest: B/L creaps,
Advise: CBC, BL chemistry.
Urgent chest xray.

37.  06/06/2015-04:00
Pt on ventilator, FIO2 100%
BP: 86/40, HR: 140/MIN
Bl urea 19 s. creatinin 277
Plan; Nephro consultation.
 Seen by Nephrologists at 05:00
Advices: Decrease IV Lasix
Maintain I/O chart
Repeat Bl chemiestry

38.  06/06/2015-06:15
Patient desaturated on ventilator
Ambubaging done
VT, No BP, DC shock 150 jules given
Pt was given CPR for 30 mints as per ACLS
protocol. Pt could not revived and declared
dead at 06: 45.

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