Treatment Protocol for MI
Treatment in emergency department:
When the patient with suspected acute MI reaches the emergency department
(ED), evaluation and initial management should take place promptly, because the
benefit of reperfusion therapy is greatest if therapy is initiated early
The initial evaluation of the patient ideally should be accomplished within 10
minutes of his or her arrival in the ED; certainly no more than 20 minutes should
elapse before an assessment is made
Treatment:
Oxygen by nasal prongs 2lit/min
sublingual nitroglycerin (unless systolic arterial pressure is less than 90 mm Hg
or heart rate is less than 50 or greater than 100 beats per minute [bpm]);
Isosorbide dinitrate 5mg sublingual
Adequate analgesia (with morphine sulphate or meperidine);
Aspirin 325 mg
Clopidogrel 300 mg
Atorvastatin 80mg or Rosuvastatin 40mg
This Is Loading Dose
If patients is come with you within 3 hrs than given antithrombotic therapy
The patient without ST-segment elevation should not receive thrombolytic
therapy
Greatest benefit occurs when thrombolysis is initiated within 3to 4 hours of the
onset of symptoms,
Thrombolytic therapy is associated with a slightly increased risk of intracranial
hemorrhage (ICH) that usually occurs within the first day of therapy. Variables
that appear to predict an increased risk of ICH include age greater than 65 years,
body weight less than 70 kg, systemic arterial hypertension, and administration
of tissue plasminogen activator (TPA).
Once reperfusion therapy is initiated, the patient with suspected acute MI should
be hospitalized. Subsequent short- and long-term management is similar,
irrespective of the appearance of the initial ECG. Thus, following the initial
triage decision regarding reperfusion therapy, treatment of the patient whose
ECG initially showed ST-segment elevation or presumably new LBBB and who
received reperfusion therapy is similar to that for the patient whose initial ECG
failed to show ST-segment elevation or LBBB and who did not receive
reperfusion therapy
Why is tPA not given after 3 hours?
Most of them are ineligible because they come to the hospital after the threehour time window." The timing of treatment is important, because giving a
strong blood thinner like tPA during a stroke or MI can cause bleeding inside the
body.
 Alteplase (Activase) — is the gold standard treatment for MI and Ischemic
Stroke.
An injection of tPA is usually given through a vein in the arm with the first three
hours
Accelerated Infusion Weight-Based Doses for Patients with AMI
Patient weight
>67 kg
≤67 kg
Intravenous
bolus
15 mg
15 mg
First 30 min
Next 60 min
50 mg
0.75 mg/kg
35 mg
0.50 mg/kg
3-hour infusion
For patients weighing ≥65 kg, the recommended treatment dose is 100 mg
administered as 60 mg in the first hour (6-10 mg administered as a bolus), 20 mg
over the second hour, and 20 mg over the third hour. For smaller patients (<65
kg), a treatment dose of 1.25 mg/kg administered over 3 hours may be used.
Weight-based doses are shown in Table 2.
3-Hour Infusion Weight-Based Doses for Patients with AMI
Patient
weight
>65 kg
≤65 kg
Bolus
6-10 mg
0.075 mg/kg
Rest of
1st hour
50-54 mg
0.675 mg/kg
2nd hour
3rd hour
20 mg
0.25 mg/kg
20 mg
0.25 mg/kg
 Tenectiplase
Administer ASAP (within 30 minutes) after onset of acute MI
30-50 mg IV bolus over 5 sec once (based on weight)
 Reteplase
10 units IV bolus (over 2 minutes), THEN
Second dose given 30 minutes after first (for total cumulative dose of 20 units)
 Streptokinase (Thrombolytic Agent )
150,000 U/hr over 1 hr
Once hospitalized, the patient with acute MI should be continuously monitored
by electrocardiography and the diagnosis of acute MI confirmed by serial ECGs
and measurements of serum cardiac markers of myocyte necrosis, such as
creatine kinase isoenzymes or cardiac specific troponin T or I. The patient should
be monitored closely for adverse electrical or mechanical events because
reinfarction and death occur most frequently within the first 24 hours.
Heparin intravenously for at least 48 hours after alteplase 5000unit TDS
B blocker
In the patient without ST-segment elevation or LBBB in whom pulmonary
congestion is absent, Diltiazem may reduce the incidence of recurrent ischemic
events
 Immediate-release
dihydropyridines (eg,
contraindicated in the patient with acute MI.
nifedipine)
are
In the patient with evolving acute MI with ST-segment elevation or LBBB, an
ACE inhibitor should be initiated within hours of hospitalization, provided that
the patient does not have hypotension or a contraindication. Subsequently, the
ACE inhibitor should be continued indefinitely in the patient with impaired LV
systolic function (ejection fraction less than 40%) or clinical congestive heart
failure (CHF)
Nitroglycerin should be infused intravenously for 24 to 48 hours,
and Magnesium Sulphate should be given as needed to replete magnesium
deficits for 24 hours for the patient who receiving alteplase.
If monomorphic ventricular tachycardia is not accompanied by chest pain,
pulmonary congestion, or hypotension, it should be treated with intravenous
lidocaine, procainamide, or amiodarone.
Drug
Aspirin
Clopidogrel
Atorvastatin
Metoprolo or Bisoprolol
Nitriglycerin
Enalapril, Ramipril
Magnesium Sulphate
lidocaine
Dose
75mg
75mg
20mg
25mg/2.5mg
0.3mg
2.5 mg/2.5 mg
1g
Duration
PO
PO
PO
PO
SL
PO
IM
0-1-0
1-0-0
0-0-1
1-0-1/ 0-1-0
SOS or 1-0-1
1-0-1/0-1-0
1-1-1-1 For only one day
than check the lab
report than decide
1-1.5 mg/kg slow IV bolus over 2-3 minutes
May repeat doses of 0.5-0.75 mg/kg in 5-10
minutes up to 3 mg/kg total if refractory VF or
pulseless VT