SAQ 443 – Cardiology – posterior STEMI with pulmonary oedema and shock

Review Completed

Marked out of 30.00

You are the consultant in charge of a tertiary emergency department at 9 pm on a Saturday. Ambulance notifies you of a 53-year-old man 20 minutes away with severe chest pain for 3 hours, unresponsive to simple analgesia but otherwise haemodynamically normal. The pre-hospital ECG is shown below.

On arrival he becomes acutely short of breath with crackles to the midzones.

Observation	Result
Heart rate	60/min
Blood pressure	85/65 mmHg
Oxygen saturation	85% on 15 L/min oxygen via Hudson mask

ECG showing anterior ST depression concerning for posterior STEMI. — Pre-hospital ECG

Give one (1) positive and two (2) negative ECG findings, and state a single unifying diagnosis.

(Marked out of 8.0)

/ 8

List six (6) immediate management steps.

(Marked out of 12.0)

/ 12

List four (4) drugs you would use to safely intubate this patient, with doses and timing.

(Marked out of 10.0)
</p> <table class="saq-prop-table"> <thead> <tr> <th>Drug</th> <th>Dose</th> <th>Timing</th> </tr> </thead> <tbody> <tr> <td>1.</td> <td></td> <td></td> </tr> <tr> <td>2.</td> <td></td> <td></td> </tr> <tr> <td>3.</td> <td></td> <td></td> </tr> <tr> <td>4.</td> <td></td> <td></td> </tr> </tbody> </table> <p>

/ 10

Total Score: 0 / 30

Percentage: 0%

Model Answer

Cardiology – posterior STEMI with pulmonary oedema and shock.

a. ECG findings and diagnosis

Positive finding: ST depression in V1-V4, around 1-2 mm, suggesting posterior infarction.
Negative findings may include no prominent anterior T waves, no prominent R waves in V1-V3, no significant inferior/lateral ST elevation, and sinus rhythm.
Unifying diagnosis: early isolated posterior STEMI, now complicated by likely cardiogenic shock and acute pulmonary oedema.

b. Immediate management

Move to resuscitation area, apply full monitoring and defibrillator pads, and use a senior team approach.
Give high-flow oxygen and start non-invasive positive pressure ventilation/CPAP if tolerated while preparing for intubation.
Call cardiology/interventional cardiology for urgent PCI/cath lab activation.
Give cautious circulatory support such as adrenaline infusion around 5 microgram/min or 10 microgram boluses titrated to response; avoid large fluid loads.
Obtain IV access and bloods including group and hold, troponin, VBG, FBE, EUC, and coagulation.
Give antiplatelet therapy such as aspirin 300 mg and clopidogrel 600 mg if no contraindication and in keeping with local STEMI pathway.
Give cautious analgesia, for example fentanyl 25 microgram increments.
Confirm with posterior leads V7-V9 if this will not delay reperfusion; bedside echo/CXR may assist but should not delay definitive care.

c. Intubation drugs

Drug	Dose	Timing
Fentanyl	About 100 microgram IV, or smaller cautious titrated doses	Give immediately pre-induction, around 1-2 minutes before induction.
Ketamine	About 1-2 mg/kg IV, titrated/cautious in shock	Induction agent after pre-oxygenation and vasopressor preparation.
Suxamethonium or rocuronium	Suxamethonium 1-1.5 mg/kg IV, or rocuronium 1.2 mg/kg IV	Give immediately after induction drug.
Adrenaline or metaraminol	Adrenaline infusion 1-200 microgram/min or 10-50 microgram IV boluses; metaraminol 0.5-1 mg IV boluses	Prepare before induction and give/titrate peri-intubation to maintain perfusion.

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