The patient, male, 50 years old, came to our emergency room at 1:23 a.m. on January x with “persistent chest pain and chest tightness with profuse sweating for 1 hour”, checked his vital signs: HR 58 times/min, R 20 times/min, BP 119/84 mmHg, gave 0.9% sodium chloride injection + pantoprazole 40 mg intravenously, and received an ECG at 1:26 a.m. He was given 0.9% sodium chloride injection + pantoprazole 40mg and was given a bedside ECG at 1:26, suggesting “inferior wall myocardial infarction”, with the following ECG.
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At 1:34, he was given clopidogrel 300mg + aspirin 300mg chewed, and at 1:36, the patient spit out the drug and gave it again. At 01:43 cardiac troponin I: <0.02ng/ml D2-polymer 248.58ng/ml brain natriuretic peptide <20pg/ml. at 01:44 low molecular heparin calcium 4100 was given subcutaneously. at 01:49 0.9% sodium chloride injection 10ml+Ritonix mg was given by static push. at 01:58 HR 62 beats/min after the end of the first thrombolysis, rechecked ECG is as follows
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At 2:19, 0.9% sodium chloride injection + 18mg of Ritonix was given as a static push. 2:28, the second thrombolysis was finished. 2:31, HR 46 times/min, atropine 1mg was given as a static push to prevent cardiac arrest. 2:40, HR 63 times/min, BP 94/58mmHg, 0.9% sodium chloride + 200ml of dobutamine was given as a 5ml/h pump. The second post-thrombolysis recheck ECG showed
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BP rose to 161/108mmHg at 03:10, and dobutamine was gradually reduced to 1ml/h. After communicating with the Family, he was transferred from the 120 green channel to the higher level hospital for emergency pcI treatment at 03:25. During the treatment, it was found that the right posterior coronary trigeminal stenosis post-dilatation diameter >5.5mm, stent maximum 4.0mm, stent could not be attached to the wall, as follows
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For the above emergency PCI, if a suitable stent cannot be given within a short Time, what should be done?
Worry about the stent does not stick to the wall is just a rhetoric, put a 4.0 stent release may also solve the problem.
There are a few hospitals that have 5.0 stents ready to go, aren’t they all booked? Many are 4.0 stent high pressure release.
The key to the problem is that this patient’s blood flow is restored after thrombolysis or balloon expansion, there is no dynamic map so I do not know if it is level 3 blood flow; on the other hand, the proximal vascular condition is not good, diffuse lesions, multiple stent tandem may not be dealt with no recurrent flow or long thrombus, do not deal with the anti-thrombotic chant, but also worried about the stage down poor perfusion cardiogenic shock, so some reluctance.
In this kind of uncomfortable, or balloon paste to see the blood flow is good to do again at an optional stage. The general principle of restoring blood flow and less unnecessary imaging is the purpose of a complex lesion with many variables in an emergency.
So put a stent or step down, this is a problem.
If available, emergency intervention to open the criminal vessels as soon as possible is the way to go! Inferior wall infarction is very easy to combine with a high degree of conduction block or even cardiac arrest, consider placing a temporary pacemaker, this has a deep lesson!
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