A repeat 12-lead ECG taken after coronary intervention showed resolution of the left bundle branch block indicating a successful procedure. Naveed was then transferred to a coronary care unit bed for ongoing monitoring.
His radial artery compression band was removed after 4hrs with haemostasis achieved and the tirofiban infusion was continued for a further 12 hours.
For further information on these drugs consult the British National Formulary
In the cath lab, the nurses start Naveed on an infusion of tirofiban (a powerful anti-platelet drug). A sheath is inserted into his radial artery and an angiogram is performed that shows an occluded left anterior descending artery. An angioplasty guidewire is passed through the catheter to the blocked artery and advanced across the blockage. A thrombus aspiration catheter is fed over this wire, and thrombus removed from the artery by suction. This restores flow to the artery and a bare metal stent is implanted in the artery to complete the procedure.
En route to the royal infirmary Naveed loses consciousness and the cardiac monitor shows Ventricular Fibrillation (VF). The cardiac monitor also shows that Naveed’s other cardiac observations have deteriorated and the alarm has been activated.
Paramedics note that Naveed has developed VF and begin Cardiopulmonary Resuscitation (CPR). Following a single 150 Joules (J) shock, sinus rhythm is restored and Naveed regains consciousness. Here are links to resuscitation council guidelines for Basic Life Support (BLS) and Advanced Life Support algorithm (ALS).
The paramedics arrive and perform a 12-lead Electrocardiogram (ECG). This shows left bundle branch block (LBBB). The ECG is telemetred to the Royal Heart Infirmary who advise transfer to the cath lab for immediate primary angioplasty. The paramedics are told that Naveed has received aspirin 300mg, so give him clopidogrel 600mg (both orally) and heparin 5000 units (iv) after establishing intravenous access. Oxygen is administered as Naveed’s saturations are low.
Left bundle branch block is caused where there is delayed depolarisation of the left ventricle. On the ECG this is seen as a lengthening of the QRS complexes. It can be a sign of an acute ST elevation MI.
Jackie considers the information provided by Naveed.
Patients with the above symptoms are suggestive of acute coronary syndrome and require immediate referral to Scottish Ambulance Service (SAS).
Jackie now contacts SAS to arrange an emergency ambulance for Naveed and speaks to Sanjita, Naveed’s granddaughter to reassure her and ensure she is aware of the situation and what action to take if Naveed’s conditions worsens prior to the arrival of the ambulance. Jackie sees from Naveed’s emergency care summary that he is prescribed aspirin and advises Sangita to give him 300mg to chew immediately.
Naveed is a 70-year old gentleman who was born in Pakistan and emigrated to Scotland in the 1960s. He lives with his wife and has worked for most of his life in the family restaurant in Edinburgh. His wife is on holiday with their daughter in Pakistan. He is being looked after by his granddaughter Sangita who is training to be a nurse.
Naveed has a history of COPD he has been a smoker for the last 50 years and has recently reduced his smoking from 30 per day to 10. He is hoping to try and stop completely. He was a keen cricketer when he was young and represented Pakistan at youth level; he has regrets about giving it up after arriving in Scotland but was unable to continue due to pressures of work. He is excited about watching the test match on TV live from Lahore where Pakistan are playing India.
During the match, Naveed notices a pain in his chest and a heavy feeling in his left arm. He asks Sanjita for his usual indigestion remedy she is worried and advises him to contact NHS 24 for further assessment.
On completion of this case you should have an understanding of:
