Inferior STEMI in a Soum Hospital Without PCI
A 58-year-old male herder presents to a soum hospital at 07:20 with crushing central chest pain that began at 05:30 while he was carrying water. He is sweaty, nauseated, and pale. BP 152/96, HR 98, RR 22, SpO2 94% on room air, temp 36.8°C. ECG shows ST elevation of 3 mm in leads II, III, and aVF with reciprocal ST depression in I and aVL. He has no history of stroke or bleeding, no recent surgery, and no allergy to aspirin. He takes no regular medicines. The nearest PCI centre is 180 km away; road conditions mean a 3-hour ambulance transfer. The hospital has aspirin, clopidogrel, tenecteplase, heparin, oxygen, and a defibrillator, but no cardiologist on site. A nurse must assist with the reperfusion decision and prepare the patient for transfer.
1. What reperfusion strategy is most appropriate and why? Include the time factors and the main contraindications you must screen for before thrombolysis.
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Thrombolysis is the most appropriate strategy here, provided there are no contraindications. Primary PCI is preferred when it can be delivered within about 120 minutes of first medical contact. This patient is 180 km away with a 3-hour ambulance transfer, so PCI would be markedly delayed. His symptom onset was 05:30 and he arrived at 07:20, so he is within the 12-hour window, and tenecteplase is stocked. The goal should be door-to-needle in under 30 minutes, followed by transfer to the PCI centre.
Screen for absolute contraindications: any prior intracranial haemorrhage, ischaemic stroke within 3 months, known cerebral neoplasm or arteriovenous malformation, suspected aortic dissection, active bleeding or bleeding disorder, recent major surgery or trauma, and severe uncontrolled hypertension above about 180/110. His BP 152/96 is acceptable. Check pregnancy, recent gastrointestinal bleed, and anticoagulant use. Because this is an inferior infarction, obtain right-sided leads and avoid nitrates if there is right ventricular involvement or hypotension. Aspirin 300 mg chewed, clopidogrel 300 mg, and weight-based tenecteplase plus heparin per protocol are appropriate if no contraindication.
2. Outline the medication and monitoring plan for the first 60 minutes, including what you would avoid and why.
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Give aspirin 300 mg chewed and clopidogrel 300 mg orally unless contraindicated. Give weight-based tenecteplase as a single intravenous bolus and heparin according to the local protocol. Apply continuous ECG monitoring, check vital signs every 15 minutes, secure a second IV line, check glucose, and keep the defibrillator at the bedside. Give oxygen only if SpO2 falls below 90%; his SpO2 is 94% on room air, so routine oxygen is not needed and may be harmful. Treat pain cautiously, but avoid intramuscular injections because of bleeding risk and unreliable absorption.
Avoid nitroglycerin if right ventricular infarction is suspected or if systolic BP falls, because inferior infarction can reduce preload and cause hypotension. Watch for reperfusion arrhythmias, bleeding, hypotension, nausea, and allergic reaction. Document the exact times of aspirin, clopidogrel, tenecteplase, and heparin. Reassess ECG and symptoms at 60-90 minutes; persistent pain or ST elevation suggests failed reperfusion and urgent transfer for rescue PCI.
3. What handover information is essential before the 3-hour transfer?
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Handover must include symptom onset time, arrival time, ECG findings and any right-sided or posterior changes, and the exact times and doses of aspirin, clopidogrel, tenecteplase, and heparin. Include allergies, weight, BP and heart rate trend, SpO2, IV access sites, and whether oxygen is running. State bleeding risk, recent procedures, and any contraindications screened. Report pain score, nausea, urine output, and neurological status.
Also hand over the consent discussion, the referral acceptance and ambulance dispatch time, and the defibrillator and monitoring plan during transfer. The receiving team needs to know whether reperfusion succeeded clinically and whether any arrhythmia or hypotension occurred. A concise written transfer note with these times prevents duplicate or missed medication and supports rescue PCI decisions on arrival.