Assessment One: Short answer questions on a case study Length: 750 words

Weighting: 30%

Due: Week 5, Monday 22nd August 2022 at 12 midnight

Aim of the assessment

The purpose of this assessment is to enable you to:

1. Explain the underlying pathophysiology related to the clinical manifestations of ST elevation myocardial infarction (STEMI)
2. Discuss the importance of reperfusion in the management of a patient presenting with STEMI
3. Identify evidence-based strategies when caring for a patient presenting with STEMI

Case Study

Introduction: Mr Raj Kumar is a 64-year-old male with no known allergies (NKA)

Situation: Mr Raj Kumar arrived at the Emergency Department at 1130 hrs with central crushing chest pain radiating to his jaw since 1100 hrs. Findings from the 12 lead ECG recorded by paramedics showed ST elevation in leads V2, V3, V4. 300mg Aspirin administered on route to hospital.

Background: Hypertension (Captopril 12.5mg bd) Hyperlipidaemia (Simvastatin 40mg nocte). Type 2 Diabetes Mellitus (DM) (diet controlled)

Assessment:

• Airway patent
• Breathing: Respiratory rate 18, bilateral air entry, breath sounds clear. SpO2 on room air 95%
• Circulation: Sinus Tachycardia 102bpm. BP 140/90. Diaphoretic and peripherally cool.

Central crushing chest pain radiating to the jaw.

COLDSPA:

Character: crushing chest pain

Onset: 11am

Location: Central, radiating to jaw

Duration: ongoing

Severity: 7/10

Pattern: at rest, not relieved by SL Anginine Spray

Associated symptoms: diaphoresis

• Disability: Alert & oriented. Pupils equal and reacting to light (PEARL). Pain score 7/10. Equal strength in all four limbs.
• Exposure: IVC Left cubital fossa.
• Fluid: NBM. NO IVF
• Weight 88kg

Results:

• Elevated Troponin 35ng/L troponin
• 12 lead ECG: ST elevation (>2mm) V2, V3, V4

A diagnosis of acute anterior STEMI is made

Recommendations:

Supplemental oxygen if SpO2 < 93% Continuous cardiac ECG monitoring

12-lead ECG now, then every 30 minutes Keep in resuscitation bay (Triage category 2) Blood tests:

Troponin now, then again in 2 hours

Medications:

Morphine 2.5mg IVI 2/24 (PRN maximum dose 10mg)

Nitro-glycerine 600mcg SL (PRN maximum 3 doses); if pain persists, consider IV Glyceryl Trinitrate infusion

Clopidogrel 300mg PO STAT Heparin 5000IU IV STAT

As per STEMI reperfusion flowchart:

Transfer to Cardiac Cath Lab for urgent primary PCI when ready (<90mins). If PCI delayed, give Tenecteplase 45mg IV as per PACSA @ 1230pm

Guided Questions:

Question 1: (250 words)

Pick one (1) clinical manifestation and discuss the related pathogenesis:

• Central crushing chest pain with radiation to the jaw or;
• ST elevation or;
• elevated Troponin (35ng/L)

Question 2: (500 words)

• Pick one (1) intervention from EACH of the three (3) categories below.

·        Provide one rationale for interventions selected form each category. Use evidence and/or pathophysiology to support your answer.

Category 1 Non-pharmacological interventions	Category 2 Pharmacological interventions	Category 3 Reperfusion interventions
Supplemental oxygen if SpO2<93%12 lead ECG within 10 minutes of arrival and then every 30 minutesTroponin at 0 and 2 hours	Morphine 2.5mg IVNitro-glycerine 600mcg SLAspirin 300mgHeparin 5000iu IVClopidogrel 300mg	Tenecteplase 45mg IVPrimary Percutaneous Coronary Intervention

Supporting resources

American Psychological Association (APA) referencing style guide (PDF 725 KB) (Western Sydney University Library, 2020).

Library Study SmartLinks to an external site.—a library resource that helps you to complete assignments (Western University Library, 2021).

Western Sydney University Library has further information about referencing on their Referencing and citation page.

Suggested readings

• Pathway for Acute Coronary Syndrome Assessment (PACSA) (New South Wales Health, 2019).
  • National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016 (Chew et al., 2016, pp. 895–951).

Guided Questions
Criteria	Mark	High Distinction	Distinction	Credit	Pass	Fail
Criteria 1: Question 1 – Demonstrates comprehensive and detailed knowledge of the pathogenesis of one (1) clinical manifestation of ST- elevation Myocardial Infarction	/20	Provides an accurate and clear explanation of the pathogenesis causing the clinical manifestation of the patient in the case study. Synthesises the information effectively in own words, explanation is developed in a logical sequence and is technically correct. The discussion is clearly and accurately supported by appropriate sources.	Explains the pathogenesis causing the clinical manifestation of the patient in the case study. Mostly synthesises the information effectively in own words and in a logical sequence. The discussion is clearly and accurately supported by appropriate sources.	Generally, provides an accurate explanation of the pathogenesis causing the clinical manifestation of the patient in the case study. The explanation is mostly developed in a logical sequence but there may be one or two omissions of information or manifestation is accurately explained but there is little logical development in the discussion. The discussion is supported by appropriate sources.	Provides a basic description of the pathogenesis of the clinical manifestation presented by the patient in the case study. There may be minor inaccuracies, omissions or repetition of information, lack of clarity or logical flow of the process. The discussion is mostly supported by appropriate sources.	Gives either a superficial description or inaccurate description of the pathogenesis of the clinical manifestation. There are significant inaccuracies, repetition, or lack of clarity. Has not accurately related the clinical manifestations to the pathogenesis.
17-20	15-16.5	13-14.5	10-12.5	≤9.5
Criteria 2 Question 2 -Category 1 Demonstrates understanding of one (1) non- pharmacological intervention for the patient presenting		Accurately identifies one (1) non- pharmacological intervention to manage a patient presenting with STEMI. The answer	Accurately identifies one (1) non- pharmacological intervention to manage a patient presenting with STEMI. The answer	Accurately identifies one (1) non- pharmacological intervention to manage a patient presenting with STEMI. The answer	Accurately identifies one (1) non- pharmacological intervention to manage a patient presenting with STEMI. The answer	Does not accurately identify one (1) non- pharmacological intervention to manage a patient presenting with

Guided Questions
Criteria	Mark	High Distinction	Distinction	Credit	Pass	Fail
with STEMI using current evidence/pathophysiology to support answer	/20	is well-supported by current evidence. The answer is accurate and clearly explains the rationale/s.	is well-supported by current evidence. The answer is accurate and clearly explains the rationale/s May be missing minor detail or requires further elaboration required	is supported by a rationale. The answer explains the rationale/s but more depth/technical information required.	is not well-supported by current evidence. More details to support the discussion required.	STEMI or provides little or inaccurate explanation of rationales. Information predominantly copied or quoted from inappropriate sources.
17-20	15-16.5	13-24.5	10-12.5	≤9.5

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