Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute, crushing substernal chest pain radiating to the jaw and left arm, associated with diaphoresis, nausea, and dyspnea. Onset was [Time] ago. Symptoms are constant, 10/10 intensity, and unresponsive to sublingual nitroglycerin. No prior history of similar episodes.
Clinical Examination Findings
Patient is in acute distress, diaphoretic, and tachypneic. Vitals: BP [Value], HR [Value], O2 sat [Value] on RA. Cardiac: Tachycardic, regular rhythm, S1/S2 present, no murmurs, rubs, or gallops. Lungs: Bilateral crackles at bases. Extremities: Cool, clammy, no peripheral edema. 12-lead ECG confirms ST-segment elevation in leads V1-V4, consistent with proximal LAD occlusion.
Treatment Protocol
Immediate activation of Cardiac Catheterization Lab for primary PCI. Administered Aspirin 325mg, P2Y12 inhibitor (loading dose), and unfractionated heparin bolus. Initiated high-intensity statin and IV nitroglycerin titration for pain control. Monitoring for arrhythmias and hemodynamic instability.