Post-Operative Myocardial Infarction

You are the General Surgery CT1 and are asked to see a 55 year old gentleman who is currently on the general surgery ward following recent laparotomy. He is tachycardic and complaining of chest pain and one of the nurses asks for you to review the patient. 

Example answer introduction

In this scenario, in a patient who is complaining of chest pain following recent surgery, I would be concerned about possible post operative cardiac event such as an MI.  I would assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate to the general surgery registrar.

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the CCISP Algorithm:

A - Patent, no stridor or stertor

B - Check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen 

C – Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output 

  • Bloods - FBC, U&E, LFTs, clotting, Group & Save, lactate, blood cultures

  • IV access - large bore 

  • IV fluid resuscitation with crystalloids if hypotensive

  • Catheterise patient to assess urine output urine output >0.5L/kg/hr

D – Glasgow Coma Score, temperature, pupillary response, blood glucose

E – Expose patient and look for rashes, systemic signs of shock. 

During this acute phase state remember to provide constant reassessment

Focused history​

  • Allergies

  • Medications - anticoagulants, antiplatelets

  • Past medical history – previous bowel surgery

  • Last meal

  • Events leading up to this point:

    • Indication for surgery​

    • Review operation notes - is this a high risk for a chest complication, was the surgery difficult etc

Examination

  1. ​Full cardiac examination

  2. Full respiratory examination

  3. Surgical site examination

  4. Calf/Leg examination for DVT

Initial investigations

  1. Bloods- FBC, CRP, UE, TROPONIN

  2. ECG

  3. CXR

Initial management

  • Analgesia

  • If evidence of MI discuss with medical registrar to discuss initiation of acute coronary syndrome (ACS) treatment and consideration of transfer to coronary care unit for monitoring

  • Ensure DVT prophylaxis

  • Monitor fluid input/output

  • Catheter if septic 

Escalation

Consider discussion with:

  • ​General Surgical registrar

  • Medical registrar/Cardiology registrar on call

 

Note: although in most cases of post operative MI, there may be a history of preceeding cardiac disease, myocardial ischaemia and even cardiac arrest can occur in an otherwise fit patient.

Although they may complain of gripping chest pain, this is not always the case, particularly in the early postoperative period or elderly diabetic patient and therefore hypotension may be the only clinical sign. It is important to have a high index of suspicion.  The absence of symptoms post op is thought to be due to residual effects of anaesthesia and to the administration of postoperative analgesia. 

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