Ebook The protocol book for intensive care: Part 1

THE PROTOCOL BOOK
for Intensive Care


THE PROTOCOL BOOK
for Intensive Care
Fourth Edition

Editor

Soumitra Kumar  MBBS  MD  DM  FCSI  FACC  FESC  FSCAI  FICC  FICP
Professor, Division of Cardiology
Department of Medicine
Vivekananda Institute of Medical Sciences
Kolkata, West Bengal, India
Forewords

Sukumar Mukherjee
Manotosh Panja
Amal Kumar Banerjee
Pradip Kumar Deb

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The Protocol Book for Intensive Care
First Edition: 2003 (by Editor)
Second Edition: 2008
Third Edition: 2010
Fourth Edition: 2014
ISBN 978-93-5090-740-5
Printed at

To
My Family,
Friends
and
Well-wishers


Swami Vivekananda

The secret of religion lies not in theories but in practice.
To be good and to do good — that is the whole of religion.


Contributors
Achyut Sarkar
Associate Professor
Department of Cardiology
Institute of Postgraduate Medical
Education and Research
Kolkata, India
Amitava Majumder
Assistant Professor
Department of Medicine
Vivekananda Institute of Medical
Sciences, Kolkata, India
Aniket Niyogi
Senior Registrar, ITU
Belle Vue Clinic, Kolkata, India
Arghya Chattopadhyay

Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India
Arup Ratan Datta
Head, Department of Nephrology
Fortis Hospital, Anandapur
Kolkata, India
Basab Bijoy Sarkar
Consultant Physician
Fortis Hospital, Anandapur
Kolkata, India
Bipul Barman
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India
Debashis Datta
Consultant Gastroenterologist
Fortis Hospital, Anandapur
Kolkata, India

Debashis Sarkar
Consultant Physician
Sri Aurobindo Seva Kendra
Kolkata, India
Dinobandhu Naga
Senior Resident
Department of Medicine
Ramakrishna Mission Seva

Pratishthan, Kolkata, India
Dipankar Mondal
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India
Jayanta Roy
Consultant Neurologist
Apollo Gleneagles Hospital
Kolkata, India
Joydeep Mukherjee
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India
Kayapanda M Mandana
Chief Cardiac Surgeon
Fortis Hospital, Anandapur
Kolkata, India
Samar Ranjan Pal
Associate Professor
Division of Rheumatology
Department of Medicine
Vivekananda Institute of Medical
Sciences, Kolkata, India
Saptarshi Mukhopadhyay
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India

viii

The Protocol Book for Intensive Care
Shuvanan Ray
Chief of Cardiac Interventions
Fortis Hospital
Anandapur, Kolkata, India
Siddhartha Bandopadhyay
Deputy Visiting Cardiologist
Department of Medicine
Ramakrishna Mission Seva
Pratishthan
Kolkata, India
Soumitra Kumar
Professor
Division of Cardiology
Department of Medicine
Vivekananda Institute of Medical
Sciences, Kolkata, India
Subhasis Chakraborty
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan
Kolkata, India
Sudeshna Majumder
Professor
Division of Cardiology

Department of Medicine
Vivekananda Institute of Medical
Sciences, Kolkata, India
Sudip Mondal
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan
Kolkata, India
Sudipto Chatterjee
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India

Sujata Majumder
Assistant Professor
Department of Medicine
Vivekananda Institute of Medical
Sciences, Kolkata, India
Sujoy Ghosh
Assistant Professor
Department of Endocrinology
Institute of Postgraduate Medical
Education and Research
Kolkata, India
Sulagna Banerjee
Medical Officer
Division of Non-invasive Cardiology
Ramakrishna Mission Seva

Pratishthan, Kolkata, India
Sumit Sen Gupta
Consultant Pulmonologist
Fortis Hospital
Anandapur, Kolkata, India
Susanta Chakraborty
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India
Sweety Trivedi
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India
Uttio Gupta
Senior Resident
Department of Medicine
Ramakrishna Mission Seva
Pratishthan, Kolkata, India
Yashesh Paliwal
Consultant Intensivist
In-charge, ICU, Fortis Hospital
Anandapur, Kolkata, India


Foreword to the Fourth Edition
Medical Sciences have progressed by leaps and bounds—not only in
understanding of pathogenesis but also in formulation of evidence-based and
cost-effective approach in their management. Parallel to novel diagnostic aids,

technological improvement in acute care medicine has supplemented quality
of management to a greater extent to achieve precision. The medical practice
is ever-changing with the introduction of newer concepts and devices in an
algorithmic manner as it is done in this fourth edition of the book The Protocol
Book for Intensive Care under the able editorship of Professor Soumitra Kumar
and his team. This book covers all the major branches of medical emergencies
such as cardiology, pulmonary medicine, central nervous system, metabolic
medicine, and of course, rheumatology. In this multidisciplinary and multiauthor book the presentations are simple, logical and maintain orderly flow
of decision-making process.
The compilation of most of the ‘acute care medicine’ by thoughtful
contribution of senior experienced clinicians of Kolkata under the guidance
of erudite Professor Kumar has come out like ‘Pocket Guidelines Update’. I am
sure this algorithmic approach with holistic vision would be very practical
for the clinicians who practice acute emergencies.
I am convinced that timely arrival of this edition will improve level of
acute care further in patients with health crisis. And for this laudable effort of
educational promotion, Professor Soumitra Kumar and his associates deserve
special appreciation and thanks.



Sukumar Mukherjee
MD FRCP(Lond) FRCP(Edinburgh)



FSMF FICP FISE FIMSA







Ex-Professor and HOD of Medicine
Medical College, Kolkata, India
Past President
Association of Physicians of India


Foreword to the Fourth Edition
It is indeed a pleasure for me to write a Foreword for this fourth edition of
The Protocol Book for Intensive Care. I have known Dr Soumitra Kumar since he
started working with me in his postgraduation days and his academic zeal was
always very commendable. He has indeed matured a great deal with times
and along with his team of acclaimed colleagues and enthusiastic students,
he has produced a real praise-worthy publication. I am given to understand
that the first 3 editions have been very popular and I am very hopeful that
the fourth one too will be equally well-appreciated and read. I wish Dr Kumar
and his team all success for the book.


Manotosh Panja



MD DM FCSI FACC FICP







Ex-Director, Professor and HOD
Department of Cardiology
Institute of Postgraduate Medical Education and Research
Kolkata, India
President
Cardiological Society of India (1995-96)
President
Association of Physicians of India (2003-04)
Dean
Indian College of Physicians (2012-13)








Foreword to the Fourth Edition
Medical Sciences, in the past few decades, have progressed at lightning
speed. The advent of intensive care has decreased morbidity and mortality
in patients with medical emergencies which constitute nearly 30-40% of
medical practice today.
Professor Soumitra Kumar first published the Protocol Book in 2003.
This year, he is going to publish the 4th edition of the book with a focus
on intensive care. Truly speaking, we need this sort of protocol book which
presents in a brief and practical manner, the approach towards diagnosis
and management of medical emergencies. This compilation of treatment

approaches on various aspects of intensive care pertaining to the various
systems has been well-chosen and written by very experienced faculty.
Professor Soumitra Kumar needs to be complimented for the excellent
selection of topics. This book shall be useful to all sections of medical
profession. Professor Kumar has set up a healthy trend in publishing the 4th
edition of this book. I am sure that this book will find a permanent place on
the shelves of all physicians.


Amal Kumar Banerjee



MD DM FACC FESC FACP FAPSC FICC FCSI FICP






Past President
Cardiological Society of India
Association of Physicians of India
SAARC Cardiac Society


Foreword to the Fourth Edition
The Fourth Edition of The Protocol Book for Intensive Care is indeed a praiseworthy compendium of contemporary guidelines on the management of
acute cardiac emergencies and related common acute medical problems.
The guidelines have been supported by relevant scientific evidence and

appropriate class of recommendation, as is the current practice. I am sure that
it will find its place in the book-shelf of many doctors’ clinics and will prove
to be very handy to both cardiologists and internists alike in their day-to-day
practice. I congratulate Dr Soumitra Kumar and the galaxy of very competent
authors for this excellent piece of work.


Pradip Kumar Deb



MD DM FCSI FESC




President
Cardiological Society of India


ALL INDIA HEART FOUNDATION

NATIONAL HEART INSTITUTE

4874 (First Floor), Ansari Road
24, Daryaganj
New Delhi-110 002

(WHO Collaborative Centre in Preventive
Cardiology)

49, Community Centre
East of Kailash
New Delhi-110 065
E-mail :

DR. S. PADMAVATI

FRCP (Lond.) FRCPE, FACC, FAMS
PRESIDENT-All India Heart Foundation
DIRECTOR-National Heart Institute

Foreword to the First Edition
The Protocol Book represents guidelines for the diagnosis and management
of common medical emergencies seen in hospitals. It covers mostly cardiac
problems but also includes respiratory, gastrointestinal, renal diseases and
diabetes. It has the same objectives as the American Heart Association/
American College of Cardiology’s Pocket Guidelines Updates compiled by the
Special Task Forces of these organisations which are proving extremely useful
for practicing physicians.
This book has been compiled by the postgraduate students of the
Vivekananda Institute of Medical Sciences, Ramakrishna Mission Seva
Pratishthan, Kolkata, under the guidance of senior consultants in these
departments at the hospital and under the able Editorship of Dr Soumitra
Kumar. The text is written in a typical ‘Senior Resident’ language that can be
easily understood by their colleagues. The latest ‘state-of-the-art’ information
and knowledge has been used in preparing the various sections. It is a very
laudable effort on the part of the postgraduate staff.
I am sure The Protocol Book will prove very useful for all categories of
physicians dealing with acute emergencies in hospitals.




S Padmavati



FRCP (London) FRCPE FACC FAMS




President—All India Heart Foundation
Director—National Heart Institute


Preface
In the Fourth edition, The Protocol Book has been renamed as The Protocol
Book for Intensive Care on the basis of feedback from the publishers that
many potential readers have felt confused to figure out what protocol it is
all about ! Now, as an editor, I feel relieved that no one will be left flustered
even if he/she is judging the book by its cover. However, I will submit with
utmost humility that if one judges by the cover alone, he/she will really miss
out on the rich content of the book inside.
Indeed, as an editor, I feel that the book is quite rich in information, more
sound in its evidence-base and very useful and handy in terms of practical
tips in handling cardiac and related medical emergencies. One chapter,
namely “Post-operative Care following Cardiac Surgery” has been added to
the previous list of chapters (as in second and third editions) making the total
number twenty-seven.

Like the previous editions, theme of this edition too is to emphasize on
the successful “total management” of the patient. I have been deeply affected
to find successful management of cardiac problems becoming futile when
the patient succumbed to non-cardiac problems like sepsis or renal failure.
I am personally grateful to all the contributors of this edition for their
sincere cooperation and hard work. My junior colleagues, mostly postgraduate students at Vivekananda Institute of Medical Sciences, Kolkata,
have really toiled hard to update the chapters to the best of their ability.
More senior contributors (many from Fortis Hospital, Anandapur, Kolkata),
who are experts in their respective fields, have supplemented this effort
with their experienced and deft-finishing touches. I am particularly thankful
to Mr B Mukherjee for his unstinting support and cooperation in primary
composition of the chapters. I also sincerely acknowledge the continued
patronage of M/s Zydus Pharmaceuticals for this title over last one decade.
Finally, I am indebted to my family members (my parents, wife and son) for
putting-up with my academic pursuits yet again often at the cost of my family
commitments.


Soumitra Kumar


Contents
1.

Acute ST-Elevation Myocardial Infarction

1

Subhasis Chakraborty, Soumitra Kumar
• Third Universal Definition of Myocardial Infarction (Joint ESC/ACCF/

AHA/WHF Task Force 2012)  1

• Prehospital Issues  5

• Initial Hospital Management  6

•
•
•
•
•

2.

Selection of Reperfusion Strategy  14
Fibrinolytic Therapy  16
Assessment of Reperfusion (Noninvasive)  19
Prehospital Thrombolysis  21
Other Complications of Acute Myocardial Infarction  30

Management of Unstable Angina and Non-ST
Elevation Myocardial Infarction

33

Bipul Barman, Soumitra Kumar
•
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•
•

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3.

Cardiac Biomarkers in Acute Coronary Syndrome  34
Risk Stratification in UA/NSTEMI   39
Beta-Blockers  42
Antiplatelet Treatment in Non-ST Elevation ACS (NSTE-ACS)  43
Newer Thienopyridine Derivatives  45
Glycoprotein IIb/IIIa Inhibitors (GPIIb/IIIa Inhibitors)  46
Unfractionated Heparin (UFH)  52
Low Molecular Weight Heparin (LMWH)   52
Direct AntiXa Inhibitor: Fondaparinux  54
Direct Thrombin Inhibitors  55
Medical Regimen on Discharge  68
Risk Factor Modification  69

Cardiogenic Shock

71

Sweety Trivedi, Soumitra Kumar, Sudeshna Majumder
•

•
•
•
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•

4.

Etiology  71
Risk Factors  72
Diagnosis  73
Management  73
Shock Trial Registry  79
Dosage  83

Acute Heart Failure
Arghya Chattopadhyay, Soumitra Kumar  85
• Etiology  85

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The Protocol Book for Intensive Care
• Mechanisms Underlying Decompensation of
Chronic Heart Failure  85
• Diagnosis of Acute Heart Failure (AHF)  86
• Echocardiography in AHF  92
• Hemodynamic Assessment by Echocardiography  92

• Hemodynamic Monitoring in AHF  96
• Approach to the Patient with Acute Heart Failure  99
• Approach to AHF with Systolic Dysfunction  100
• Approach to AHF with Hypotension  100
• Further Management of Hypotension Depending
on Hemodynamic Subsets  101
• Recommendation for Hospitalization Patients
with Acute Docompensated Heart Failure (ADHF)  102
• Phase of Management  103
• Discharge Criteria for Patients with AHF  110
• Cardiac Disease and AHF Requiring Surgical Treatment  111
• Scope of LV Assist Devices in AHF  111
• Acute Heart Failure and Normal Left Ventricular
Ejection Fraction   112
• Evidence Base of Treatment of AHF with NEF  113
• Treatment Guidelines in AHF with PLVEF  115

5.  Management of Chronic Heart Failure  119
Arghya Chattopadhyay, Soumitra Kumar
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Chronic HF  119
Principles of Treatment  119
History  119
Clinical Examination  120
Investigation  120
Biomarkers in Heart Failure  121
Stages of Heart Failure  123
Outline of Treatment of CHF  123
Pharmacotherapy of Congestive Heart Failure  124
Guidelines for Use of Diuretics  124
ACE-Inhibitors  125
Angiotensin-Receptor Blockers  126
Guidelines for Use of ACEIs and ARBs  126
Beta-blockers  126
Guidelines for Use of β-blocker  127
Digitalis  128
Vasodilators in CHF  129
Positive Inotropic Therapy in CHF  131

Antithrombotics in CHF  131
Antiarrhythmics in CHF  131
Worsening Heart Failure  132
Follow-up of CRT  136


Contents

6.

Syncope

146

Saptarshi Mukhopadhyay, Sulagna Banerjee, Soumitra Kumar
•
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•

7.

Causes of Syncope  146
Cardiac Syncope  147
Key Points in History Taking  149
Differentiation of Seizures from True Syncope  150
Treatment of Syncope  152

Atrial Fibrillation

158

Uttio Gupta, Siddhartha Bandopadhyay, Soumitra Kumar
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8.

Patterns of Atrial Fibrillation  158
Clinical Evaluation of AF Patient  158
Additional Testing  159
Management of Newly Discovered AF  159
Pharmacological Management of Patients
with Recurrent Paroxysmal AF  161

Pharmacological Management of
Patients with Recurrent Persistent AF or Permanent AF  161
Antiarrhythmic Drug Therapy to Maintain Sinus Rhythm
in Patients with Recurrent Paroxysmal or Persistent AF  162
Electrical Cardioversion  162
Stroke Risk in Patients by CHA2DS2 VASc Score   164
Alternatives to Warfarin  166
Surgical Ablation  177
Hybrid Therapy of Atrial Fibrillation  177
Absolute Indications for Lifelong Oral Anticoagulation  180
Management of Antithrombotic Perioperatively  181
A Practical Approach to Bridge Therapy   182
When to Stop Warfarin   183
Management of Anticoagulants in Pregnancy   189

Tachycardias

191

Dipankar Mondal, Soumitra Kumar
• Approach to the Patient with Narrow
QRS Complex Tachycardia  193
• Initial Treatment of AVNRT (AV Nodal Re-entry Tachycardia)  194
• Management of Narrow QRS Tachycardia  195
• Wide Complex Tachycardia  204
• Classification of Ventricular Tachyarrhythmias  206
• Classification of Ventricular Tachyarrhythmias
by Electrocardiography  207
• Pharmacological Aids for the Diagnosis of Wide
QRS Tachycardia  207

• Incessant Ventricular Tachycardia  209

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The Protocol Book for Intensive Care
• Recommendations of Electrophysiological
Testing in Patients with Coronary Heart Disease  210
• Recommendations for Treatment of Ventricular
Arrhythmias in Patients with Prior MI  211
• Ventricular Arrhythmias in Arrhythmogenic
Right Ventricular Cardiomyopathy  212
• Ventricular Arrhythmias in Hypertrophic Cardiomyopathy  213
• Brugada Syndrome  213
• Spectrum of Individuals Who Exhibit Brugada ECG Pattern  214
• Catecholaminergic Polymorphic Ventricular Tachycardia  216
• Digoxin Induced Toxic Fascicular Tachycardia  216
• Ventricular Tachycardia in Normal Heart  216
• Classification of Polymorphic VT (PMVT)  219
• Congenital Long Q-T Syndrome  220
• PMVT Associated with Ischemic Heart Disease  221
• Long Q-T Syndrome—Rx  222
• Short QT Syndrome  222

9.

Cardiopulmonary Resuscitation

225

Sujata Majumder, Amitava Majumder, Soumitra Kumar
•
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•

Adult Basic Life Support  225
Advanced Cardiac Life Support (ACLS)  229
Cardio-cerebral Resuscitation  232
Common Interventions and Medications Used in ACLS   235

10. Percutaneous Coronary Intervention in Acute
Myocardial Infarction

238

Shuvanan Ray
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Why Primary PCI is different from an Elective PCI?  238
Protocol for Primary PCI  240
Choice of Balloon Dilatation Catheters  243
Coronary Stenting  245
Management of Thrombus  245
Management of No-reflow  247
Treatment of No-reflow  247
Prevention of No-reflow  248
Management of Reperfusion Injury  248
Supportive Management in the Cath-Lab  249
Vascular Access Management  250

11. Vascular Emergencies
Shuvanan Ray, Aniket Niyogi, Soumitra Kumar
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Venous Thromboembolic Disorders  255
Investigations for DVT  256
Pulmonary Embolism  262
Aortic Dissection  269

255


Contents
• Management of Pericardial Tamponade   272

• Acute Limb Ischemia  273

12. Acute Cardiac Care in Pediatric Practice

278

Achyut Sarkar
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•

Case 1  278
Case 2  279
Case 3  280
Case 4  282
Case 5  283
Case 6  284
Infant with CHF: Initial “Normal Echo”  287

13. Hypertensive Crisis

289

Saptarshi Mukhopadhyay, Soumitra Kumar
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Caution  291
Management of Specific Situations  294
Hypertensive Emergency in Pregnancy  296
Acute Stroke and Hypertension  299

14. Acid-base Disturbances

304

Joydeep Mukherjee, Debashis Sarkar
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Types of Acid-base Disorder  304
Normal Values  305
Approach to Diagnose Mixed Acid-base Disorders  305
Individual Acid-base Disorders  307

15. Electrolyte Imbalance

317

Sudip Mondal, Basab Bijoy Sarkar
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Hyponatremia  317
Hyponatremia: Treatment  318
Hypernatremia - Plasma (Na+) > 145 mmol  320
Hyperkalemia  322
Hypokalemia  323
Treatment  325
Hypermagnesemia  325
Hypomagnesemia  325
Hypercalcemia  326
Hypocalcemia  327
Hypophosphatemia  328
Hyperphosphatemia  328

16. Management of Adult Severe Acute Asthma
Dinobandhu Naga, Sumit Sen Gupta
• Diagnosis of Asthma  330
• Differential Diagnosis of Acute Asthma  330
• Assessment  331

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The Protocol Book for Intensive Care

17. Management of Acute Exacerbation of COPD

338

Dinobandhu Naga, Sumit Sen Gupta
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Diagnosis—Is it AECOPD?  338
Differential Diagnosis  338
Is it only AECOPD?  338
Noninvasive Ventilation in AECOPD  341
Subsequent Management  341

18. Mechanical Ventilation

344

Sumit Sen Gupta
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Indications for Mechanical Ventilation  344
Invasive Ventilation in Asthma  345
Acute Cardiogenic Pulmonary Edema Protocol  345
Acute Exacerbation of COPD  346
Weaning  346
Complications of Ventilation  348
Barotrauma (Pneumothorax and Pneumomediastinum)  353

19. Acute Respiratory Distress Syndrome/
Acute Lung Injury

359

Sumit Sen Gupta
• Causes of Acute Respiratory Distress Syndrome/
Acute Lung Injury  359

20. Management of Upper Gastrointestinal
Bleeding

366

Sweety Trivedi, Debashis Datta
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•

History  366
Clinical Examination  366
Causes of Upper GI Bleeding  366
Initial Risk Assessment and Triage  367
Management  369
Obscure GI Bleeding   374

21. Stroke
Dipankar Mondal, Jayanta Roy
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Classification of Ischemic Stroke  377
Intracerebral Hemorrhage  378
Prehospital Assessment of Stroke  378

Emergency Assessment of Acute Stroke  379
Management of Acute Ischemic Stroke  379
Guidelines for Use of rtPA in Acute Ischemic Stroke  380
Management of Intracerebral Hemorrhage  387
Algorithm for Management of Cerebellar Hemorrhage  390

377


Contents

22. Acute Kidney Injury

400

Sweety Trivedi, Arup Ratan Dutta
• Diagnosis and Management Protocol  400

23. Endocrine Emergencies

415

Sudipto Chatterjee, Sujoy Ghosh
• Adrenal Crisis  415
• Pituitary Apoplexy  417

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Pheochromocytoma and Hypertensive Crisis  419
Thyroid Storm/Thyrotoxic Crisis  420
Myxedema Coma  422
Diabetic Emergencies  424
Management Ideally in ICU  432
Hypoglycemia  433
Hyperglycemia: Its Impact on Infections in the ICU Patient   436
Complications of Hyperglycemia in the ICU Patient  437
Acute Hypercalcemia  437
Hypocalcemia  438

24. Rheumatological Emergencies

440

Arghya Chattopadhyay, Samar Ranjan Pal
• Approach to a Rheumatologic Emergency  441

25. Antimicrobial Therapy Including Management
of Septic Shock

448

Susanta Chakraborty, Yashesh Paliwal
• General Principles of Antimicrobial Therapy  448
• Sepsis and Septic Shock  450
• Resuscitation and Hemodynamic Support of the
Septic Patient   455
• Evaluation of Sources of Sepsis  461
• Source Control in Sepsis  461
• Antifungal Agents  466
• Tropical Infections in the ICU  467

26. Cardiac Surgery: Postoperative Care

473

Kayapanda M Mandana
• Postoperative Care  473
• Department of Cardiac Surgery  474
• Cardiac Output and its Determinants  477

27. Drugs Used in Cardiovascular Emergency
Soumitra Kumar
• Adenosine  482
• Amiodarone  482

482

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Alprostadil (Prostaglandin E1)  483
Atropine  484
Beta-blockers for Acute Indications  484

Digoxin for Acute Indications  485
Diltiazem (IV)  486
Dobutamine  486
Dopamine  487
Epinephrine (Adrenaline)  487
Fibrinolytic Agents  488
GPIIb/IIIa Inhibitors  488
Heparin (Unfractionated and Low Molecular Weight Heparin)  488
Isoprenaline (Isoproterenol)  488
Levosimendan  488
Lignocaine (Lidocaine)  489
Magnesium Sulfate  490
Milrinone  490
Morphine Sulfate  490
Nitroglycerin (Acute)  491
Nitroprusside  491
Norepinephrine  492
Phenoxybenzamine  493
Phenylephrine  493
Verapamil (Intravenous)  493
Vasopressin  494

Index

509


Acute ST-Elevation
Myocardial Infarction

chapter

1

Subhasis Chakraborty, Soumitra Kumar

Third Universal Definition of Myocardial Infarction
(Joint ESC/ACCF/AHA/WHF Task Force 2012)
Definition of Myocardial Infarction
Criteria for Acute Myocardial Infarction
The term acute myocardial infarction (MI) should be used when there is
evidence of myocardial necrosis in a clinical setting consistent with acute
myocardial ischemia. Under these conditions any one of the following criteria
meets the diagnosis for MI:
Flow chart 1.1  Classification of acute coronary syndrome

(Abbreviation: LBBB: Left bundle branch block; NSTEACS: Non-ST segment elevation
acute coronary syndromes; QMI: Q-wave myocardial infarction; NQMI: Non-Qwave myocardial infarction; MI: Myocardial infarction; STEMI: ST segment elevation
myocardial infarction; NSTEMI: Non-ST segment elevation myocardial infarction)


2

The Protocol Book for Intensive Care

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Detection of rise and/or fall of cardiac biomarker values [preferably cardiac
troponin (cTn)] with at least one value above the 99th percentile upper
reference limit (URL) and with at least one of the following:
–Symptoms of ischemia
–
New or presumed new significant ST-segment-T wave (ST-T) changes
or new left bundle branch block (LBBB)
–Development of pathological Q-waves in the echocardiogram (ECG)
–
Imaging evidence of new loss of viable myocardium or new regional
wall motion abnormality
–Identification of an intracoronary thrombus by angiography or autopsy
Cardiac death with symptoms suggestive of myocardial ischemia and
presumed new ischemic ECG changes, or new LBBB, but death occurred
before cardiac biomarkers were obtained, or before cardiac biomarker
values would be increased.

Percutaneous coronary intervention (PCI) related MI is arbitrarily defined
by elevation of cTn values (> 5 × 99th percentile URL) in patients with
normal baseline values (≤ 99th percentile URL) or a rise of cTn values >20%
if the baseline values are elevated and are stable or falling. In addition
either:
i. Symptoms suggestive of myocardial ischemia, or
ii. New ischemic ECG changes, or
iii. Angiographic findings consistent with a procedural complication,
or
iv. Imaging demonstration of new loss of viable myocardium or new
regional wall motion abnormality are required.
Stent thrombosis associated with MI when detected by coronary
angiography or autopsy in the setting of myocardial ischemia and with a
rise and/or fall of cardiac biomarker values with at least one value above
the 99th percentile URL.
Coronary artery bypass grafting (CABG) related MI is arbitrarily defined
by elevation of cardiac biomarker values (>10 × 99th percentile URL)
in patients with normal baseline cTn values (≤99th percentile URL).
In addition, either (i) new pathological Q-waves or new LBBB, or
(ii) antiographically documented new graft or new native coronary artery
occlusion, or (iii) imaging evidence of new loss of viable myocardium or
new regional wall motion abnormality.

Criteria for Prior Myocardial Infarction
Any one of the following criteria meets the diagnosis for prior MI:
• Pathological Q-waves with or without symptoms in the absence of nonischemic causes
• Imaging evidence of a region of loss of viable myocardium that is thinned
and fails to contract, in the absence of a nonischemic cause
• Pathological findings of a prior MI.

Acute ST-Elevation Myocardial Infarction

Classification of Myocardial Infarction
Type I: Spontaneous Myocardial Infarction
Spontaneous myocardial infarction related to atherosclerotic plaque rupture,
ulceration, fissuring, erosion, or dissection with resulting intraluminal
thrombus in one or more of the coronary arteries leading to decreased
myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis.
The patient may have underlying severe coronary artery disease (CAD) but
on occasion nonobstructive or no CAD.

Type 2: Myocardial Infarction Secondary to an Ischemic Imbalance
In instances of myocardial injury with necrosis where a condition other than
CAD contributes to an imbalance between myocardial oxygen supply and/
or demand, e.g. coronary endothelial dysfunction, coronary artery spasm,
coronary embolism, tachy-/brady-arrhythmias, anemia, respiratory failure,
hypotension, and hypertension with or without left ventricular hypertrophy
(LVH).
Type 3: Myocardial Infarction Resulting in Death when Biomarker
Values are Available
Cardiac death with symptoms suggestive of myocardial ischemia and
presumed new ischemic ECG changes or new LBBB, but death occurring
before blood samples could be obtained, before cardiac biomarker could
rise, or in rare cases, cardiac biomarkers were not collected.
Type 4a: Myocardial Infarction Related to Percutaneous Coronary
Intervention
Myocardial infarction associated with percutaneous coronary intervention
(PCI) is arbitrarily defined by elevation of cTn values >5 × 99th percentile URL
in patients with normal baseline values (≤99th percentile URL) or a rise of cTn

values >20%, if the baseline values are elevated and are stable or falling. In
addition, either:
i. Symptoms suggestive of myocardial ischemia, or
ii. New ischemic ECG changes or new LBBB, or
iii. Angiographic loss of patency of a major coronary artery or a side branch
or persistent slow- or no-flow or embolization, or
iv. Imaging demonstration of new loss of viable myocardium or new
regional wall motion abormality are required.

Type 4b: Myocardial Infarction Related to Stent Thrombosis
Myocardial infarction associated with stent thrombosis is detected by
coronary angiography or autopsy in the setting of myocardial ischemia and
with a rise and/or fall of cardiac biomarkers values with at least one value
above the 99th percentile URL.

3


4

The Protocol Book for Intensive Care
Flow chart 1.2  Initial hospital management and selection of reperfusion therapy