Diagnosis of nonhemorrhagic infarct can be made in 36% (95% confidence interval [CI], 29 to 43) of patients with a high level of accuracy (100% in the external validity study, which gives a 95% CI of 93 to 100). Thus, 43% (95% CI, 36 to 50) of patients with a nonhemorrhagic infarct could receive a bedside diagnosis. The score is simple and can be calculated from information available to all physicians.
Heart disease is prevalent in current patient population at an increasing level. Some of these patients have had interventions such as stent placements to improve quality of life and are started on antiplatelet therapy for a definite period of time or indefinitely based on their risk factors, comorbidities or type of stents placed. When these patients present to the hospital with major trauma, the surgical and anesthetic management threads a delicate line between protection of the stents and preventing life-threatening bleeding. We present a 66-year-old patient on dual antiplatelet therapy (DAPT) admitted for femur fracture with arterial injury after an auto-pedestrian collision. He was in hemorrhagic shock. A decision was made to stop his DAPT and taken to the operating room for intramedullary nailing of the left femur the next day. He tolerated the procedure with one episode of intraoperative hypotension responsive to vasoactive agents. He received four units of packed red blood cells (PRBCs) and two units of fresh frozen plasma (FFP) but suffered a perioperative Non-ST segment elevation myocardial infarction (NSTEMI). He was taken to cardiac catheterization lab the next day and revascularized. This was a high-risk patient with significant bleeding from the accident potentially justifying the need to stop the DAPT; however, this action may have contributed to his myocardial infarction. Other considerations include a preoperative/posttrauma MI that was not diagnosed prior to surgery.
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