ACLS EP cardiac1

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Learning Station 1

CardiovascularEmergencies Case 11999 American Heart Association


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Acknowledgments

Janice Ritchie Saia, RN, EMT-P, of St. Petersburg,

FL, first developed these materials. She has

generously donated her work to the AHA. Steve Anderson, MD, of Auburn, WA, provided

helpful scripts for this case.

Mary Fran Hazinski, RN, MSN, and John Field, MD,

provided many refinements during final review. We

appreciate the hard work of each of these people.

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Learning Objectives

Apply the Five Quadrads Approach to patients withcomplex cardiovascular emergencies

Discuss, assess, and manage acute MI

Identify ECG changes consistent with

Myocardial ischemia/infarction

Location of infarct

Infarct-related coronary artery

After completing this learning station you should beable to


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Case History

Mr. B. Skimmer, age 45, complains of chest

discomfort, nausea, severe fatigue

Past Med Hx: hypertension (poor control),

2 to 3 pack/day cigarettes, high stress job

Refuses coworkers assistance

States: Its just the flu

Goes to break room to rest


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Case Progression

One hour later a coworker finds Mr. Skimmer

lethargic, pale, profusely diaphoretic

Coworker offers to drive Mr. Skimmer to ED,

only 3 minutes away

Should M r. Skimmer go to ED byALS ambulance?

WHY?


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Case Progression

Mr. Skimmer arrives at your ED with O2

via NRB; IV LR @ KVO

Received MONA in field; BP dropped

alarmingly, near syncope

Triaged as urgent

Placed in ED critical care bed

What should youas the key

ACLS providerdo first?


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The Five Quadrads Approachto ACLS-EP

1. Primary ABCD Survey

2. Secondary ABCD Survey

3. OxygenIVmonitorfluids

4. TempBPHRRR

5. Tanktankpumprate


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AssessmentF ive Quadrads Approach

Primary Survey

Airway: adequate

Breathing: present with equal chest rise,

adequate tidal volume

Circulation: pulse present carotid and

radial

Defibrillation: not needed


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Secondary Survey

Airway: adequate

Breathing: lung sounds clearOxygen sat 97% with NRB

Circulation: sinus rhythm

2-mm ST-elevation in leads II, III, aVF

BP 126/84 mm Hg; IV access present

Differential diagnosis: AMI. Others?



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OxygenIVmonitorfluids

Started by EMS; continued in ED

Vital signs

T=99.1F, BP=126/84 mm Hg,HR=74 bpm, RR=28/min

Tanktankpumprate Consider sources of hemodynamic

compromise



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What would you like to doNOW?


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Immediate ED Assessments

O2IVmonitorfluids (done by EMS)

Grade chest pain: character, intensity

H & P: focus on thrombolytic screening

VSfrequent recordings

Multilead ECG? (12, 15, or 22 leads)

First set serum markers Electrolytes; coagulation studies

Portable chest film


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12-Lead ECG Findings

1. ST-segment

elevationor new LBBB

strongly suspicious

for injury

2. ST-segment

depression/dynamicT-wave inversion;

strongly suspicious

for ischemia

3. Nondiagnostic

or normal ECG;chest pain strongly

suspicious for

ischemia


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Localizing Ischemia or Injury

aVF inferiorIII inferior V3 anterior V6 lateral

aVL lateralII inferior V2 septal V5 lateral

aVRI lateral V1 septal V4 anterior


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ECG 1: Interpretation?


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ECG 1: elevated ST segments; inferior leads (II, III, aVF);ST depression: precordial leads V2-V5; lateral leads I, aVL

Suspect occlusionr ight coronary artery


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Coronary Artery Distribution

Left

Septal wall of LV

Anterior and lateral

walls of LV

Inferior wall LV

(10%)

Both bundle branches

Right

Inferior wall of LV

Posterior wall of

LV (90%)

AV node (90%)

Right ventricle


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Cardiac Anatomy in Relationto Coronary Artery

Rightcoronary

artery

Septal wallV1-V2

Left anteriordescending artery

Anterior wallV3-V4

Left main

coronaryartery

Circumflexartery

Lateral wallI, aVL, V5-V6


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NOTE 1: Inferior wallsupplied by either the right

(85% to 90% of people) or

left coronary artery.

NOTE 2: If there is acute

injury in inferior leads(II, III, aVF), unknown

whether left or right

coronary artery is blocked.

NOTE 3: KEYyou

must obtain a RIGHT-SIDED ECG at once.

Posterior View of the Heart

HOW TO GET

RIGHT-SIDED ECG?

Leads II, III, aVF

(from leftcoronaryartery)

Lateral wall

Inferior wall

Right coronaryartery

Posteriordescending

artery

Posteriorwall

Circumflexartery


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Lead Placement for aRight-sided ECG

V1

V3R

V4RV5

RV6R

V2


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Right Ventricular Infarction

Inferior lead changes RV infarction?

Use lead V4R (ST elevation >1 mm)

Clinical significance:

Increased mortality

Preload dependence

Vasodilators may cause severe hypotension

What is management of RV infarction?


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How would you managethis patient?


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Nitroglycerin

Mechanism of action

Indications

Administration

Cautions


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Narcotic Analgesia

Morphine sulfatereadily available

Effects

Relieves pain and anxiety Reduces myocardial oxygen needs

Administration

2 to 5 mg IV q 5 minutes (slow) Caution

N & V, low BP, respiratory depression


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Aspirin

Aspirin inhibits platelet cyclo-oxygenase

decreases thromboxane A2 production

Aspirin benefits

Reduces overall mortality in AMI

Reduces incidence of nonfatal reinfarction

Dose: 160 to 325 mg PO ASAP


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-BlockersMechanism of action

Block catecholamines from binding to

-adrenergic receptors

Nonselective and cardioselective

Reduce HR, BP, myocardial

contractility, and oxygen consumption

Decrease AV nodal conduction


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-Blockers

Severe CHF/PE Hypotension

(SBP


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Heparin

Mechanism of action

Indirect thrombin inhibitor (with AT III)

Indications

PTCA or CABG

With fibrin-specific lytics (eg, alteplase)

High risk for systemic emboli Large anterior MI, atrial fib, LV thrombus


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ACE Inhibitors

Mechanism of action

Lower BP by inhibiting angiotensin-

converting enzyme (ACE) Attenuate LV remodeling by inhibiting

tissue ACE

Lower peripheral vascular resistance byvasodilatation mechanism

Reduce mortality from AMI

P t i d


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Potassium andMagnesium Sulfate

Potassium deficiency but not magnesium

deficiency associated with arrhythmias,

sudden death Recent studies suggest no reduction in AMI

mortality with magnesium administration


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I s M r. Skimmer a candidate for

thrombolysis?

What information do you need to

make this decision?

Case Progression

C t i di ti t


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Contraindications toThrombolytic Therapy

Previous hemorrhagicstroke any time

Other stroke, CVAwithin 1 year; ICneoplasm

Active internal bleeding(not menses)

Suspected aorticdissection

Severe uncontrolledhypertension (>180/110)

Current use ofanticoagulants

Recent trauma (2 to 4 wk);major surgery


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Percutaneous TransluminalCoronary Angioplasty

Direct treatment

Mechanical reperfusion of infarct-related

coronary artery

Best outcome achieved for patients with AMI

plus cardiogenic shock


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Case Progression

Mr. Skimmer received oxygen, aspirin,

metoprolol IV, and heparin

No nitroglycerin or morphine in ED

Now pain-free; stable BP; O2 sat 98%

Reperfusion therapy: t-PA + heparin


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Case Progression

Mr. Skimmer transferred to CCU

Uneventful night

No chest pain or shortness of breathNo arrhythmias

Treatment:

Oxygen at 2 L/min Heparin, ACE inhibitors, -blockers

Nitroglycerin not given


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The next day

In CCU Mr. Skimmer begins complaining of

Chest pressure

Light-headedness

Increasing intensity over 20 minutes

What should you do now?


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The Five Quadrads

Primary Survey: no CPR or defibrillation indicated

Secondary Survey

Airway: adequate Breathing: dyspnea, + JVD, rales in lower third

of lung fields

Circulation: diaphoretic; peripheralpulses weak

Differential diagnosis: obtain 12-lead ECG


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The Five Quadrads

OxygenIVmonitorfluids

Vital signs

BP 76/64 mm Hg, HR 80 bpm, RR 32/min

Tanktankpumprate

What is the nature of the problem?

Check 12-lead ECG


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SR with ST-segment elevation in leads II, III,

aVF; reciprocal changes throughout

T t t C id ti


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Treatment ConsiderationsAcute Pulmonary Edema With Hypotension

Oxygen

Furosemide Avoid, if possible,

nitroglycerin or

morphine, especially if

patient is hypotensive

Dopamine

Dobutamine PEEP (caution)

CPAP

First-line Actions Second-line Actions


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Treatment Considerations

Priority actions

Thrombolytic therapy (repeat t-PA)

Coronary angiography and angioplasty or

emergency surgical revascularization

Intra-aortic balloon pump


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Differential Diagnosis

Reocclusion RCA; infarct extension

Mechanical complications (eg, mitral

regurgitation, VSD)

Low cardiac output

Pulmonary embolus


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Case Progression

Pulmonary edema persists

Cardiogenic shock continues

Patient remains hypotensive

ECG: ST elevation consistent with reocclusion

Strategy: coronary angiography

Outcome: angioplasty and stent proximal RCA


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Summary

Five Quadrads Layered approach; guides actions and thinking

Apply whenever you arrive at an emergency setting Goals of coronary syndrome treatment

Early reperfusion therapy (myocardial salvage) whenindicated

Reduce morbidity and mortality through adjunctive agents(ASA, -blockers, ACE, statins)

Recognize and anticipate serious early complications:unstable post-MI angina, CHF, late VT/VF


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Summary

A focused history and assessment facilitates

early initiation of reperfusion therapy

The 12-lead ECG may be used to localizeinjury and guide therapy

Serum markers may be used to triage patients

and assess prognosis


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Summary

Several treatments help patients by

Decreasing mortality

Limiting extent of infarction Limiting incidence of reinfarction

Knowledge of complicated AMIs enables us to

Anticipate complications Care for patients with complex acute coronary

syndromes

ACLS EP cardiac1

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