Cardio Exam 4 (ACS, Bradycardia, Tachy, Stroke, Pregnancy, Opioids)

Acute Coronary Syndromes

All cases will start out with the patient receiving a 12 lead EKG to classify patient into 1 of 3 EKGs

- ST-segment elevation suggesting current injury

- ST-segment depression suggesting ischemia

- Nondiagnostic or normal EKG

Key Components of ACS

Identification, assessment and triage of acute ischemic chest discomfort

Initial treatment of possible ACS

Emphasis on early reperfusion of the patient with ACS/STEMI

Early Treatment Priorities ACS

Rapid Reperfusion

Relief of ischemic pain

Treatment of early life-threatening complications

Drugs used to relieve discomfort of ACS:

Oxygen

Aspirin

Nitroglycerin

Morphine

Fibrinolytic Therapy

Heparin

What arrhythmia most likely to develop during first 4 hours after onset of symptoms?

VF

Program Development Needed in Communities for ACS to:

Recognize symptoms of ACS

Activation of EMS

Early CPR

Early Defibrillation

Public AEDs

Coordinated System between EMS, ED, and Cardiac Team

Primary Goals of Therapy for ACS

Identification of patients with STEMI and triage for reperfusion

Relief of ischemic chest pain

Prevention of MACE: (Major Adverse Coronary Event)

Treatment of acute, life-threatening complications of ACS, such as VF/Pulseless VT, Symptomatic Bradycardias, and unstable tachycardias

Symptoms suggestive of ischemia or infarction?

Chest pain is number #1

Pressure or fullness in center of chest

Shoulder, neck, arm, jaw pain

Pain in back between shoulder blades

Light-headedness, dizziness, fainting, sweating, nausea, vomiting

Sudden SOB

Obtain 12 lead EKG -

Providing EKG while in route to hospital along with interpretation will help mobilize the hospitals cardiac team to respond to STEMI

STEMI

ST Elevation

High Risk NSTEMI

ST depression or T wave inverse

Minutes after heart attack starts:

ST shifts

Hours later of Heart attack

ST shifted

R dropping

Q appears to be noticeable

1-2 days after Heart Attack

T inverted

Q goes lower

Several days after Heart Attack

ST Normal

T inverted

Weeks after the attack

ST and T normal

Q no change

Intermediate Low Risk

Normal EKG

Clot Busters Examples are

are rtPA (Recombinant Tissue Plasminogen Activator) , reteplase, tenecteplase, and streptokinase

Fibrinolytic Therapy

Should be administered within 30 minutes of patient's arrival to ER.

If no contraindications - F.T. should be administered within 12 hours of onset of symptoms. Not recommended for those over 12 hours. Do NOT give in those greater that 24 hours after

Percutaneous coronary intervention (PCI) is?

Stent Placement is most common

Used in those that fail to reperfuse with fibrinolytics and if it can be done in less than 90 minutes from first medical contact

Which is superior PCI or fibrinolytic therapy?

PCI

- Transfer to a PCI facility may be more important that to a fibrinolytic only facility

Other Treatments for ACS

IV nitro

Heparin

B-Blockers

ACE Inhibitors

Statins

Defibrillation:

Shock used during a code situation

Cardioversion:

Synchronized shock that is conducted only during the R wave of the QRS. Usually planned. (SVT)

Transcutaneous Pacing

Delivers an electrical stimulus for electrical depolarization and cardiac contraction (during bradycardia or blocks)

Symptomatic Bradycardia:

HR < 50/min

Heart rate is slow

Patient symptoms for Bradycardia

Chest pain

SOB

Decreased LOC

Weakness/fatigue

Dizziness

Syncope

- The symptoms are due to the slow rate

What to do for a stable bradycardia?

Monitor

What to do for an unstable bradycardia?

1. Atropine first

2. Dopamine

3. Epi Drip

4. Pacing

Signs of Bradycardia

Hypotension

Sudden Drop in BP

Diaphoresis

CHF

Pulmonary Edema

PVCs

Persistent Bradycardia causing:

Hypotension?

Acutely altered mental status?

Signs of shock?

Ischemic chest discomfort?

Acute heart failure?

Atropine

1 mg bolus ; max 3 mg

Dopamine

5-20 mcg/kg

Epinephrine IV infusion

2-10 mcg per minute infusion. Titrate to patient response.

Transcutaneous Pacing is?

Delivers an electrical stimulus for electrical depolarization and cardiac contraction (during bradycardia or blocks)

- Most defibrillators now have a pacing device

- Conscious patients will need pain control

Pacing impulses delivered to the heart through:

the skin with cutaneous electrodes

Indications for use include of Pacing is:

symptomatic Bradycardia that is unstable

Contraindicated of Pacing in:

severe hypothermia and asystole

Tachycardia

HR >100

Answer these questions when determining Tachy:

Are symptoms present or absent

Is the patient stable or unstable

Is the QRS narrow or wide

Is the rhythm regular or irregular

Is the QRS monomorphic or polymorphic

Stable Tachy

HR >100

No significant signs or symptoms

Underlying cardiac abnormality that generates the rhythm

If the patient is stable/non symptomatic tachy, do not:

Do not cardiovert

If shock is given, it could actually increase the HR in a stable tachy.

Unstable Tachy

Tachyarrhythmias - HR > 100/min

Symptomatic Tachyarrhythmia

HR >100/min with signs and symptoms due to the rapid HR

Beating so fast that CO is reduced can be caused by

pulmonary edema, coronary ischemia, reduced blood flow

Beating ineffectively so that coordination between the atrium and ventricles reduces:

CO

Symptoms and Signs of Unstable Tachy

Hypotension

Acutely Altered Mental Status

Signs of Shock

Ischemic Chest Discomfort

Acute Heart Failure

Must be able to recognize 2 key things quickly for unstable tachy:

1. Patient is significantly symptomatic or unstable

2. Signs and symptoms are caused by the tachy

What to do for a Stable Tachy?

Vagal maneuver

Adenosine

Beta-blockers

Wide QRS >12 seconds indicate for:

Adenosine (if regular)

Adenosine

1st: 6 mg rapid IV push

2nd: 12 mg

Procainamide

20-50 mg/min

Amiodarone

150 mg

Prior to a Cardioversion, what do you do?

Get IV access and sedate the patient

Synchronized Cardioversion

uses a sensor to deliver a shock that is synchronized with a peak of a QRS complex. Press the SHOCK button, delay may occur until the defibrillator catches a R wave in a QRS. This avoids shock during repolarization (T wave) which could lead to Vfib.

When is shock delivered for synchronized cardioversion?

When it catches the R wave of QRS

Defibrillation Shock

Electrical shock will be delivered as soon as the operator pushes the SHOCK button. The shock will fall randomly anywhere in the cardiac cycle. They should use higher energy levels than synchronized cardioversion

When is shock delivered for Defib?

Delivered right as soon as operator pushes SHOCK, it'll fall anywhere in cardiac cycle

Potential Problems with Synchronization:

- If the R waves have low amplitude, the sensor may not be able to identify and will not deliver the shock

- Some cardioversion machines will not synchronize through the quick paddles which some rescuers may not realize

- Synchronization can take extra time (attaching electrodes, being unfamiliar with the equipment, catching the R wave)

When to Use Synchronized Cardioversion?

Unstable SVT

Unstable AFib

Unstable AFlutter

Unstable regular monomorphic tachy with pulse

When to use Defibrillation/Shock?

Pt is Vfib or Pulseless VTach

Pre-arrest deterioration when a delay in converting could result in arrest

Energy level Unstable AFib

200J

Energy level Unstable Monomorphic VT

100J

Energy level Unstable SVT

200J

Energy level Unstable Polymorphic VT

Defibrillation high dose shock (Treat as VF)

Ischemic Strokes

87% of strokes - usually caused by an occlusion of an artery to a region of the brain

Hemorrhagic Stroke

13% of strokes - blood vessel in the brain suddenly ruptures into the surrounding tissue

The goal of stroke care is

to minimize brain injury and maximize the patient's recovery

Stroke Chain of Survival

Rapid recognition and reaction to stroke warning signs

Rapid EMS dispatch

Rapid EMS system transport and prearrival notification to receiving hospital

Rapid diagnosis and treatment in the hospital.

The 8 D's of Stroke Care

Detection - Recognition of stroke

Dispatch - Early Activation

Delivery - Rapid EMS identification and transport

Door - Triage to stroke center

Data - Rapid evaluation within the ER

Decision - Stroke expertise & therapy selection

Drug/Device - Fibrinolytic or Endovascular

Disposition - Admission to stroke unit

Critical Time Intervals: 10 Mins

Immediate General Assessment

Critical Time Intervals: 20 Mins

Immediate Neuro Assessment & CT

Critical Time Intervals: 45 Mins

Interp of CT

Critical Time Intervals: 60 Mins

Admin of Fibrinolytic Therapy timed from ER arrival

Critical Time Intervals: 3 hours

Admin of Fibrinolytic Therapy timed from onset of symptoms

Critical Time Intervals: 6 hours

Admin of Endovascular Therapy timed from onset of symptoms

Warning Signs & Symptoms of Stroke:

Sudden weakness or numbness of face, arm, leg (doesn't have to be all 3)

Sudden confusion

Trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking

Dizziness or loss of balance or coordination

Sudden severe headache with no known cause

If stroke is suspected:

activate EMS immediately, TIME IS CRITICAL!

Cincinnati Prehospital Stroke Scale

Facial droop, arm drift, abnormal speech

Facial Droop

have patient smile to show teeth

Abnormal - one side of face does not move as well as the other

Arm Drift

Close eyes, extend both arms straight out, palms up for 10 seconds

Abnormal - One arm does not move or drifts down compared with the other arm

Abnormal speech

Patient say "you can't teach an old dog new tricks"

Abnormal - Patient slurs words, uses wrong words, or unable to speak

If any 1 of the 3 signs:

is abnormal, the probability of a stroke is 72%

Fibrinolytic Therapy Candidate

Less than 3 hours of onset of symptoms

Ischemic stroke causing deficit

Older than 18 years

If patient accepts for Fibrinolytic Therapy:

Start rtPA therapy (alteplase)

Do not give anticoagulants for 24 hours

Not a Fibrinolytic Therapy Candidate

Head Trauma

Intracranial Hemorrhage

Elevated BP Systolic > 185 or Diastolic > 110

Active bleeding

Low platelets

Use of Heparin within 48 hours

Extended rtPA Window

3-4.5 hours

- Although outcomes are not as good, evidence shows that some stroke patients may benefit from receiving rtPA even if the 3 hour mark has passed, up to 4.5 hours.

Candidate for Extended rtPA Window:

ischemic stroke is present

onset of symptoms is 3-4.5 hours

Non Candidate for Extended rtPA Window:

Age is >80 years

Severe stroke

Taking oral anticoagulants

History of both diabetes and prior stroke

General Stroke Care

Stroke Pathway

- Admit to stroke unit and monitor BP and Neuro status

Support Airway, Breathing, Circulation

Monitor Glucose (insulin for Glucose > 185)

Monitor Temp

Dysphagia Screening

Monitor Adverse reactions to fibrinolytic therapy

Transfer to ICU if needed

Fibrinolytic Therapy Adverse Effects

Hypertension

Seizures

Intracranial Hemorrhage (High ICP)

Other bleeding complications

Hypotension from blood loss

Hypertension Management

Manage hypertension with medications such as Labetalol, Nicardipine, etc.

Goal is to keep BP below 185/110 so that patient is a candidate for rtPA

Cardiac Arrest in Pregnancy

Continuous lateral uterine displacement to move the baby to left side to help with CPR

Cardiac Arrest wtih Opioids

Give narcan

Make sure the patient has a patent airway