Advanced Cardiovascular Life Unstable angina; and Support Course - PDF document

6/17/2016 Advanced Advanced Life Support Life Support Acute Coronary Syndrome (ACS) includes: Advanced Cardiovascular Life • Unstable angina; and Support Course • Acute Myocardial Infarction (AMI)-** AMI is associated with STEMI or NSTEMI and treatment is likely to differ upon diagnosis** Acute Coronary Syndrome (ACS) Overview Advanced Advanced Life Support Life Support Signs and symptoms associated with ACS, including Acute Primary goals of therapy for patients with ACS: Myocardial Infarction (AMI): • Reduce the amount of myocardial necrosis that occurs in • Uncomfortable chest pressure, fullness, squeezing, or pain in the center of the patients with AMI; chest; • Pain spreading to the shoulders, neck, arms or jaw or pain in the back or • Prevent Major Adverse Cardiac Events (MACE): Death, Non- between the shoulder blades; fatal MI, and the need for revascularization; and • Chest discomfort with lightheadedness, fainting, sweating and/or nausea; and • Shortness of breath with or without chest discomfort • Treat acute, life-threatening complications such as ventricular fibrillation, pulseless ventricular tachycardia, • Feeling of impending doom symptomatic/unstable bradycardia and symptomatic/unstable tachycardia; 1

6/17/2016 Advanced Advanced Life Support Life Support Underlying, life-threatening causes of chest discomfort Immediate Assessment and Treatment for ACS include: include: • Oxygen therapy, maintaining 02 Saturation of 94%-99%; • Aortic dissection; • ECG Monitor; • Aspirin, Nitroglycerine and Morphine if indicated; • Pulmonary embolism; • 12-lead ECG with interpretation; • Perform focused history and physical exam; • Acute pericarditis with effusion and tamponade; and • Assess vital signs; • Establish IV/IO access; and • Tension pneumothorax • Obtain initial cardiac markers and portable x-ray Advanced Advanced Life Support Life Support Diagnosis-specific Treatment : Inpatient STEMI • Associated with higher mortality STEMI • More frequently missed • Inpatients have more atypical s/sx due to their – Begin adjunctive therapies with no delay in reperfusion comorbidities and medications (i.e. opioids) • At UNCH, any EKG that reads “ACUTE MI”, “STEMI”, or – If time from onset is <12 hrs, initiate reperfusion strategies: “Infarct, Possible” must be read by a cardiology fellow or • Door-to-balloon inflation (PCI) goal of 90 minutes attending. • Door-to-needle (fibrinolysis) goal of 30 minutes – Activate a Cardiac Response Team (direct page in ICUs, activated by Rapid Response Consult Nurse in stepdowns) 2

6/17/2016 Advanced Advanced Life Support Life Support Prehospital ROSC – Potential STEMI Non-STEMI but has ST depression or T-Wave Inversion • Any out-of-hospital cardiac arrest patient who achieves – Assess if Troponin is elevated or patient is high risk; and ROSC must be transported to a facility that can perform an emergent PCI (percutaneous coronary intervention). – Consider early invasive strategy if: • Refractory ischemic chest discomfort • This allows for STEMI treatment to be quickly initiated if • Recurrent ST deviation a STEMI was the cause of the initial arrest. • Ventricular Tachycardia • Hemodynamic instability • Reperfusion therapy reduces mortality and saves heart • Signs of heart failure muscle. The shorter the time the greater the benefit. Advanced Advanced Life Support Life Support ACS Contraindication to Fibrinolytic therapy: • Systolic BP > 180-200 or diastolic BP > 100-110; • Right vs. left arm systolic BP difference > 15 mm Hg; – Consider admission to chest pain unit or appropriate bed and continue: • History of CNS disease; • Significant closed head/ facial trauma within 3 weeks; • Serial cardiac markers; • Stroke > 3 hours or < 3 months; • Recent ( 2-4 weeks ) major trauma, surgery, GI/GU bleed; • Repeat 12-lead ECG/ST-segment monitoring; and • History of intracranial hemorrhage; • Pregnant; or • Non-invasive diagnostic testing • Serious systemic disease 3

6/17/2016 Advanced Advanced Life Support Life Support ACS Initial Treatment / Medication Review High Risk for Fibrinolytic Therapy Nitroglycerine – 0.4 mg Sublingual tablet or spray • Heart rate > 100/min AND systolic BP < 100 mm Hg; – Contraindicated if Viagra/Revatio (Sildenafil Citrate), or Levitra (Vardenafil Hydrochloride) taken within the past 24 hours or • Pulmonary edema; Cialis/Adcirca (Tadalafil) taken with the past 48 hours – Should be administered following 12-lead ECG with • Signs of shock; interpretation, if possible – Contraindicated if the systolic BP < 90 mm Hg • Cardiac Arrest; or Aspirin – 160-325 mg PO • Patient meets any previously mentioned contraindications to – Should be administered upon onset of symptoms and may be fibrinolytic therapy combined with prescribed blood thinner medications Advanced Advanced Life Support Life Support Oxygen Advanced Cardiovascular Life – Begin at 4 lpm and titrate, maintaining oxygen Support Course saturation of > 90% or to relieve shortness of breath Morphine – Dosing is 2 – 4 mg IV for pain management Suspected Stroke Overview 4

6/17/2016 Advanced Advanced Life Support Life Support Signs and symptoms associated with Stroke: REMEMBER TIME IS BRAIN – do not • Altered Mental Status (confusion or just the inability to say what they want to say although they have total understanding); delay calling 911. • Weakness or paralysis on part of or all of one side of the body; EMS would rather respond and not transport if there is • Speech abnormalities; really no problem than have a delayed response!!!! • Visual disturbances; • Swallowing/choking potential; and • Headache Advanced Advanced Life Support Life Support REMEMBER TIME IS BRAIN The 8 D’s of Stroke Care Detection – rapid recognition of symptoms • EMS - rapid identification and assessment and rapid transport to a Dispatch – stroke facility Call 911 early Delivery – Rapid EMS identification and transport • The goal for EMS is to be off the scene, transporting to a stroke Door – facility within 10 minutes of arrival Get to an appropriate stroke center Data – Rapid triage within ED Decision – Stroke expertise and therapy • In-hospital – rapid determination of fibrinolytic eligibility Drug – Fibrinolytic therapy • The goal for the hospital is door (arrival at the hospital) to starting Disposition – Rapid admission to stroke unit or CCU fibrinolytic therapy is 60 minutes. 5

6/17/2016 Advanced Advanced Life Support Life Support Stroke Assessment Cincinnati Prehospital Stroke Scale Advanced Advanced Life Support Life Support • Time from arrival at hospital to the CT being run is 25 minutes Types of Stroke: with the CT being run and interpreted in 45 minutes of arrival at the hospital Ischemic – 87% of • The CT must be completed and read to determine which type all strokes of stroke • Hemorrhage = Yes Hemorrhagic – 13% – Neurology consult and admission to a stroke or IC unit of all strokes • Hemorrhage = No – Consider fibrinolytic therapy 6

6/17/2016 Advanced Advanced Life Support Life Support Fibrinolytic Check List More Stroke Fundamentals • “Standard” fibrinolytic therapy for stroke: Because we know a CT must be done EMS systems transporting a – At least 18, onset of symptoms < 3 hours, ischemic stroke seen on CT suspected stroke patient “code stroke” should skip any hospitals that do • “Select” fibrinolytic therapy for stroke: not have a functioning CT. This is why family should not transport but – Onset of symptoms between 3 and 4.5 hours, age < 80, no oral anticoagulant use call EMS whenever a stroke is suspected. regardless of INR, no history of diabetes and no history of prior ischemic stroke • Edovascular treatments for stroke: Time is BRAIN – This therapy can be used up to 6 hours from the onset of symptoms but per the AHA has not been approved by the FDA • Cerebral Intra-arterial rtPA: – This therapy can be used up to 6 hours from the onset of symptoms but per the AHA Going to the wrong facility will cost BRAIN has not been approved by the FDA 7