What is the algorithm for acute coronary syndrome?
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A) Immediately - apply oxygen at 4L if O2 is less than 90%. Give Aspirin 160-325 mg if not given by EMS. Nitro then morphine if nitro doesn't work.
B) Assessment within 10 mins - vitals, insert IV, focused physical assessment, review fibrinolytic checklist, get a rainbow set of blood tubes, and a chest xray within a half hour.
C) ECG interpretation
D) STEMI - If onset of symptoms is less than 12 hours get pt to cath lab within 90 mins or fibrinolysis within 30 mins
E) High risk non-STEMI (elevated troponin) - start heparin and nitro
F) Low risk ACS - pt admission for more monitoring
A) Oxygen - if O2 is less than 90% administer @ 4L and titrate up
B) Aspirin - 160-325 mg of non-enteric coated ASA for antiplatelet aggregation if they have no hx of allergy or recent GI bleed. Give 300 mg rectal ASA for pts with n/v, active peptic ulcer disease or upper GI tract disorders
C) Nitro - 1 subligual tab q3-5 mins up to 3 doses, only give if SBP is over 90 and HR is 50-100. Don't use if pt has inferior wall MI and RV infarction, have hypotension, bradycardia, or tachycardia, or recently took viagra.
D) Morphine - give if unresponsive to nitro for chest pain.
A) STEMI - ST elevation in 2 or more leads. J=point greater than 2mm in lead 2 and 3 and 1 mm or more in all other leads. 2.5 mm in men under 40 and 1.5 mm in all women
B) NSTE-ACS - ST depression 0.5 mm or inverted T wave with pain. non-persistent ST elevation of 0.5 mm or more for less than 20 minutes
C) low/intermediate risk ACS - normal or nondiagnostic change in ST segment or T-wave.
10 minutes - general assessment
25 minutes - neurological assessment and head CT
45 minutes - CT interpretation
60 minutes - administration of fibrinolytic therapy, timed from ED arrival
3 hours - admission to monitored bed
3-4.5 hours - administration of fibrionlytic therapy from last known well time
6 hours - administration of endovascular therapy from last known well time in selected patients.
A) within 10 minutes - general assessment, VS, O2 PRN, IV access w/ labs, glucose check, neuro screening, activate stroke alert, order CT, obtain 12 lead ECG
B) within 25 minutes - review pt hx, establish last known well time, perform NIH stroke scale
C) CT shows hemorrhage - consult neurosureon and start hemorrhagic stroke pathway with admit to stoke unit or ICU
D) CT shows ischemia - check for fibrinolytic exclusions, repeat neuro exam. if pt can have TPA give it (no anticoagulants or antiplatelets within past 24 hours) then start post-TPA pathway and aggresssively monitor BP and neuro checks then get to ICU. If pt can't have TPA, give aspirin and get to ICU
A) Start CPR - give O2 and attach to monitor/defibrillator
B) Shockable rhythm - pt is in vfib/pulseless vtach so shock then start 2 mins of CPR and establish IV access. Assess for shockable rhythm again, if yes give shock and start 2 mins of CPR with 1 mg epinephrine Q3-5 minutes and consider advanced airway with capnography. Assess for shockable rhythm and shock if needed then 2 minutes of CPR. Can give 300 mg amiodarone bolus and second dose 150 mg
C) No Shockable rhythm - pt has asystole or PEA so start CPR for 2 mins, establish IV/IO access, epinephrine Q3-5 mins and consider advanecd airway with capnography. Assess for shockable rhythm, if none then continue CPR for 2 mins. Assess for shockable rhythm again, if no ROSC continue with CPR
A) Amiodarone - vFib or pulseless vtach unresponsive to shock, CPR and a vasopressor. Administer 300 mg bolus then 150 mg in 3-5 minutes if arrhythmia persists
B) Lidocaine - may use when amiodarone is not available. give 1-1.5 mg/kg IV. Repeat at 0.5-0.75 mg/kg over 5-10 minute intervals to a maximum of 3 mg/kg
C) Magnesium sulfate - used for torsades
A) identify and treat underlying cause - maintain airway, O2 prn, cardiac monitor with BP and SpO2
B) Symptomatic tachycardia - do synchronized cardioversion; consider sedation for this and if there are regular but narrow complexes, consider adenosine to identify underlying rhythm.
C) Asymptomatic tachycardia if there is not a wide QRS complex - then establish IV, have pt do a vagal maneuver, administer adenosine if rhythm is regular, administer a beta blocker or calcium channel blocker and consider expert consultation. D) Asymptomatic tachycardia with a wide QRS complex - establish IV access and get 12 lead ECG, consider adenosine only if regular and monomorphic, and consider antiarrhythmic infusion and seek expert consultation.
What is the post-cardiac arrest care algorithm?1) return of spontaneous circulation (ROSC) is established 2) optimize ventilation - maintain O2 > 94%, consider advanced airway and capnography 3) treat hypotension - IV bolus, vasopressor infusion and treat reversible causes 4) 12-lead ECGWhat medications are used to treat hypotension?A) IV bolus - NS or LR B) Norepinephrine - 0.1-0.5 mcg/kg per minute, titrated to achieve a minimum CBP of more than 90 SBP or a MAP of more than 65 C) Epinehrine - 0.1-0.5 mcg/kg per minute titrated to achieve a minimum CBP of more than 90 SBP or a MAP of more than 65 D) Dopamine - 5-10 mcg/kg per minute titrated to achieve a minimum CBP of more than 90 SBP or a MAP of more than 65