A: Cariac (Non-Arrest) Flashcards
MDSO: ACS - MEDS
1) NITRO
Can start at usual at 0.4 mg SL q 5 x 6 (No Patch)
***make sure HR > 60, BP > 100, no ED Rx, not RVI
CCP : NITRO INFUSION: (MAP > 70) @ 10 mcg/min Tby5q5 to MAX 100 mcg/min - target CP (IP)
**note if MAP <70 - consider Cardiogenic Shock MDSO, do not use NITRO without TMP patch
**If Wet Lungs, also consider Cardiogenic Pulm Edema - BiPAP 10/5 - 20/10 (5/5 - 10/10) + Nitro if BP high
**if Wet Lungs but BP low (Edema + Shock) - Ressuc - NE/Dobutamine/BiPAP/LASIX/NitroPrussive (see Cardiogenic Shock and Pulm Edmea MDSO)
2) ASA - 160 mg (usual, r/o bleeding, allergy, asthma , stroke) (NO Patch)
3) FENTANYL (MAP > 70) @ usual doses of 25-50 mcg q 5 min PRN (Max 300mcg) - (No Patch) ** to be added if Nitro not effective for pain
4) PATCH FOR Ticagrelor 180 mg OR Clopidogrel 300 mg
5) CONSIDER / PATCH for METOPROLOL (if HTN or TACHY) @ 5mg q 5 x 3
FOR NEXT STEP NEED TO KNOW IF STEMI or NOT
6) PATCH for HEPARIN - @ 60 u/kg LOADING (**Max 5000 if NO TNK; 4000 if got/getting TNK), then infusion same at 12 u/kg/hr. Measure aPTT then check/adjust at 4 hrs. (Rule out - Hx Heparin Induced Thrombocytopenia / Allergy)
MDSO: ACS - things to consider when assessing your CP patient
Wet Lungs ? —- > Acute Pulmonary Edema MDSO
Hypotensive (< 70) —> Cardiogenic Shock MDSO
Sometimes both of the above in conjunction…..
STEMI ? If so - < 120 min to PCI ? If > 120 min to PCI (from first Medical Contact) - consider TNK
TNK only for STEMI, only if no PCI < 120 min
HEPARIN - adjust loading dose to 4000 IU if got/getting TNK
LOOK AT RATE ? - possible assoc Tachydysrhythmia or Symptomatic Bradycardia
MDSO: Cardiogenic Pulm Edema: Treatment / Meds
1) BiPAP 10/5 (5/5) to 20/10 (10/10). - IP
2) NITRO SPRAY (No Patch) - any nitro rule out RVI, Hypotension, EDRx
SBP > 100 MAP > 70
0.4 mg SL q 5 min x 6
IF SBP > 140 and IV in place —-> 0.8 mg SL q 5 min x 6
3) NITRO INFUSION (MP)
10 mcg/min Tq5b5 to MAX 200 mcg/min (same start and Titrate as ACS, but max in ACS is 100 mcg/min)
4) LASIX (MP)
40 mg IVP (or double patient’s regular dose) - Max 160 mg (good to have foley in place)
MDSO / Flowchart : Cardiogenic Edema: Flowchart divides it into Mild/Moderate, Severe and APE with Cardiogenic Shock. Define these categories and Assoc Treatments.
Mild /Moderate: MAP > 70 - milder - some crackles : TX : Nitro Spray, Patch for Furosemide
Severe: MAP > 70 - WOB+++, but NO SHOCK: Tx: Nitro Spray, BiPAP, Nitro Infusion, Furosemide, +/- ETT
APE w SHOCK: MAP < 70: AVOID NITRO, FUROSEMIDE, MORPHINE, PROP, MIDAZ, LORAZEPAM
**S/S - Hypotension, altered LOC, lactic Acidosis, Resp Distress+++, cool / clammy
TX: Resussitate (see Cardiogenic SHOCK MDSO) and Intubate
MDSO: Cardiogenic Shock : Meds
1) NS - 250 mL Fluid Challenge PRN (to Max of 10 mL /kg - 50 kg = 500 mL) - NO PATCH
2) DOPAMINE is an Option, but we don’t really use it as CCP
3) NE - usual dose : 0-0.5 mcg/kg/min - Target MAP > 65. (IP)
4) DOBUTAMINE (MP) - MINIMUM MAP > 60: 5-20 mcg/kg/min, start at 5 , titrate to perfusion
MDSO / Flowchart : Cardiogenic Shock: If patient is in Cardiogenic Shock, what other Medical Directives do you need to consider for concomitant treatment ?
ACS +/- STEMI
Tachydysthmias / Symptomatic Bracdycardia
Acute Pulmonary Edmea - - - but if in SHOCK (MAP < 70) - you don’t give Nitro - and if lungs are flooded and WOB+++ AND low BP (Cardiogenic Shock) - basically just moving to intubation but ressucitation first with Cardiogenic Shock MDSO + Preoxygenation. - - - could have some discussions when calling about intubation about R vs L Heart Failure. If LV HF, reduction in afterload may be appropriate even if on pressors. - - -but this is a discussion after BiPAP/INTUBATION/ NE/DOBUTAMINE - - - to maybe consider along with TMP
MDSO: Symptomatic Bradycardia: MEDS and PACING Tx
1) Atropine (IP) = 0.5 mg q 3-5, Max 3 mg (6 doses)
2) Dopamine (IP) = 5-20 mcg/kg/min (IP) EPI Infusion not in MDSO, but worth calling for
3) Proceedural Sedation (if not Peri Arrest, and patient can feel pain - do this first)
Ketamine: 0.1 mg/kg titrated to effect to max 0.5 mg/kg
Example: 70 kg = 0.1mg/kg x 70 = 7mg first dose, reassess, repeat x 5 total for 0.5 mg/kg total
7 mg, 7 mg, 7 mg, 7 mg, 7mg = 35 mg total
500mg/50 mL = 10mg/mL; 7mg=0.7 mL = so kg/10 = mL of 500mg/50mL
3) TCP
Rate: 70
( mA) : 10 - start, and dial up until electrical AND Mechanical Capture + 10 %
MDSO / Flowchart: Symptomatic Bradycardia: The flowchart states that if “NO” “Cardiorespiratory Compromise” - then just “Support ABC’s, O2 and PATCH” - if “YES” then go through MDSO.
So - How do they define “Cardiorespiratory Compromise” ?
Hypotension
Decreased LOA
CP
SOB+++ / CHF
MDSO: Symptomatic Bradycardia. What other MDSO might you consider with a low HR / low BP?
TOX - OD
ACS/STEMI
Cardiogenic Shock
Acute Cardiogenic Pulm Edema
Universal Airway Algorythm
What are the three Tachydysrhythmia MDSO ?
Afib/Flutter
PSVT
VT with Pulse
MDSO: Afib/Flutter Tachy. : What is treatment ? When do you consider it ?
If unstable —-> HR > 150 + Cardiorespiratory Compromise
1) Ketamine for Procedural Sedation
0.1 mg/kg x 5 to max total 0.5 mg
Kg/100 = mL of standard 10mg/mL bag.
2) Synchronized Cardioversion
Joules : 100, 150, 200 J…..for A fib start at 150
MDSO / Flowchart : Symptomatic Afib/ Flutter: Other than the specifics of the Medical Directive, what else should you consider/treat?
Is it compensatory ? Is something else causing it ?
LOOK FOR AND TREAT UNDERLYING:
Sepsis, MI , OD ?
MDSO / Flowchart: PSVT: This MDSO can be subdivided into THREE categories, which alter your treatment pathway. What are these ? And the treatment pathway for both.
CARDIORESPIRATORY COMPROMISE : YES or NO
Tx NO:
Modified Vasalva
Adenosine 6mg + 20 mL rapid flush, then 12 mg if needed.
Tx YES - NOT PERI-ARREST - Same as NO
Tx YES - PERI-ARREST
- can Attempt 6 mg Adenosine while preparing for Cardioversion
- Proceedural Sedation 0.1 mg/kg x 5 PRN
- Cardioversion 100, 150 , 200 J. remember to SYNC
MDSO / FLOWchart: PSVT: Other than drugs and procedures from MDSO….what are some potential precipitating causes to consider ?
Hypoxemia
Sympathomimetic OD
Hypovelemia
Always look for underlying causes that you might be able to reverse.
Ex: Start with a Fluid Bolus and Optimizing O2…..if still > 150….and BP LOW….then cardiovert……when back to normal rate…..and still low, then can add pressors as appropriate
MDSO: VT with Pulse: There are 3 pathways, what are they and their associated treatments ?
1 A=NO
A = CARDIOPULMONARY COMPROMISE : YES / NO
B =HR > 150
AMIODARONE 150 mg > 10 min
LOOK FOR OTHER CAUSES and TREAT
BBB ? SEPSIS ? HYPOVOLEMIA ?
Ketamine for Proceedural Sedation (if appropriate) 0.1 mg/kg
Synchronized Cardioversion 100, 150 200
Consider Amiodarone, same as above after Cardioversion
That being said : really it’s two pathways - is it > 150 or < 150 to even consider for PSVT, then Stable or Unstable…… the middle one < 150 - - - look for other reasons.
