MDSO - Cardiac (Non Arrest) Flashcards
ACS - Regular Treatment, then CCTU Tx /Doses / Patch Status
Regular : Nitro 0.4 mg SL q 5 x 6 (rule out RVI, BP > MAP 70, no PDE - 48 hrs); ASA 160 mg (no Hx of Asthma Exacerbation ; CVA - 24 hrs)
CCP :
Nitroglycerine Infusion ? - IP to start, or no patch to continue (at less than 100 mcg/min) if initiated by hospital MAP>70 - 10 mcg/min, titrate q 5 min by 5 mcg/min to Max 100 mcg
PLAVIX (MP) 300-600 mg PO ….OR ….TICAGRELOR (MP) 180 mg PO….
METOPROLOL (MP) - - IF patient is hypertensive or tachycardic…. 5 mg IV/IO q 5 min to MAX 15 mg
HEPARIN - no patch required if within nomogram (or post initiations PTT not available), if started by Hosp
—-if initiating Heparin - - - >. 60 u/kg bolus to MAX 5000 U then Infuse at 12 u/kg/hr
Repeat aPTT at 4 hrs - 6hrs after any changes of dosing. Target aPTT of 60-85, change as per nomogram
What is the aPTT normal and target for ACS Heparin ?
Normal is 30 - 40 sec
Target on Heparin therapy for ACS : 60 -85
Ornge Guidelines: STEMI - PCI and Fibrinolytics GOALS
FMC to Device for PCI - < 90 min in PCI capable hosp
FMC to Device for PCI - < 120 min in a non capable PCI hosp (needs transfer)
If > 120 min, to PCI - assuming no contraindications - — > then Fibrinolytic Therapy
*Reperfusion via PCI of STEMI patients with symptom onset between 12 to 24 hrs , or clinical evidence of ongoing Ischemia is reasonable - although Primary PCI is ideal.
*STEMI + Cariogenic. Shock / HF —- immediate transfer to PCI, regardless of onset of MI
Ornge Guidelines : STEMI - in addition to ASA, you should give a P2Y12 - ASAP with STEMI: What are the 2 common ones and their dose.
Clopidogrel 600mg
TICAGRELOR 180 mg
Ornge Guideline : STEMI - Anticoagulant Therapy: used for which patients, what are the options ?
Give Oxygen, Antiplatelet (ASA) and P2Y12 (Clopidogrel or Ticagrelor) , then consider Anticoagulant therapy :
Who gets it ? 1) STEMI going for primary PCI 2) Patients not getting PCI < 120 min, (no primary PCI) but getting Fibrinolytic - should receive anticoagulant therapy until revascularization is performed.
So all STEMI patients get it:
Usually UFH (Heparin) - loading dose of 60 u/ kg to max 5000 u, then infusion at 12 u/kg/hr - aim for aPTT of 60-80 sec. (1.5 - 2 x normal values)
Sometimes (specially if they are waiting for revascularization PCI - - - Enoxaparin or Fondaparinux
If patient has received TNKase for STEMI, how does that change Heparin dosing ?
For ACS/STEMI not getting TNK (ie PCI < 120 min) it’s 60 u/ kg to max 5000 u, but if they have gotten TNKase (fibrinolytic) max drops to 4000 u.
On the post bolus side, the infusion stays the same : 12 u / kg/ hr BUT 1000 u/hr MAX for TNK patient, no Max for ACS/STEMI without TNK)
Explain key features of HIT (Heparin Induced Thrombocytopenia) ?
HIT results from autoantibodies which react to an antigen created by the combination of heparin plus platelet factor 4 (PF4) causing activation of platelets, leading to arterial and venous thrombosis. Consumption of activated platelets leads to thrombocytopenia.
HIT is rare, yet important to recognize early. HIT is challenging to diagnose, because the vast majority of patients with DVT or thrombocytopenia won’t have HIT.
In ~10% of cases, HIT leads to overt DIC. These cases are distinguished by unusually low platelet counts (e.g. <20,000), lab derangements of DIC (e.g., elevated INR and low fibrinogen), and often microvascular thrombosis. This combination of HIT and DIC can be difficult to diagnose, because the unusually low platelet count will confound diagnostic algorithms for HIT.
Diagnose HITT - see IBCC - couldn’t get both images here
Who gets considered for TNK (us) or tPA? - with cardiac ? Is there a checklist.
Any STEMI - if can’t get to cath within 120 min. Ideally given within 30 min of FMC. - Yes there is a checklist in the MDSO
Treatments used as CCP for Cardiogenic Pulm Edema: Tx, Dose, Patch ? , Conditions
1) CPAP/NIPPV- IP - (it says CPAP - but giving BIPAP type values)
- start at 10/5 (T1 = 5/5)……up to 20/10 (T1 10/10)
2) Nitroglycerin Spray q 5 min x 6. (No Patch Required)
- > 140 w Hx or IV - - - 0.8 mg
- otherwise 0.4 mg
- CCP - MANDATORY PATCH - Nitro Drip @ 10 mcg/min IV titrate by 5 mcg q 5 min up to MAX 200 mcg/min
3) Furosemide (LASIX)
- 40 mg IV. (Or if patient already takes it at home, double their usual dose) - MAX 160 mg
Cardiogenic Pulmonary Edema: Flowchart:
AVOID Nitro, Furosemide, Morphine, Propofol, Midaz and Lorazepam in context of CARDIOGENIC SHOCK (even if they have Pulm Edema)
According to flow chart, to give any meds, MAP > 70
According to flow chart, if MAP < 65 (and Cardiogenic Shock - <65, altered LOC, lactic acidosis, oliguria, cool/clammy, resp distress) —— NO MEDS for EDEMA. - - - > RESUSCITATE then INTUBATE, add pressors - start with NE generally, but then discussion around DOBUTAMINE vs EPI - depending based L or R failure (based on conversation with Scott - not exactly sure how R vs L vs Dobutamine vs EPI works, I’ll take his word on in - but start with NE regardless)
