Myocardial Infarction Flashcards
Subendocardial
The MI extends partially through the thickness of the myocardium. May or may not produce a pathological Q-waves (Q-waves > 0.04s) on future 12 lead EKGs
STEMI what to look for?
1mm or more ST segment elevation in two or more anatomically contiguous or numerically consecutive leads
Anatomically contiguous
1, aVL, V5, V6
II, III, aVF
V1, V2
V3, V4
Numerically Consecutive
V1-V2
V3-V4
V3-V4
V4-V5
V5-V6
Names of Myocardial Infarctions
1, aVL, V5, V6 = Lateral Wall MI
II, III, avF = Inferior Wall MI
V1, V2 = Septal Wall MI
V3, V4 = Anterior Wall MI
V2, V3 = Anteroseptal MI
V4, V5 = Anterolateral MI
V2, V3, V4, V5 = Extensive Anterior Wall MI
Right sided 12 Lead EKG
Inferior wall Mi = STMI = II, III, aVF = v4R
Right Coronary Artery supplies the Posterior Descending Artery and the Right marginal Artery
The posterior Descending Artery supplies the inferior wall
The right Marginal Artery Supplies The Right Ventricle
Inferior wall MI - right sided 12 lead to identify the occlusion is happening in the posterior descending artery or if proximal RCA
Right ventricle = concern with preload and nitro administration
RVI = fluid to support pre load (starling’s law), aspirin, and oxygen
Bundle Branch Blocks
Right and Left
Left - left anterior and left posterior
1) Lead V1 QRS > 0.12 (3 small boxes)
2) V1 up = righ; down = left
ACLS Slow HR < 60 BPM
*Patient must be symptomatic
- Sinus Bradycardia
- Junctional Escape
- Second Degree Type 1
- Second Degree Type 2
- Third Degree
- Idioventricular
ACLS Slow HR (Above AV)
- Sinus Bradycardia
- Junctional Escape
- Second Degree Type 1
- Atropine 1mg, max of 3mg
- Transcutaneous Pacing 60 BPM; 50+ mA until mechanical capture (pulse) and electrical capture (captured pacer spike)
- Vasopressor infusion
- Dopamine: 5-20mcg/kg/min
- Epinephrine: 2-10mcg/min
ACLS Slow HR (Below AV)
- Second Degree Type 2
- Third Degree
- Idioventricular
- TCP: 60 BPM; 50+mA until mechanical (pulse) and electrical (captured
- Vasopressor infusion
- Dopamine: 5-20mcg/kg/min
- Epinephrine: 2-10mcg/minute
- Dopamine: 5-20mcg/kg/min
Normal ACLS
HR: 60-150BPM
- Normal Sinus Rhythm
- Sinus Tachycardia
- Atrial Fibrillation
- Atrial Flutter
- Accelerated Junctional
- Junctional Tachycardia
treat underlying problem - but not going to speed or slow patient heart down
ACLS Fast HR ( >150 BPM)
- SVT
- Ventricular Tachycardia (w/pulse)
Stable SVT
- Vagal maneuvers (“bear down”)
- Adenosine, 6mg rapid IVP
- Adenosine, 12mg rapid IVP
Unstable SVT
Synchronized cardioversion (50-100J, 200J, 300J, 360J…)
May consider sedation prior to cardioversion
Stable VT
Amiodarone: 150mg over 10 minutes or
Procainamide: 25-50mg/minute
Sotalol: 100mg (1.5mg/kg) over 5 min
Unstable VT
Synchronized Cardioversion
(50-100J, 200J, 300J, 360J)
May consider sedation prior to cardioversion
ACLS Dead
- Aystole/PEA
- Ventricular Fibrillation
- Pulse less Ventricular Tachycardia
Ventricular Fibrillation Pulse less Ventricular Tachycardia
SHOCKABLE
Immediately begin CPR (2 minutes/5 cycles for duration of code)
Defibrillate when it becomes available
IV/IO access
Epinephrine, 1mg, 1:10,000 (every 3-5 minutes for duration of code)
In refractory VF/pVT (rhythm sustains after two defilbrillations)
Amiodarone, 300mg IVP
Remains Refractory…
Amiodarone, 150mg IVP
H & T’s throughout cardiac arrest
Dead - Asystole/PEA
NONSHOCKABLE
Immediately begin CPR (2 minutes/5 cycles for duration of code)
IV/IO access
Epinephrine, 1mg, 1:10,000 (Every 3-5 minutes for duration of code)
H & T’s through
ACLS Medication Adenosine
Anti dysrhymthmic: delays conduction through the atrioventricular (AV) node
Used in stable SVT 6mg, 12mg -> 18mg total (may consider second dose of 12mg for a maximum of 30mg)
Rapid IV push, peripheral IV site, followed by 10-20 mL saline flush
**Adenosine has a 10-second half life
ACLS Medications Amiodarone (Cordarone)
Class III Anti dysrhythmic: blocks potassium channels, which increases the effective refractory period. Also blocks sodium channel and has some calcium channel blocking properties
Indications: Recurrent Ventricular Fibrillation and Pulseless Ventricular Tachycardia 300mg IVp (first dose), 150mg IVP (second dose)
Stable Ventricular Tachycardia (with a pulse) 150mg infused over 10 minutes (minimal)
ACLS Medications Aspirin
Antipyretic, Antiplatlet Aggregator: Blocks platelet aggregation (prevents from stick together, thus, reduces risk of clot formation)
Indication: Chest pain, acute coronary syndrome
Contraindications: children, known hypersensitivity, active ulcer disease, signs of or history of stroke
Dose: 81 - 324mg (1 baby aspirin tablet = 81mg)
If patient has taken aspirin in lat 24 hours, give remaining tablets to total 325mg
ACLS Medication Atropine
Parasympatholytic & Anticholinergic: inhibits parasympatholytic nervous system; acts on the vagus nerve (CN X - Cranial Nerve 10)
Used in:
Symptomatic Bradycardia
- 1mg (max of 3mg cumulative dose)
- Push rapid, too slow of administration can cause refractory bradycardia
Organophosphate posioning
- 1mg every 3-5 minutes to control secretions (Sludge)
ACLS Medications Dopamine (Intropin)
Endogenous Catecholamine
0.5-2mcg/kg/min -> dopaminergic dose -> dilates renal and mesenteric arteries
2-10mcg/kg/min -> beta receptor stimulation -> positive inotropy, chronotropy, dromotropy
10-20mcg/kg/min -> alpha dose -> alpha receptor stimulation -> vasoconstriction
ACLS Epinephrine (Adrenalin)
Endogenous Catecholamine & Sympathomimetic
Cardiac Arrest dose -> used every 3-5 minutes for the duration of the cardiac arrest
1mg IV/IO, 1:10,000
Used in shockable and non-shockable cardiac arrest rhythms
ACLS Medication Lidocaine (Xylocaine)
Antidysrhythmic
Ventricular Fibrillation or Pulseless Ventricular Tachycardia
1-1.5mg/kg IV/IO (first dose)
0.5-0.75mg/kg IV/IO (second dose
IF conversion -> give 0.5mg/kg IV/IO, in 10 minute increments (two times)
ACLS Medication Nitroglycerin
Potent Vasodilator
Indications: Chest Pain: obtain 12 lead first and establish IV access
Pulmonary edema: Administer with CPAP to help with evacuating fluid from the alveoli
Dose: 0.4 SL (3 times, every 3-5 minutes as needed, 1.2mg maximum total dose) Monitor blood pressure with each dose -> do not administer with systolic blood pressure under 100mmHG (some protocols may vary)
*Obtain IV access prior to administration when possible, always obtain 12 lead prior to administration to rule in/out RVI
Nitro-Bid is the paste form of nitroglycerin and is applied in a 1* circle (!5mg TD) to upper left chest area
ACLS Medication Procainamide (Pronestyl)
Antidysrhythmic: Blocks influx of sodium, slows conduction (decrease both atrial and ventricular rates)
Consider in stable tachycardic rhythms (>150bpm; SVT/VT/A-Fib)
25-50mg/minute
ACLS Medications Sodium Bicarbonate
Alkalizing agent
Cardiac arrest for known dialysis patients or prolonged down time 1mEq/kg IV/IO
May cause transient increase in capnography
ACLS Medications Sotalol (BetaPace)
Antidysrhythmic
Considered in stable tachycardic rhythms (>150bpm; SVT/VT/A-Fib)
100mg (1.5mg/kg) over 5 minutes
