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PEA
Pulseless Electrical Activity
Two MOST common underlying and potentially reversible causes of PEA
- Hypovolemia
- Hypoxia—absence of enough )2j in the cells and
tissues to maintain homeostasis
ROSC
Return Of spontaneous Circulation
Hypovolemia produces WHAT classic physiologic response
Sinus Tachycardia—rapid, narrow complex
What does hypovolemia typically do to
1. Systolic BP
2. Diastolic BP
- Decreases SBP
- Increases DBP
Two major/common causes of hypovolemia
- Occult internal hemorrhage
- Dehydration
IHCA
In-house cardiac arrest
pVT
Pulseless Ventricular Tachycardia
ACS
Acute Coronary Syndrome
What ACS drugs are initially used to relieve ischemic discomfort, dissolve clots, and inhibit thrombin and platelets
- Oxygen
- Aspirin
- Nitroglycerin
- Opiates (e.g. morphine)
- Fibrinolytic therapy
- Heparin (unfractionated-low-molecular weight)
STEMI chain of command
- Recognize ACS symptoms
- Activating/Notifying EMS
- Providing CPR if needed, providing early defib with AED
- Providing coordinated system of care among EMS and
hospital
What disease is underlying reason for many clinical syndromes, resulting in varying degrees of artery occlusion
Coronary Atherosclerosis
What ECG interpretation indicates an MI (myocardial infarction)
ST elevation
2 examples of adjunct therapies
- Nitroglycerin
- Heparin
What are two of the most important points to be aware for STEMI need?
- The EG=CG is essential
- STEMI patients don’t need evidence of elevated cardiac markers to decide to administer fibrinolytic therapy, or perform coronary angiography with interventions (angioplasty, stenting).
For ACS response, hospital intervention should occur when
Less than 10 minutes
Major ischemia or infarction symptoms include:
- Chest pain
- Shoulder pain
- Dyspnea
- Nausea
What is the most common symptom of myocardial ischemia and infarction
Retrosternal chest discomfort….Patient may perceive discomfort as tightness or pressure
What should a person do before arrival of first responders with presentation of ACS symptoms
Chew aspirin (162-325 mg non-enteric coated) if no contraindications
During EMS assessment, what should be done IMMEDIATELY upon ECG determination of ST-elevation
- Notify hospital of results of ECG
- Note time of onset
- Note first medical contact
Assessing ABS’s includes:
- Monitoring vit signs and cardiac rhythms
- Being prepared to provide CPR
Using a defibrillator if needed
What are the parameters for administering nitroglycerin to reduce ischemic chest discomfort
- Give 1 s/l or translingual dose every 3 to 5 minutes for
a maximum of 3 doses - Give only if SPP > 90, or if SPB is no lower than 30
below baseline (if known) - HR is 50-100
Nitroglycerin, being a venous dilator, caution should be taken in patients with inadequate ventricular pre-load. What are these situations
- Inferior wall and RV infarct
- Hypotension, Bradycardia, Tachycardia
- Recent phosphodiesterase inhibitor use…..sildenafil,
vardenafil, tadalafil (all erectile dysfunctional drugs)
Is morphine a venodilator
YES
For STEMI diagnosed hospitalizations, other than ASA, do not administer other non-0steroid anti-inflammatory drugs. WHY
- Increased risk of death
- Reinfarction
- Hypertension
- HF
- Myocardial rupture
What is the ONLY way to identify a STEMI
12-Lead ECG
What time frame should labs, chest x-ray be conducted once patient arrives at the ED
30 minutes
What are the goals of reperfusion for STEMI patients
- PCI (percutaneous coronary intervention)…should
begin within 90 minutes from medical contact to
balloon inflation - Fibrinolytic administration should begin within 30
minutes of patient’s arrival in ED
If oxygen saturation i <90% , what intervention is needed
Start O2 at 4 Lpm and titrate
What is the most serious drawback of using morphine n ACS patients
Morphine decreases the absorption of oral antiplatelet medications
NSTE-ACS
Non ST-Elevation Acute Coronary Syndrome
-Unstable angina
-Non ST-Elevation MI
T or F
More than one ECG is necessary to confirm ACS
TRUE
How is early perfusion therapy achieved with patients with STEMI
- Primary PCI
- Fibrinolytics
A patient with a STEMI should be treated how long after onset of symptoms
Within 12 hours
Delay therapy during inpatient evaluation may occur in 4 ways, referred to as the 4 D’s. What are the 4 D’s
- In-hospital evaluation
- Door to Data (ECG)
- Data to Decision
- Decision to Drug (PCI)
What are the drugs used for treatment of strokes
- Alteplase
- Glucose (D10/D50)
- Labetalol
- Nicardipine
- Cilnidipine
- Aspirin
What are the two types of strokes
- Ischemic (blockage)
- Hemorrhagic (bleeding)
Which type of stroke is eligible for fibrinolytic therapy
Ischemic
What percentage of strokes are ischemic
87%
What percentage of strokes are hemorrhagic
13%
What are the 8 D’s of a stroke
- Detection
- Dispatch
- Delivery
- Door
- Data
- Decision
- Drug device
- Disposition
EVT
Endovascular Thrombectomy
LVO
Large Vessel Occlusion
What is TIME ZERO
The last time the patient was seen to be normal
What SpO2 level would supplemental O2 be administered to possible stroke patient
94% or less
What are the 3 physical findings identifying a stroke outline by the CPSS (Cincinnati prehospital stroke scale)
- Facial droop
-Can patient smile/show teeth - Arm drift
-Pt close eyes, arms out with palms up for 10 seconds - Abnormal speech
-Have patient say, “you can’t teach an old dog new
tricks”
CPSS has a probability of what percentage of identifying stroke pre-hospital evaluated
72%
When using the CPSS tool, how many indicators must be present for a probability of 72% stroke?
1 out of 3
What is the highest level designation for a stroke center?
Level 4
ASRH
Acute
Stroke
Ready
Hospital
Is an ASRH (acute stroke ready hospital) usually rural or urban
Rural
What is the hospital designation for the HIGHEST level of stroke care
CSC (Comprehensive Stroke Center)
In what timeframe should a possible stroke patient be assessed when arriving at the ED
10 minutes
What is the timeframe for the DOOR TO NEEDLE intervention for stroke patients
60 minutes
Is ALTEPLASE an effective intervention for a HEMORRHGE diagnosed stroke
No (alteplase is only effective on ischemic strokes
INR/PTT results should be available to the ED within what timeframe
No longer than 30 minutes
For possible stroke patients, is it ok to delay obtaining a CT/MRI for obtaining an ECG
No
PENUMBRA
Reversibly injured brain tissue around the ischemic core, which is the target area of repair for an ischemic stroke. Rescue of the Penumbra is the goal to treatment of an ischemic stroke
