Questions and Answers
When should you consider IO access in an advanced airway scenario?
What is the recommended rate for PPV in adult patients?
What is the indication for administering aspirin 324mg in a patient with suspected ACS?
What is the maximum dose of epinephrine for pediatric patients?
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When should the 12-L ECG be performed in a patient with suspected ACS?
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When should you give medications in an advanced airway scenario?
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What is the primary contraindication for administering aspirin 324mg?
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What is the recommended position of the head of the bed when using a CPR device?
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What is the indication for NS TKO?
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How often should the 12-L ECG be repeated if the patient has ongoing pain or symptoms?
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What is the initial dose of nitroglycerin administered sublingually in a patient with ACS?
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What is the purpose of transmitting the 12-L ECG tracing to the receiving hospital?
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What is the systolic blood pressure threshold for administering nitroglycerin in a patient with ACS?
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When should the STEMI alert be called?
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Which of the following comorbidities is NOT typically considered when obtaining a patient's PMH in the context of heart failure?
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What is the primary purpose of assessing lung sounds in all lobes, front and back, in a patient with suspected heart failure?
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In a patient with pulmonary edema, what is the recommended initial PEEP setting for C-PAP?
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What is the recommended dose of aspirin in the context of ACS SOP?
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What is the recommended frequency of repeating nitroglycerin 0.4 mg SL in a patient with pulmonary edema?
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What is the primary indication for considering ADV airway in a patient with pulmonary edema?
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What should you do if the cardiac monitor senses a native rhythm with CPR in progress?
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What is the recommended joule dosage for pediatric patients weighing less than 50 kg?
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What should you do during a perishock pause when using a CPR device?
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When should you check for a pulse or rhythm during CPR?
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What is the recommended action if the patient has very fine VF and/or EtCO2 is low or decreasing?
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What is the priority order for ALS interventions?
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What should you do if you are unable to identify a rhythm during CPR?
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What should you do if you are using a CPR device without a cardiac monitor?
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What is a typical symptom associated with an acute coronary syndrome (ACS)?
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Which populations are likely to present with atypical symptoms of acute coronary syndrome?
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When should aspirin (ASA) and nitroglycerin (NTG) be deferred in management of a patient with ACS?
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What is the primary goal in the immediate management of a suspected STEMI patient?
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What SpO2 level should be targeted when titrating oxygen in patients showing dyspnea or signs of heart failure?
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Which medication history should be specifically obtained in patients with suspected cardiac issues?
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Study Notes
Acute Coronary Syndrome (ACS)
- Typical symptoms: pain, discomfort, or tightness in the chest, neck, jaw, teeth, back, arm, or abdomen of suspected cardiac origin
- May also present with dyspnea, sweating, nausea, vomiting, dizziness, fatigue, or weakness and may be associated with presyncope, syncope, acute HF, or shock = medical emergency
- Atypical symptoms may be seen in elderly, women, diabetics, and those with recent thoracic surgery or trauma
Initial Management of Chest Pain (IMC)
- Begin immediate IMC
- Decrease O2 demand: limit activity, do not allow to walk, sit up, loosen tight clothing
- If dyspnea, hypoxemia, or obvious signs of HF, titrate O2 to achieve SpO2 of 94%
- Cardiac monitor: assess for rate, rhythm, pump, or volume problem; hypoperfusion & CR compromise
- Rx per appropriate SOP
- Obtain medication Hx: Is pt taking beta-or calcium channel blockers, clonidine, digoxin, anticoagulants, or meds for erectile dysfunction or pulmonary HTN (vasodilators)
Aspirin Administration
- Indication: Cardiac ischemia due to suspected ACS regardless of chest pain
- Contraindications: Drug appendix + confirmed adequate dose taken after symptom onset; chest pain after trauma
- Dosage: 324 mg (4 tabs 81 mg) chewed and swallowed while prepping for 12-L ECG
12-Lead ECG
- Perform within 5 min of pt contact
- Ensure good skin prep & interface | Correct lead placement
- Clear tracing w/o artifact: capture while stationary - may transmit while moving
- Call STEMI alert ASAP if + 12 L ECG changes present
- Communicate & document: Clinical S&S (OPQRST), Pt age, gender, DNR status, PCP/cardiologist if known, Meds, PMH of AMI, PCI/stent/CABG, chronic kidney disease, or contrast allergy (GWTG)
Nitroglycerin Administration
- Dosage: 0.4 mg SL [BLS] unless contraindicated – see drug appendix
- Repeat NTG 0.4 mg SL every 3-5 min X 2; monitor for SE [BLS]
- Pain persists | SBP ≥90 (MAP ≥65) after NTG or NTG contraindicated: Rx per PAIN Mgt.SOP
Early Defibrillation
- Apply defib pads on exposed chest w/o interrupting compressions (anterolateral or anteroposterior)
- Connect to cardiac monitor [ALS] / AED [BLS] (See Peds IMC p. 72 for peds pad sizes)
- RHYTHM: Does monitor sense native rhythm with CPR in progress?
- Joules: Monitor-specific joules (see bottom of next page)
- Defibrillation caveats: Perishock pause, NO CPR device, NO rhythm/pulse check until after 2 min of CPR unless evidence of ROSC, Continue to defibrillate shockable rhythms per above procedure in 2-minute cycles
Advanced Life Support (ALS) Interventions
- Priority order: IV/IO access | EPINEPHRINE | Adv.airway
- Vascular access: May consider IO (approved site) if attempts at IV access are unsuccessful or not feasible
- Early EPINEPHRINE: Non-shockable rhythm: as soon as feasible | Shockable: after initial defibs
- EPINEPHRINE dosage: Adult: 1 mg (each dose), Peds: 0.01 mg/kg (0.1 mL/kg) (max 1 mg/dose)
- PPV: O2 15 L/BVM at 10 BPM with continuous chest compressions
Pulmonary Edema
- IMC special considerations:
- Position patient sitting upright at 90˚ (if tolerated); dangle legs over sides of stretcher
- C-PAP 5-10 cm PEEP | If SBP < 90 (MAP < 65): Titrate PEEP down to 5 cm; remove if MAP < 60
- If resp.distress & CPAP contraindicated/not tolerated: Assess need for ADV airway [ALS]; O2 15 L/NRM
- Nitroglycerin administration: 0.4 mg SL | If SBP ≥ 90 (MAP ≥ 65): Repeat NTG 0.4 mg SL q. 3-5 min – no dose limit
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Description
This quiz covers the signs and symptoms of Acute Coronary Syndrome (ACS) and ST-Segment Elevation Myocardial Infarction (STEMI), including chest pain and discomfort in the chest, neck, jaw, and other areas.
