updates in acls 2005
TRANSCRIPT
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ACLS
01
Panita Worapratya
Emergency Department
Prince of Songkhla University
Circ
ula
tion
20
05
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Effective Chest compression
Goals
Minimized interruption
Fully recoil
Push hard &
fast
How to achieve
Push 100/minDeep 1/3 of chest wall
Avoid fatiqueResume CPRNo pause for check pulse
Fully recoilDon’t let hands off the chest wall
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WINTERTemplateACLS
Pulseless Arrest
Circ
ula
tion
20
05
Panita Worapratya
Emergency Department
Prince of Songkhla University
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Pulseless Arrest•BLS algorithm, Call for help ,give CPR•Give oxygen when avialable•Attach moniter/ AED when avialable
Check rhythm. Shockable ?
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Pulseless Arrest•BLS algorithm, Call for help ,give CPR•Give oxygen when avialable•Attach moniter/ AED when avialable
Check rhythm. Shockable ?
Asystole/PEAVF/VT Asystole/PEA
Resume CPR immediatelyI.V/I.O access, given vasopressor• Epinephrine 1 mg I.V/ I.O q 3-5 min•Vasopressin 40 U I.V/I.O to replace epinerphine•Consider atropine 1 mg I.V/I.O for asystole or slow PEA
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Pulseless Arrest•BLS algorithm, Call for help ,give CPR•Give oxygen when avialable•Attach moniter/ AED when avialable
Check rhythm. Shockable ?
Asystole/PEAVF/VT
Give 1 shock•Manual biphasic 200J•Monophasic 300 J•AED when avialable
Resume CPR immediately
Check rhythm. Shockable ?
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Check rhythm. Shockable ?
Asystole/PEAVF/VT
Give 1 shock•Manual biphasic 200J•Monophasic 300 J•AED when avialable
Resume CPR immediately
Check rhythm. Shockable ?
Continue CPR while defibrilator is charging
Give 1 shock•Manual biphasic 200J•Monophasic 300 J•AED when avialable
Resume CPR immediately after shockWhen I.V or I.O access give vasopressEpinephrine 1 mg I.V/I.O q 3-5 minOr one dose of vasopressin 40 U I.V/I.O
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Continue CPR while defibrilator is charging
Give 1 shockResume CPR immediately after shockEpinephrine 1 mg I.V/I.O q 3-5 min
Check rhythm. Shockable ?
Continue CPR while defibrilator is charging
Give 1 shockResume CPR immediately after shockEpinephrine 1 mg I.V/I.O q 3-5 minConsider antiarrythmic drug•Amiodarone 300 mg I.V/I.O then 150 mg I.V•Lidocaine 1-1.5 mg/kg I.V/I.O then 0.5-7.5 mg/kg I.V/I.O•Consider MgSO4 1-2 g I.V/I.O •After 5 cycle of CPR , look for 6H,5T
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Questions
• ชายอาย 55 ป เปนโรคหวใจอยเดม ถกน าสงร.พ ดวยเรองหมดสต ญาตใหประวตวาเปนขณะออกก าลงกาย แรกรบ Unconsciousness, no pulse. EKG เปนดงรป ทานจะใหการรกษาอยางไร
a. Chest compression
b. Atropine 1 amp iv stat
c. Synchronized cardioversion 100 J
d. Defibrillation 200 J
e. Search for 6H, 5T
pulseless VF : Defibrillation 200 J
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Questions
• หญงอาย 45 ป Underlying เปน CA breat with distance metastasis ญาตพบวาตอนเชาปลกไมตน ตวเยน ซดเขยว ไมหายใจ ไมทราบวาตงแตเมอใด แรกรบ Unconsciousness, no pulse. EKG เปนดงรป ทานจะใหการรกษาอยางไร
a. Chest compression 5 cycle
b. Atropine 1 amp iv stat
c. Synchronized cardioversion 100 J
d. Defibrillation 200 J
e. Search for 6H, 5T Asystole : CPR 5 cycle
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Questions
• ขณะททมก าลง CPR ผปวยหญงอาย 68 ป ไมทราบประวต มาดวยไมรสกตว ไดใส ET-Tube , i.v access, adrenaline 1 amp iv q 3-5 min และ High quality CPR แลวไมดขน EKG ยงคงเปนดงรป หลงจากทานไดท า Defibrillation ไปแลว 3 ครง ทานจะใหการรกษาอยางไรตอ ? (อาจเลอกไดมากกวา 1 ขอ)
a. Antiarrhythmic drug
b. NaHCO3 50 mEq
c. Escalating dose epinephrine 3 mg
d. Search for 6H, 5T
Refractory VT :
•Amiodarone 300 mg i.v/i.o
•6H, 5T
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Contributing factor
6 H
• Hypovolumia
• Hypoxia
• Hydrogen ion
• Hypo/hyper kalemia
• Hypoglycemia
• Hypothermia
5 T
• Toxin
• Temponade (cardiac)
• Tension pneumothorax
• Thrombosis
• Trauma
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Questions
Route of drug administration
• ผปวย cardiac arrest. EKG เปน VF ซงไมตอบสนองตอการท าDefibrillation. พยาบาลไดพยายามเปดเสนเลอด 2 ครง แตไมเปนผลผปวยไดใส ET-Tube แลว ทานคดวาจะใหยากชพทางใดดทสด
a. Endotracheal
b. Femeral vein
c. Intraosseous
d. External jugular vein
Intraosseous
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IntraosseousSite of administration
2 cm. below medial tuberosity
2 cm. above medial condyle
2 cm. above medial maleolous
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Questions
• You are arrive on scene to fine CPR is in progress. Nursing staff report that the patient was recovering form pulmonary embolism and suddenly collapsed. There is no pulse or spontaneous respiration. High quallity CPR is in progress and effetive circulation is being provided with bag mask. An i.v is establish, you would now…?
a. Give atropine 1 mg i.vb. Give NaHCO3 1 amp iv c. Immediate CPRd. Immediate endotracheal intubatione. Initiate transcutaneous pacing
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Questions
• Following initiation of CPR and one shock for
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Questions
• ผปวยชายอาย 35 ป เปนชางซอมเสาไฟฟา น าสงร.พ เนองจากโดนไฟฟาแรงสงชอต และตกจากทสง 5 เมตร ไมรสกตว แรกรบไมมสญญาณชพ MoniterEKG เปนดงรป จงใหการรกษา
a. Give atropine 1 mg i.vb. Give epineprhine 1 mg i.vc. Give Synchronized cardioversion 100 Jd. Immediate Defibrillation 200J
e. Initiate transcutaneous pacing
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WINTERTemplateBrady &
Tacchycardia
20
05
Panita Worapratya
Emergency Department
Prince of Songkhla University
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• 35 yr-old woman with palpitation, light headness and stable tacchycardia. EKG as picture. An IV has been established. What drug should be administered IV? o Atropine 0.5 mg
o Lidocaine 1 mg/kg
o Epinephrine 2-10 µg/kg/min
o Adenosine 6 mg
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67 Yr-old male ไมรสกตวมา 30 min >V/S : BP 64/24,PR 30/min หลงจากทานไดใสทอชวยหายใจ เปดเสนเลอด ตด monitor EKG แลว คลนไฟฟาหวใจเปนดงรปทานคดวาการกระท าใดเหมาะสมทสดo On external pacingo Atropine 0.6 mg iv stato 7.5 % NaHCO3 1 amp iv stat o 10% Ca-gluconate 1 amp iv stat
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55 Yr-old female บนจกแนนหนาอกทลนปมา 1 ช.ม เปนขณะพก ประวตวาเคยไปตรวจทคลนคแพทยบอกวาหวใจโต V/S : BP 140/86 PR 87/min ,regular-full peripheral pulse. EKG เปนดงรป ทานจะท าอยางไรo ให ASA, ISDN, Morphine
o ให serial EKG ไปกอน รอ cardiac enzyme
o Consult cardiologist ทนท สงสย AMI
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58 Yr-old male บนแนนหนาอก หนามดจะเปนลม 30 นาท V/S BP 90/60 PR 33/min ,sweating, look anxiousness. EKG เปนดงรป ทานจะท าอยางไรo ให atropine 1 amp iv. stat
o ให serial EKG รอ cardiac enzyme
o Consult cardiologist ทนท สงสย AMI
o ใส Transcutaneous pacing
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61 Yr-old male หนามด ขณะนงรบประทานอาหาร ไมมจกแนนหนาอก แตมใจสน V/S แรกรบ BP 95/57 PR 42/min , irregular, sweating ถามตอบไมรเรอง o ให atropine 1 amp iv. stat
o ให serial EKG รอ cardiac enzyme
o Consult cardiologist ทนท o ใส Transcutaneous pacing
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66 Yr-old male, underlying CAD with history of coronary bypass graft. มาดวยเปนลมหมดสต ไมรสกตว BP วดไมได ปลายมอปลายเทาซด เยน o ให adenosine 6 mg iv stat
o ให synchronized cardioversion 100 J
o ให cordarone 150 mg iv stat
o ให Defib 200 J
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• 57 yr-old woman with palpitation, chest discomfort and tacchycardia. The moniter as picture. She becomes diaphoretic and BP 80/60 mmHg. The next action is
o Obtain 12 lead EKG
o Perform immediate electrical cardioversion
o Establish IV and give sedation for electrical cardioversion
o Give amiodarone 300 mg IV push
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• 27 ปผชาย อย ๆ มอาการใจสน หนามด จะเปนลม เหงอแตก ไมเคยเปนเชนนมากอน มาท ER ปลายมอปลายเทาเยน BP 120/84 PR 210 EKG เปนดงรป จงใหการรกษา o Adenosine 6 mg iv stat
o Give amiodarone 300 mg IV push
o Perform immediate Defibrillation
o Establish IV and give sedation for synchronized cardioversion
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WINTERTemplateBasic
EKG
01
Panita Worapratya
Emergency Department
Prince of Songkhla University
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01Basic EKG
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Basic EKG Analysis
• Step 1 : Regular or not ?
• Step 2 : P wave ?
• Step 3 : QRS ? (wide/narrow)
• Step 4 : ST-segment elevation
• Step 5 : QT segment
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Step 1 : Regular or not ?
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Rate & rhythm
• RR interval is 2 large block, rate = 150 beats/min (300/2)• RR interval is 3 large block, rate = 100 beats/min (300/3)• RR interval is 4 large block, rate = 75 beats/min (300/4)
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Step 2 : P wave
• Normal (sinus P wave) present?
• Abnormal (non sinus P wave) present ?
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Step 2 : P wave
• No P wave : SVT or junctional
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Step 2 : P wave
• Repalcement of P wave by other atrial wave?
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Step 3 : QRS complex
Wide QRS complexStable V/S ?
StableUnstable
Immediate Cardioversion Consider common cause
•VT : Most common, especially underlying heart disease•SVT with pre-existing RBBB•SVT with aberrant conduction
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Differrentiate Wide QRS
Wide QRS complex
IVCDTypical RBB Typical LBB
•QRS wide > 0.11 s•rSR' or rsR' in V1•Wide terminal S wave in Lead I, V6
•QRS wide > 0.12 s•Upright (monophasic) QRS in Lead I, V6•Negative QRS in V1
•QRS wide > 0.11 s.•Neither typical RBB nor LBB present(เปนตด ไมใช LBB กไมใช RBB กไมเชง)
LBB
RBB
Excluded VT and WPW !!
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Wide QRS differrentiation
Wide QRS complex
WPW•Short PR• Delta wave• Wide QRS complex
Excluded VT and WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? ( independent P/QRS, capture
beats, fusion beat)
Yes = VT
2. Is there an RS in any precordial lead?
No = VT
3. Is there QRS onset to nadir of S wave > 100 msec in any precordial lead?
Yes = VT
4. Are there morphologic criteria for VT in both V1 or V6?
Yest = VT
5. If no, SVT
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Wide QRS differrentiation
Wide QRS complexExcluded VT and
WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? ( independent P/QRS, capture
beats, fusion beat)
Yes = VT
2. Is there an RS in any precordial lead?
No = VT
3. Is there QRS onset to nadir of S wave > 100 msec in any precordial lead?
Yes = VT
4. Are there morphologic criteria for VT in both V1 or V6?
Yest = VT
5. If no, SVT
AV dissociation
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Wide QRS differrentiation
Wide QRS complexExcluded VT and
WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? ( independent P/QRS, capture
beats, fusion beat)
Yes = VT
2. Is there an RS in any precordial lead?
No = VT
3. Is there QRS onset to nadir of S wave > 100 msec in any precordial lead?
Yes = VT
4. Are there morphologic criteria for VT in both V1 or V6?
Yest = VT
5. If no, SVT No RS wave in any precordial leads
100 % specific for VTSensitivity 26%
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Wide QRS differrentiation
Wide QRS complexExcluded VT and
WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? ( independent P/QRS, capture
beats, fusion beat)
Yes = VT
2. Is there an RS in any precordial lead?
No = VT
3. Is there QRS onset to nadir of S wave > 160 msec in any precordial lead?
Yes = VT
4. Are there morphologic criteria for VT in both V1,2 or V6?
Yest = VT
5. If no, SVT
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Wide QRS differrentiation
Wide QRS complexExcluded VT and
WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? ( independent P/QRS, capture
beats, fusion beat)
Yes = VT
2. Is there an RS in any precordial lead?
No = VT
3. Is there QRS onset to nadir of S wave > 100 msec in any precordial lead?
Yes = VT
4. Are there morphologic criteria for VT in both V1,2 or V6?
Yest = VT
5. If no, SVT
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Wide QRS differrentiation
Wide QRS complexExcluded VT and
WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? ( independent P/QRS, capture
beats, fusion beat)
Yes = VT
2. Is there an RS in any precordial lead?
No = VT
3. Is there QRS onset to nadir of S wave > 100 msec in any precordial lead?
Yes = VT
4. Are there morphologic criteria for VT in both V1,2 or V6?
Yest = VT
5. If no, SVT
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WINTERTemplate
Differrentiate Wide QRS
Wide QRS complex
IVCDTypical RBB Typical LBB
•QRS wide > 0.11 s•rSR' or rsR' in V1•Wide terminal S wave in Lead I, V6
•QRS wide > 0.12 s•Upright (monophasic) QRS in Lead I, V6•Negative QRS in V1
•QRS wide > 0.11 s.•Neither typical RBB nor LBB present(เปนตด ไมใช LBB กไมใช RBB กไมเชง)
LBB
RBB
Excluded VT and WPW !!
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Step 4 : Analysis rhythm
Narrow complex tacchycardia
• Sinus tacchycardia
• Atrial fibrillation
• Atrial flutter
• AV nodal reentry
• Accessory pathway-mediated tachycardia
• Atrial tacchycardia (ectopic or reentrance)
• Multifocal atrial tacchycardia (MAT)
• Junctional tacchycardia
Wide QRS complex tacchycardia
• Ventricular tacchycardia
• SVT with aberrancy
• Pre-excited tacchycardia
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Step 4 : Analysis rhythmNarrow complex tacchycardia
• Measure rate and rhythm
• Look for P wave & QRS relationship– If P > QRS : Atrial arrythmia
– If P = QRS : Look for timing of P-wave• P in QRS = AVRT
• P fused with QRS = AVNRT
– If P < QRS : Junctional arrythmia
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Step 4 : Analysis rhythmNarrow complex tacchycardia
P > QRS= Atrial arrythmia
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Narrow complex tacchycardiaP = QRS
P in QRS = AVRT
AVRT with reentrance circuit consisting of 2 limbs, the antrograde limb involve the normal QRS and retrograde limbs involve accessory pathway
WPW : Normal electrical conduction through AV node and accessory pathway cause slurred upstoke of QRS wave (delta wave
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Narrow complex tacchycardia
P = QRSP fused with QRS
= AVNRT
AVNRT :Reentrance circuit around AV nodeleading to rapid stimulation of ventricle and tacchycardia.
These AV nodal reentry beats stimulate both the atrium and the ventricles rapidly in typically a 1 to 1 fashion with a strip of the EKG shown at the bottom.
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Narrow complex tacchycardia
P < QRS = Junctional taccycardia
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Wide complex tacchycardia
. Monomorphic VT Polymorphic VT
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Narrow complex Bradycardia
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Narrow complex Bradycardia
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2nd degree AV block
PR segment
Group of beat ?
PR Prolonger
PR equal prolong
Morbitz I Morbitz II
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WINTERTemplateBrady &
Tacchycardia
20
05
Panita Worapratya
Emergency Department
Prince of Songkhla University
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Tacchycardia
•Assess & support ABCD•Given oxygen•Moniter EKG, BP, oxymetry•Identify & treat reversible cause
•Establish AV access•Obtain 12 Leads EKG
Is QRS narrow? (<0.12 s)
Is patient stable ?
Immediate Synchronized cardioversionImmediate I.V accessExpert consultationIf pulseless arrest develop, follow guideline
Yes Yes
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•Establish AV access•Obtain 12 Leads EKG
Is QRS narrow? (<0.12 s)
Stable patient
Narrow QRS complex Wide QRS complex
Regular or not?
Regular-narrow complex•Attempt vagal maneuver•Adenosine 6 mg iv push then 12 mg iv push
may repeat 12 mg iv push at once
Irregular –narrow complexPossible AF, atrial flutter or MATConsider expert consultationControle rate : Diltiazem, B-blockerCaution B-blocker in CHF, Hypotension
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Regular-narrow complex•Attempt vagal maneuver•Adenosine 6 mg iv push then 12 mg iv push
may repeat 12 mg iv push at once
Does rhythm convert ?
Rhythm Convert= Possible SVT•Observe for recurrent•Treat recurrent with adenosine or AV blocking agent (diltiazem/B-blocker)
Rhythm Dose not Convert= Possible atrial flutter, ectopic atrialtacchycardia, or junctional tacchycardia• Controle rate (diatiazem, b-blocker)• Treat underlying cause• Expert consultation
During evaluation consider =6H= =5T=Hypovolumia ToxinHypoxia TemponadeHydrogen ion ThrombosisHypoglycemia Tension pneumothoraxHypo/hyper kalemia TraumaHypothermia
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Wide QRS complex
If ventricular tacchycardia or uncertain rhythm •Amiodarone 150 mg i.v over 10 min Repeat as needed to maximum dose 2.2 g/24 hr•Prepare for synchronized cardioversionIf SVT with aberrency ,•Give adenosine
Regular Irregular
If atrial fibrillation with aberrency• Treat as irregular narrow complex tacchycardiaIf preexite atrial fibrillation (AF with WPW)• Expert consultation• Avoid AV nodal blocking agent (adenosine, digoxin, diltiazem, verapamil)• Consider antiarrhythmic drug (amiodarone 150 mg iv over 10 min)If recurrent polymorphic VT• Expert consultationIf torsade de point give •MgSO4 1-2 g over 5-60 min then infusion
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Answer : SVT =Adenosine 6 mg
• 35 yr-old woman with palpitation, light headness and stable tacchycardia. EKG as picture. An IV has been established. What drug should be administered IV? o Atropine 0.5 mg
o Lidocaine 1 mg/kg
o Epinephrine 2-10 µg/kg/min
o Adenosine 6 mg
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WINTERTemplate
67 Yr-old male ไมรสกตวมา 30 min >V/S : BP 64/24,PR 30/min หลงจากทานไดใสทอชวยหายใจ เปดเสนเลอด ตด monitor EKG แลว คลนไฟฟาหวใจเปนดงรปทานคดวาการกระท าใดเหมาะสมทสดo On external pacingo Atropine 0.6 mg iv stato 7.5 % NaHCO3 1 amp iv stat o 10% Ca-gluconate 1 amp iv stat
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WINTERTemplate
55 Yr-old female บนจกแนนหนาอกทลนปมา 1 ช.ม เปนขณะพก ประวตวาเคยไปตรวจทคลนคแพทยบอกวาหวใจโต V/S : BP 140/86 PR 87/min ,regular-full peripheral pulse. EKG เปนดงรป ทานจะท าอยางไรo ให ASA, ISDN, Morphine
o ให serial EKG ไปกอน รอ cardiac enzyme
o Consult cardiologist ทนท สงสย AMI
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WINTERTemplate
58 Yr-old male บนแนนหนาอก หนามดจะเปนลม 30 นาท V/S BP 90/60 PR 33/min ,sweating, look anxiousness. EKG เปนดงรป ทานจะท าอยางไรo ให atropine 1 amp iv. stat
o ให serial EKG รอ cardiac enzyme
o Consult cardiologist ทนท สงสย AMI
o ใส Transcutaneous pacing
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WINTERTemplate
61 Yr-old male หนามด ขณะนงรบประทานอาหาร ไมมจกแนนหนาอก แตมใจสน V/S แรกรบ BP 95/57 PR 42/min , irregular, sweating ถามตอบไมรเรอง o ให atropine 1 amp iv. stat
o ให serial EKG รอ cardiac enzyme
o Consult cardiologist ทนท o ใส Transcutaneous pacing
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WINTERTemplate
66 Yr-old male, underlying CAD with history of coronary bypass graft. มาดวยเปนลมหมดสต ไมรสกตว BP วดไมได ปลายมอปลายเทาซด เยน o ให adenosine 6 mg iv stat
o ให synchronized cardioversion 100 J
o ให cordarone 150 mg iv stat
o ให Defib 200 J
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Answer : VT with pulse
Immediate electrical cardioversion
• 57 yr-old woman with palpitation, chest discomfort and tacchycardia. The moniter as picture. She becomes diaphoretic and BP 80/60 mmHg. The next action is
o Obtain 12 lead EKG
o Perform immediate electrical cardioversion
o Establish IV and give sedation for electrical cardioversion
o Give amiodarone 300 mg IV push
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• If the patient is monomorphic, unstable VT but has pulse, treat with synchronized cardioversion initial dose is 100J. and stepwise (200J, 300J, 360J)
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• 27 ปผชาย อย ๆ มอาการใจสน หนามด จะเปนลม เหงอแตก ไมเคยเปนเชนนมากอน มาท ER ปลายมอปลายเทาเยน BP 120/84 PR 210 EKG เปนดงรป จงใหการรกษา o Adenosine 6 mg iv stat
o Give amiodarone 300 mg IV push
o Perform immediate Defibrillation
o Establish IV and give sedation for synchronized cardioversion
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WINTERTemplateCoronary
Syndrome
20
05
Panita Worapratya
Emergency Department
Prince of Songkhla University
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WINTERTemplateBasic EKG for
ACS
20
05
Panita Worapratya
Emergency Department
Prince of Songkhla University
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WINTERTemplate
EKG change during ischemia
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WINTERTemplate
EKG change during ischemia
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WINTERTemplate
EKG change during ischemia
LCA origin : Lt. sinus of aortic valve
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WINTERTemplate
EKG change during ischemia
LAD : Anteroseptal
Distal LAD : Anastomosiswith posterior diagonal branch of RCA
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WINTERTemplate
EKG change during ischemia
LCx : Anterolateral wall
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WINTERTemplate
EKG change during ischemia
RCA : RV, inferior wall
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Inferior wall II, III, aVF RCA or LCA
RV infarction II, III, aVF, V4R Prox. RCA
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Inferior wall II, III, aVF RCA or LCA
RV infarction II, III, aVF, V4R Prox. RCA
Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Anterior V2-4 Mid LAD
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Anterior V2-4 Mid LAD
Ant-Lat-Sep V1-6, aVL Prox LAD
Lateral I, aVL,V5,6 Diagonal branch of LAD
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Anterior V2-4 Mid LAD
Ant-Lat-Sep V1-6, aVL Prox LAD
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Anterior V2-4 Mid LAD
Ant-Lat-Sep V1-6, aVL Prox LAD
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Anterior V2-4 Mid LAD
Ant-Lat-Sep V1-6, aVL Prox LAD
Lateral I, aVL,V5,6 Diagonal branch of LAD
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WINTERTemplate
Basic Leads group
Wall EKG Blood supply
Inferior wall II, III, aVF RCA or LCA
RV infarction II, III, aVF, V4R Prox. RCA
Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA
Anterior V2-4 Mid LAD
Ant-Lat-Sep V1-6, aVL Prox LAD
Lateral I, aVL,V5,6 Diagonal branch of LAD
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WINTERTemplate
RCA or RCx
RCA occlusion
• ST elevation III > II
• ST depression in Lead I
• Isoelectric V4R
RCx occlusion
• ST elevation II > III
• ST elevate in Lead I
• Negative V4R
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WINTERTemplate
Various cause of ST segment Deviation
ST elevation ST depression
Suggest MI
Early repolarization
Asymmetric ST depression in lateral leads
Symmetric ST inversion in
contiguous leads
“Scooping or strain like pattern
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WINTERTemplate
EKG Evolution in non-reperfused MI
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WINTERTemplate
Morphology of ST elevate
LVH LBB Hyper K+ MI MI + RBBB BrugadaPericarditis
• Deep S wave in V1,V2• Tall R in V5,V6
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WINTERTemplate
Morphology of ST elevate
LVH LBB Hyper K+ MI MI + RBBB BrugadaPericarditis
• Predominate negative QRS in V1• QRS widening > 0.12 s• Upright QRS in Lead I, V6
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WINTERTemplate
Morphology of ST elevate
LVH LBB Hyper K+ MI MI + RBBB BrugadaPericarditis
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WINTERTemplate
Morphology of ST elevate
LVH LBB Hyper K+ MI MI + RBBB BrugadaPericarditis
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WINTERTemplate
Morphology of ST elevate
LVH LBB Hyper K+ MI MI + RBBB BrugadaPericarditis
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WINTERTemplate
Morphology of ST elevate
LVH LBB Hyper K+ MI MI + RBBB BrugadaPericarditis
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WINTERTemplate
Morphology of ST elevate
LVH LBB Hyper K+ MI MI + RBBB BrugadaPericarditis
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WINTERTemplate
Morphology of ST elevate
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Chest comfortsuggest of ischemia
EMS careand Hosp. preparation• Moniter, ABC support, prepare for CPR & defibrillation
• Administer MONA (morphine,oxygen,nitroglycerine, ASA) as needed• Obtain EKG, if ST-elevation
• Notify receiving hospital• Begin fibrinolytic check list
• Notify hospital to response MI.
Immediate ED assessment < 10 min• Check V/S, evaluate oxygen saturation• Obtain 12 leads EKG• Brief target Hx & PE• Review fibrinolytic check list• Obtain initial cardiac marker level, E-lyte and coagulopathy• Obtain portable CXR < 30min
Immediate ED general treatmentStart O2 4 L/min, maintain O2 sat > 90%ASA 160-325 mg (if not given by EMS)NTG sublingual,spray or i.vMorphine i.v if not improved by NTG
1
2
3
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Review 12 Leads EKG
ST elevation or new LBBB
Strongly suspected STEMI
ST depression or dynamic T-wave, strongly suspected
ischemia
UA high risk /NSTEMI
Normal or nondiagnostic ST-wave change
Intermediate or low risk
Start adjunctive treatment as indicated
• B-adrenergic receptor block• Clopidogrel• Heparin
Start adjunctive treatment as indicated
• Nitroglycerine• B-adrenergic blocker• Clopidogrel• Glycoprotein Iib/IIIa
Develop High or Intermediate risk criteria (Table 3,4)
or Troponin positive
4
5
6
9 13
10 14
Time form onset of symptoms ≤ 12 hr
7Admit to moniter and risk assessment (Table
3,4)
Consider admission to ED chest pain unit or
monitered bed• Serial cardiac marder• Repeate EKG• consider stress test
11 15
YES
No
≥ 12hr
< 12hr
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Review 12 Leads EKG
ST elevation or new LBBB
Strongly suspected STEMI
ST depression or dynamic T-wave, strongly suspected
ischemia
UA high risk /NSTEMI
Normal or nondiagnostic ST-wave change
Intermediate or low risk
Start adjunctive treatment as indicated
• B-adrenergic receptor block• Clopidogrel• Heparin
4
5
6
9 13
Time form onset of symptoms ≤ 12 hr
7Admit to moniter and risk assessment (Table
3,4)
11≥ 12hr
< 12hr
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Time form onset of symptoms ≤ 12 hr
7
Reperfusion therapy•Reperfusion goal
•Door to balloon (PCI) < 90 min•Door to needle (fibrinolysis) 30min
•Continue adjuctivetherapy and..
• ACE-I or ARB < 24 of onset• HMG co A reductaseinhibitor
8
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Review 12 Leads EKG
ST elevation or new LBBB
Strongly suspected STEMI
ST depression or dynamic T-wave, strongly suspected
ischemia
UA high risk /NSTEMI
Normal or nondiagnostic ST-wave change
Intermediate or low risk
Start adjunctive treatment as indicated
• Nitroglycerine• B-adrenergic blocker• Clopidogrel• Glycoprotein Iib/IIIa
4
5 9 13
10
Admit to moniter and risk assessment (Table
3,4)
11
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Admit to moniter and risk assessment (Table
3,4)
11
High risk patient (table 3,4 for risk stratification)• Refractory ischemic chest pain• Recurrent persistent STE• Ventricular tacchycardia• Hemodynamic instability• Early invasive strategy, including PCI and revascularization for shock ≤ 48 hr. of AMIContinue ASA, heparin and other therapy as indicated• ACE-I/ ARB• HMG co A reductase inhibitor
12
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Review 12 Leads EKG
ST elevation or new LBBB
Strongly suspected STEMI
ST depression or dynamic T-wave, strongly suspected
ischemia
UA high risk /NSTEMI
Normal or nondiagnostic ST-wave change
Intermediate or low risk
Start adjunctive treatment as indicated
• Nitroglycerine• B-adrenergic blocker• Clopidogrel• Glycoprotein Iib/IIIa
Develop High or Intermediate risk criteria (Table 3,4)
or Troponin positive
4
5 9 13
14
Admit to moniter and risk assessment (Table
3,4)
Consider admission to ED chest pain unit or
monitered bed• Serial cardiac marder• Repeate EKG• consider stress test
15
YES
No
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Consider admission to ED chest pain unit or
monitered bed• Serial cardiac marder• Repeate EKG• consider stress test
15
Develop High or Intermediate risk criteria (Table 3,4)
or Troponin positive
16
If no evidence of ischemia or infarction, can discharge with F/U
17
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Check list for STEMI fibrinolytic therapy
SBP > 180 mm Hg □ YES □ NO
DBP > 110 mmHg □ YES □ NO
∆ Rt. VS Lt. arm SBP > 15 mmHg □ YES □ NO
History of structural CNS disease □ YES □ NO
Significant closed head or facial trauma < 3 mo □ YES □ NO
Recent major surgery or trauma or GU/GI bleed < 6 wk □ YES □ NO
Bleeding or clotting problem □ YES □ NO
CPR > 10 min □ YES □ NO
Pregnant female □ YES □ NO
Serious systemic disease □ YES □ NO
Chest discomfort > 15 min, < 12 hr
EKG show STEMI or new LBBB ?
Are there contraindication for fibrinolysis ?
stop
YES
YES
Step 1
Step 2
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Check list for STEMI fibrinolytic therapy
HR ≥ 100/min and SBP < 100 mmHg □ YES □ NO
Pulmonary edmema (rale) □ YES □ NO
Sign of shock (cool, clamy) □ YES □ NO
Contraindication for fibrinolytid therapy □ YES □ NO
Is a pateint any high risk ?If any of following check “YES” , consider PCI
Are there contraindication for fibrinolysis ?
NO
Step 2
Step 3
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Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment changeLikelihood of ischemic etiology
A : High likelihoodAny of following
B : Intermediate likelihoodNo A with any of following
C : Low likelihoodNo A & B with any of following
History • Chief complaint of Lt. arm pain or discomfort plus Current pain reproduce pain of prior pain document angina and Known CAD including MI
Physical Exam • Transient MR• Hypotension• Diaphoresis• Pulmonary edema or rale
EKG • New (or persume new) transient ST deviation (>0.5 mm) or T wave inversion (> 2 mm) with symptoms
Cardiac marker • Elevate troponin I or T • Elevate CK-MB
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Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment changeLikelihood of ischemic etiology
A : High likelihoodAny of following
B : Intermediate likelihoodNo A with any of following
C : Low likelihoodNo A & B with any of following
History • Chief complaint of Lt. arm pain or discomfort plus Current pain reproduce pain of prior pain document angina and Known CAD including MI
• Chief complaint is Lt. arm painor dyscomfort• Age > 70 yr.• Male sex• Diabetic mellitus
Physical Exam • Transient MR• Hypotension• Diaphoresis• Pulmonary edema or rale
• Extravascular disease
EKG • New (or persume new) transient ST deviation (>0.5 mm) or T wave inversion (> 2 mm) with symptoms
• Fixd Q wave • Abnormal ST segment or T wave that are not new
Cardiac marker • Elevate troponin I or T • Elevate CK-MB
• Normal
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Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment changeLikelihood of ischemic etiology
A : High likelihoodAny of following
B : Intermediate likelihoodNo A with any of following
C : Low likelihoodNo A & B with any of following
History • Chief complaint of Lt. arm pain or discomfort plus Current pain reproduce pain of prior pain document angina and Known CAD including MI
• Chief complaint is Lt. arm painor dyscomfort• Age > 70 yr.• Male sex• Diabetic mellitus
• Probable ischemic symptoms• Recent cocaine use
Physical Exam • Transient MR• Hypotension• Diaphoresis• Pulmonary edema or rale
• Extravascular disease • Chest discomfort reproduce by palpation
EKG • New (or persume new) transient ST deviation (>0.5 mm) or T wave inversion (> 2 mm) with symptoms
• Fixd Q wave • Abnormal ST segment or T wave that are not new
• Normal EKG or T wave flattening or T wave inversion in leads which dominant R wave
Cardiac marker • Elevate troponin I or T • Elevate CK-MB
• Normal • Normal
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Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high or intermediate likelihood of ischemia (column A, B in Part I)
High risk Any of the following
Intermediate risk Any of the following
Low risk Any of the following
History • Accelerating tempo of ischemic symptoms over prior 48 hr.
Character of pain • Prolong continue > 20 min of rest pain
Physical exam • Age > 75 yr • Pulmonary edema secondary to ischemia• New or worse MR• Hypotension, brady/tacchycardia• S3 gallops or new or worsening rale
EKG • Transient ST segment deviation(≥ 0.5 mm with rest agina) • Persume new LBBB• Sustain VT
Cardiac marker • Elevate cardiac troponin• Elevate CK-MB
Table 3 : Likely hood of ischemic etiology (short term risk)
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Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high or intermediate likelihood of ischemia (column A, B in Part I)
High risk Any of the following
Intermediate risk Any of the following
Low risk Any of the following
History • Accelerating tempo of ischemic symptoms over prior 48 hr.
• Prior MI or• Peripheral artery disease or• Cerebrovascular disease or• CABG, prior ASA use
Character of pain • Prolong continue > 20 min of restpain
• Prolong > 20 min rest angina is now resolved (moderate to high likely hood of CAD)• Rest angina (<20 min) or relieved by rest or sublingual nitroglycerine
Physical exam • Age > 75 yr • Pulmonary edema secondary to ischemia• New or worse MR• Hypotension, brady/tacchycardia• S3 gallops or new or worsening rale
• Age > 70 yr
EKG • Transient ST segment deviation (≥ 0.5 mm with rest agina) • Persume new LBBB• Sustain VT
• T wave inversion ≥ 2 mm.• Pathologic T wave or Q wave that are not new
Cardiac marker • Elevate cardiac troponin• Elevate CK-MB
• Any or above , plus normal
Table 3 : Likely hood of ischemic etiology (short term risk)
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Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high or intermediate likelihood of ischemia (column A, B in Part I)
High risk Any of the following
Intermediate risk Any of the following
Low risk Any of the following
History • Accelerating tempo of ischemic symptoms over prior 48 hr.
• Prior MI or• Peripheral artery disease or• Cerebrovascular disease or• CABG, prior ASA use
Character of pain • Prolong continue > 20 min of restpain
• Prolong > 20 min rest angina is now resolved (moderate to high likely hood of CAD)• Rest angina (<20 min) or relieved by rest or sublingual nitroglycerine
• New onset functional angina (Class III or IV) in past 2 wk. without prolong rest pain (but with moderate to high likelihood of CAD)
Physical exam • Age > 75 yr • Pulmonary edema secondary to ischemia• New or worse MR• Hypotension, brady/tacchycardia• S3 gallops or new or worsening rale
• Age > 70 yr
EKG • Transient ST segment deviation (≥ 0.5 mm with rest agina) • Persume new LBBB• Sustain VT
• T wave inversion ≥ 2 mm.• Pathologic T wave or Q wave that are not new
• Normal or unchanged EKG during an episode of chest discomfort
Cardiac marker • Elevate cardiac troponin• Elevate CK-MB
• Any or above , plus normal • Normal
Table 3 : Likely hood of ischemic etiology (short term risk)
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Table 4 : TIMI risk score for patient with UA and NSTEMI
Predictor variable
Age > 65 year≥ 3 risk factor of CAD ASA used in Last 7 daysRecent , severe symptoms of anginaElevated cardiac markerST deviation ≥ 0.5 mm.Prior coronary a. stenosis > 50%
Risk factor of CAD• Family Hx of CAD• HT• Hypercholesteralemia• D.M• Current smoker
≥ 2 angina event in last 24 hr
•ST depression > 0.5 mm is significant•Transient ST deviation > 0.5 mm < 20 min is high risk•STE > 1 mm (>20 min) = STEMI
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Table 4 : TIMI risk score for patient with UA and NSTEMI
Predictor variable
Age > 65 year≥ 3 risk factor of CAD ASA used in Last 7 daysRecent , severe symptoms of anginaElevated cardiac markerST deviation ≥ 0.5 mm.Prior coronary a. stenosis > 50%
Calculated TIMI risk score
Risk of ≥ 1 primary end point in 14
days
Risk status
0-2 5-8% Low
3-4 13-20% Intermediate
5 26% High
6 or 7 41% High
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WINTERTemplate
Case Presentation
• ชายอาย 42 ป : 3 วนมอาการใจสน แนนหนาอก ไมสมพนธกบการออกก าลง อาการเปน ๆ หาย ๆ เจบหนาอกครงสดทาย 45 นาทกอนมาร.พ เพอนน าสงร.พ
V/S : BT 36 c PR 40/min , RR 20/min, BP 69/37 mmHg
Consciousness พดเปนค า ท าตามสงบาง ไมท าตามสงบาง เหงอแตก มอเทาเยน บนแนนหนาอก
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Case Presentation
A : Anxiousness. B : Lung is clear . O2 sat วดไมได C : PR 40/min,irregular rate, no murmur. Poor peripheral pluse, acrocyanosis. D : E3V5M5-6 No moter weakness.
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Case Presentation
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Case Presentation
Initial managementA : None
B : O2 cannular 3 LPM
C : Moniter EKG, I.V access
สง Lab + cardiac enzyme
0.9 % NSS iv load 1000 ml iv freee flow 300 ml Atropine 1 amp iv stat
On External pacemaker
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WINTERTemplate
Case Presentation
หลง Load fluid ครบ 300 ml และให atropine 1 amp
V/S : PR 65/min BP 72/47 , O2 sat 100%
เรมถามตอบไมรเรอง มองไมสอความหมาย
Mx : ET-Tube No 7.5 ขด 23 cm.
EKG เปนดงรป (next slide)
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WINTERTemplate
Case Presentation
หลง Load fluid ครบ 300 ml และให atropine 1 amp
V/S : PR 65/min BP 72/47 , O2 sat 100%
เรมถามตอบไมรเรอง มองไมสอความหมาย
Mx : ET-Tube No 7.5 ขด 23 cm.
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Case Presentation
• At 19.37 หลงใส ET-Tube คนไขเรม unconsciousness , คล า pulse ไมไดทานจะท าอยางไรตอไป
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Case Presentation
• หลงจาก CPRไปได 2 นาท ให adrenaline run q 3 min คลนไฟฟาหวใจเปนดงรป ทานจะท าอยางไรตอไป
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WINTERTemplate
Case Presentation
• ไดท า defibrillation x 3 ครง EKG ยงคงเปนเชนน ทานจะท าอยางไรตอไป
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WINTERTemplate
Case Presentation
• หลงจากทาน ได check lead, ขยาย amplitude แลว EKG เปนดงน ทานจะท าอยางไรตอไป
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WINTERTemplate
Case Presentation
หลงจากทานได Defibrillation แลว EKG เปนดงน ทานจะท าอยางไรo Atropine 1 amp iv stat
o External pacemakero Transfer to ICUo Load 0.9% NSS
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20
05
Panita Worapratya
Emergency Department
Prince of Songkhla University
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Common cause of ST depression
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Review 12 Leads EKG
ST elevation or new LBBB
Strongly suspected STEMI
ST depression or dynamic T-wave, strongly suspected
ischemia
UA high risk /NSTEMI
Normal or nondiagnostic ST-wave change
Intermediate or low risk
Start adjunctive treatment as indicated
• B-adrenergic receptor block• Clopidogrel• Heparin
Start adjunctive treatment as indicated
• Nitroglycerine• B-adrenergic blocker• Clopidogrel• Glycoprotein Iib/IIIa
Develop High or Intermediate risk criteria (Table 3,4)
or Troponin positive
4
5
6
9 13
10 14
Time form onset of symptoms ≤ 12 hr
7Admit to moniter and risk assessment (Table
3,4)
Consider admission to ED chest pain unit or
monitered bed• Serial cardiac marder• Repeate EKG• consider stress test
11 15
YES
No
≥ 12hr
< 12hr