Mod-3 Acute Coronary Syndromes 12 LEAD

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MODULE 3:

MODULE 3 Acute Coronary Syndromes Part 1

Acute Coronary Syndromes:

Acute Coronary Syndromes Definition: Sudden ischemic disorders of the heart Include unstable angina and acute myocardial infarction Represent a continuum of a similar disease process

Acute Coronary Syndromes:

Acute Coronary Syndromes Acute Coronary Syndromes ACS Unstable Angina USA Non-Q Wave Infarct NQMI Q Wave Infarct QMI

Acute Coronary Syndromes:

Acute Coronary Syndromes Unstable angina (USA) Non-Q wave MI (NQMI) Q wave MI (QMI)

Acute Coronary Syndromes:

Acute Coronary Syndromes All have sudden ischemia Can not be differentiated in the first hours All have the same initiating events

Initiating Events:

Initiating Events Plaque rupture Thrombus formation Vasoconstriction

Plaque Rupture:

Lumen Plaque Rupture Lipid Core Fibrous Cap Stable Vulnerable Lumen Lipid Core Fibrous Cap

Plaque Rupture:

Plaque Rupture Lipid Core Fibrous Cap Lumen

Thrombus Formation:

Thrombus Formation Lipid Core Fibrous Cap Platelets Adhere

Thrombus Formation:

Thrombus Formation Platelet Aggregation Lipid Core

Thrombus Formation:

Thrombus Formation Platelet Aggregation Lipid Core

Thrombus Formation:

Thrombus Formation Platelet Aggregation Lipid Core Fibrin

Vasoconstriction:

Vasoconstriction

Will Infarct Occur?:

Will Infarct Occur? Tissue Death? Plaque Rupture Thrombus Formation Coronary Vasoconstriction Collateral Circulation Myocardial Oxygen Demand

The Three I’s:

The Three I’s Ischemia lack of oxygenation ST depression or T inversion Injury prolonged ischemia ST elevation Infarct death of tissue may or may not show in Q wave

Slide 16:

Epicardial Coronary Artery Lateral Wall of LV Positive Electrode Septum Left Ventricular Cavity Interior Wall of LV Well Perfused Myocardium

Normal ECG:

Normal ECG

Slide 18:

Epicardial Coronary Artery Lateral Wall of LV Positive Electrode Septum Left Ventricular Cavity Interior Wall of LV Ischemia

Ischemia:

Ischemia Inadequate oxygen to tissue Subendocardial Represented by ST depression or T inversion May or may not result in infarct

ST depression:

ST depression

Slide 21:

Thrombus Ischemia Injury

Injury:

Injury Prolonged ischemia Transmural Represented by ST elevation Usually results in infarct

ST elevation:

ST elevation

Infarct:

Infarct Death of tissue Represented by Q wave Not all infarcts develop Q waves

Slide 25:

Infarcted Area Electrically Silent Depolarization Many infarcts do not develop Q waves Infarction

Q Waves :

Q Waves

Slide 27:

Infarcted Area Electrically Silent Thrombus Depolarization Ischemia

Summary:

Summary A normal ECG does NOT rule out ACS ST segment depression represents ischemia Possible infarct ST segment elevation is evidence of AMI Q wave MI may follow ST elevation or depression

Acute Coronary Syndromes:

Acute Coronary Syndromes Rapid Recognition and Treatment of ACS

Small Group Task:

Small Group Task List and rank risk factors Describe symptoms of the last AMI patient attended Describe the symptoms of a friend or relative when they suffered an AMI

Goals for Module 3:

Goals for Module 3 Rapidly recognize and treat patients with sudden myocardial ischemia

Immediate Evaluation:

Immediate Evaluation Story Risk factors ECG

Clinical Presentations of ACS :

Clinical Presentations of ACS Classic anginal chest pain Atypical chest pain Anginal equivalents

Classic Anginal Chest Pain:

Classic Anginal Chest Pain Central anterior chest Dull, fullness, pressure, tightness, crushing Radiates to arms, neck, back

Atypical Pain:

Atypical Pain Musculoskeletal, positional or pleuritic features Often unilateral May be described as sharp or stabbing Includes epigastric discomfort Females often express atypical pain

Anginal Equivalents:

Anginal Equivalents Dyspnea Palpitations Syncope or pre-syncope General weakness DKA

Atypical Presentations:

Atypical Presentations Often seen in Female Diabetics Elderly

Important Notation:

Important Notation Note EXACT time symptoms began Duration of symptoms may effect therapeutic options and destination decisions

Review Group Activity:

Review Group Activity How many had presentations with classic anginal pain? How many had atypical pain? How many were anginal equivalents?

Review Group Activity:

Review Group Activity How many risk factors did you list? How did you rate them?

Consider Risk Factors:

Consider Risk Factors Patients with severe or multiple risk factors should be evaluated with a high index of suspicion for acute coronary syndrome

Risk Factors of ACS :

Risk Factors of ACS Diabetes Smoking Hypertension Age Family history of CAD Obesity Stress Sedentary

Age:

Age Males over 35 Females over 40 Infarct can occur at any age Increasing age = increasing risk

Summary:

Summary Unstable angina and acute myocardial infarction are indistinguishable in the first few hours “Atypical” presentations are common Risk factor evaluation helps identify ACS patients

Chronic Stable Angina versus ACS:

Chronic Stable Angina versus ACS Not chronic stable angina if… New onset Lower exertion threshold Change in pattern of relief New or different associated symptoms

General Therapy for ACS:

General Therapy for ACS Assessment Expose the chest Story and risks Monitor & 12-lead Vital signs & Sa0 2 Lab draw/cardiac markers Treatment Oxygen IV access Aspirin NTG Morphine

General Therapy for ACS:

General Therapy for ACS Assessment and therapy occur simultaneously Findings may alter therapeutic path

Expose the Chest:

Expose the Chest Expose the chest immediately Avoids delays in obtaining ECG Prevents entanglement of IV lines, monitor wires, etc. Use reasonable judgement Have gowns available

Oxygen:

Oxygen 4 lpm nasal cannula if respiratory rate normal and Sa0 2 >95 High flow mask if hypoxia or tachypnea are evident or suspected Advanced airway care for continued or severe hypoxia

Vital Signs:

Vital Signs Respiratory rate and effort Pulse rate, rhythm, force Blood pressure in both arms, manual then automatic Sa0 2 monitor Cardiac monitor and 12-lead ECG

12-Lead ECG:

12-Lead ECG Obtain and transmit with the first set of vital signs Repeat with each set of vital signs Repeat as often as necessary

IV Access:

IV Access Adequate line in a suitable vein Draw initial blood as indicated Point of care cardiac markers Blood glucose

Aspirin:

Aspirin 160-325 mg - chew or swallow Only absolute contraindication is known hypersensitivity to ASA Issues: Asthma patients may have been told to avoid ASA Patients on anti-coagulants Taken ASA already today

Nitroglycerin:

Nitroglycerin Dilates conduit arteries Antagonizes vasospasm Improves collateral circulation Inhibits venous return Reduces intramyocardial wall tension

Nitroglycerin:

Nitroglycerin 0.4mg sublingual Repeat every five minutes Contraindications include; Hypotension Viagra within 24 hours

NTG Precautions:

NTG Precautions Avoid hypotension Limit systolic drop Don’t use NTG as an analgesic Watch for RVI

Morphine:

Morphine 2 - 4mg every 5 minutes PRN May require several doses for adequate relief of pain Decreases myocardial oxygen requirements Watch for respiratory depression and hypotension

General Therapy for ACS:

General Therapy for ACS Outcomes to general therapy equal reperfusion therapy Some components are time dependent Monitor compliance and outcomes via quality assurance program

Module 3: Case 1 :

Module 3: Case 1 48 year old male Dull central CP 2/10, began at rest Pale and wet Overweight, smoker Vital signs: RR 18, P 80, BP 180/110, Sa0 2 94% on room air

Module 3: Case 1:

Module 3: Case 1

Module 3: Case 1:

Module 3: Case 1 Story Risk factors ECG Treatment

Module 3: Case 2:

Module 3: Case 2 68 year old female Sudden onset of anxiety and restlessness, States she “can’t catch her breath” Denies chest pain or other discomfort History of IDDM and hypertension RR 22, P 110, BP 190/90, Sa0 2 88% on NC at 4 lpm.

Module 3, Case 2:

Module 3, Case 2

Module 3: Case 2:

Module 3: Case 2 Story Risk factors ECG Treatment

Lab for Module 3:

Lab for Module 3 Study each ECG Fill in the blanks Provide your impression Examine the case studies Discuss the case