updates in acls 2005

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Panita Worapratya

Emergency Department

Prince of Songkhla University

Effective Chest compression

Minimized interruption

Fully recoil

Push hard &

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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Pulseless Arrest

Panita Worapratya

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

Asystole/PEAVF/VT

Give 1 shock•Manual biphasic 200J•Monophasic 300 J•AED when avialable

Resume CPR immediately

Asystole/PEAVF/VT

Resume CPR immediately

Continue CPR while defibrilator is charging

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

Give 1 shockResume CPR immediately after shockEpinephrine 1 mg I.V/I.O q 3-5 min

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

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

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

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

Contributing factor

• Hypovolumia

• Hypoxia

• Hydrogen ion

• Hypo/hyper kalemia

• Hypoglycemia

• Hypothermia

• Toxin

• Temponade (cardiac)

• Tension pneumothorax

• Thrombosis

• Trauma

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

IntraosseousSite of administration

2 cm. below medial tuberosity

2 cm. above medial condyle

2 cm. above medial maleolous

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

Questions

• Following initiation of CPR and one shock for

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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Tacchycardia

Panita Worapratya

• 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 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 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

• 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

• 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 Perform immediate Defibrillation

o Establish IV and give sedation for synchronized cardioversion

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Panita Worapratya

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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)

Excluded VT and WPW !!

Wide QRS differrentiation

Wide QRS complex

WPW•Short PR• Delta wave• Wide QRS complex

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

Wide QRS complexExcluded VT and

WPW !!

Question Answer

beats, fusion beat)

Yes = VT

No = VT

Yes = VT

Yest = VT

5. If no, SVT

AV dissociation

WPW !!

Question Answer

beats, fusion beat)

Yes = VT

No = VT

Yes = VT

Yest = VT

5. If no, SVT No RS wave in any precordial leads

100 % specific for VTSensitivity 26%

WPW !!

Question Answer

beats, fusion beat)

Yes = VT

No = VT

Yes = VT

4. Are there morphologic criteria for VT in both V1,2 or V6?

Yest = VT

5. If no, SVT

WPW !!

Question Answer

beats, fusion beat)

Yes = VT

No = VT

Yes = VT

Yest = VT

5. If no, SVT

WPW !!

Question Answer

beats, fusion beat)

Yes = VT

No = VT

Yes = VT

Yest = VT

5. If no, SVT

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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)

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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

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

Step 4 : Analysis rhythmNarrow complex tacchycardia

P > QRS= Atrial arrythmia

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

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.

P < QRS = Junctional taccycardia

Wide complex tacchycardia

. Monomorphic VT Polymorphic VT

Narrow complex Bradycardia

2nd degree AV block

PR segment

Group of beat ?

PR Prolonger

PR equal prolong

Morbitz I Morbitz II

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Tacchycardia

Panita Worapratya

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

•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

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

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

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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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

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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 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 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

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

• If the patient is monomorphic, unstable VT but has pulse, treat with synchronized cardioversion initial dose is 100J. and stepwise (200J, 300J, 360J)

• 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 Perform immediate Defibrillation

o Establish IV and give sedation for synchronized cardioversion

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Syndrome

Panita Worapratya

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Panita Worapratya

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EKG change during ischemia

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LCA origin : Lt. sinus of aortic valve

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LAD : Anteroseptal

Distal LAD : Anastomosiswith posterior diagonal branch of RCA

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LCx : Anterolateral wall

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RCA : RV, inferior wall

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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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Basic Leads group

Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA

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Basic Leads group

Anterior V2-4 Mid LAD

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Basic Leads group

Ant-Lat-Sep V1-6, aVL Prox LAD

Lateral I, aVL,V5,6 Diagonal branch of LAD

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Basic Leads group

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Basic Leads group

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Basic Leads group

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Basic Leads group

Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA

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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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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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EKG Evolution in non-reperfused MI

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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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• Predominate negative QRS in V1• QRS widening > 0.12 s• Upright QRS in Lead I, V6

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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

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

• Nitroglycerine• B-adrenergic blocker• Clopidogrel• Glycoprotein Iib/IIIa

Develop High or Intermediate risk criteria (Table 3,4)

or Troponin positive

Time form onset of symptoms ≤ 12 hr

7Admit to moniter and risk assessment (Table

Consider admission to ED chest pain unit or

monitered bed• Serial cardiac marder• Repeate EKG• consider stress test

≥ 12hr

< 12hr

Review 12 Leads EKG

ischemia

11≥ 12hr

< 12hr

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

Review 12 Leads EKG

ischemia

5 9 13

Admit to moniter and risk assessment (Table

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

Review 12 Leads EKG

ischemia

5 9 13

Admit to moniter and risk assessment (Table

If no evidence of ischemia or infarction, can discharge with F/U

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 ?

Step 1

Step 2

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 ?

Step 2

Step 3

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

• Chief complaint is Lt. arm painor dyscomfort• Age > 70 yr.• Male sex• Diabetic mellitus

• Extravascular disease

• Fixd Q wave • Abnormal ST segment or T wave that are not new

• Normal

• Chief complaint is Lt. arm painor dyscomfort• Age > 70 yr.• Male sex• Diabetic mellitus

• Probable ischemic symptoms• Recent cocaine use

• Extravascular disease • Chest discomfort reproduce by palpation

• 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

• Normal • Normal

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

• 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

• 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

• Any or above , plus normal

• 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)

• 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

• Any or above , plus normal • Normal

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

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

Risk status

0-2 5-8% Low

3-4 13-20% Intermediate

5 26% High

6 or 7 41% High

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

WINTERTemplate

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.

WINTERTemplate

Case Presentation

WINTERTemplate

Case Presentation

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Case Presentation

WINTERTemplate

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

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)

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.

WINTERTemplate

Case Presentation

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Case Presentation

• At 19.37 หลงใส ET-Tube คนไขเรม unconsciousness , คล า pulse ไมไดทานจะท าอยางไรตอไป

WINTERTemplate

Case Presentation

• หลงจาก CPRไปได 2 นาท ให adrenaline run q 3 min คลนไฟฟาหวใจเปนดงรป ทานจะท าอยางไรตอไป

WINTERTemplate

Case Presentation

• ไดท า defibrillation x 3 ครง EKG ยงคงเปนเชนน ทานจะท าอยางไรตอไป

WINTERTemplate

Case Presentation

• หลงจากทาน ได check lead, ขยาย amplitude แลว EKG เปนดงน ทานจะท าอยางไรตอไป

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

WINTERTemplateThank You

Panita Worapratya

Common cause of ST depression

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