Transcript time

Jackpot!
Brenda Larson RN, BSN
Chest Pain Clinical Program Coordinator
University of Wisconsin Hospital
Historical Perspective
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Coronary artery disease remains the leading
killer in the U.S.
Heart attacks occur when a blood clot forms in
a blood vessel in the heart – starving the
downstream muscle of oxygen.
Time is critical! Every minute the artery is
blocked, heart muscle is damaged.
Time is muscle!!
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3/6/2008
Dispatched - 14:39
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Dejope Casino
71 year old male
pale, c/o chest pain, difficulty breathing
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Initial EMS Assessment
Arrived on scene: 14:49
• 71 year old male
• sitting in a wheelchair
Chief Complaint:
“Arms and legs hurt bad and terrible pains in the chest.”
“Didn’t feel like himself ”
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Primary Assessment
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Mentation: A&O x4
Airway/Breathing:
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Regular
Circulation:
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Skin
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color: pink
temperature: normal
moisture: dry
Vital signs:
BP:
142/100
HR:
68
RR:
18
SaO2:
98%
ECG:
NSR
Cap Refill: <2 seconds
No major bleeds
Determine Priority:
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History
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Signs/symptoms:
O: playing slots
 P: walking made pain worse
 Q: dull pain, substernal
 R: left arm and jaw/neck
 S: 5/10
 T: 2:00 PM
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History
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Allergies:
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Medications:
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Pertinent past medical history:
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Last oral intake:
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Events:
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NKDA
Glipizide
Type II DM
Unknown
playing slots
chest pain is getting worse
asks wife to take him home
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Interventions
Time BP - HR - RR - SaO2
Assessment
Interventions
14:36
911 called
14:39
Dispatched
14:49
Arrived on Scene
Initial Assessment &
History
12 lead ECG: SR & ST elevation
ASA 324 mg PO (chewed)
O2: 3L NC
18 gauge IV started x 1 with 0.9
NS at TKO
14:59
142/100 - 68 -18 - 98%
Neuro: GCS 15, PERL
Lungs: Clear Bilat
Skin: unchanged
NTG SL 0.4 mg
Faxed 12 lead to UW
Leave Scene
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Interventions
Time
BP - HR - RR -SaO2
Assessment
14:59
Interventions
Leave Scene
15:05 130/P - 68 - 18 - 98%
Chest pain unchanged
Heart Attack Team
activated
NTG SL 0.4mg
15:08 120/P - 62 - 18 - 98%
Chest pain “improved”
but not gone.
Assessment unchanged
NTG SL 0.4 mg
Morphine IV 2 mg IV
15:16
Arrival to UW
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Chest Pain Protocol
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General
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Assess ABCs
IV NSS, oxygen, pulse oximetry and ECG monitor
Vital signs
Obtain a severity value of chest pain (1 to 10)
Obtain and interpret 12 Lead ECG if patient condition
permits
Do not delay transport for 12 Lead ECG. Obtain ECG
during transport and transmit to receiving hospital if
possible. Communicate your impression of ECG during
report.
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Chest Pain Protocol
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Medications
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Aspirin 324 mg PO - chew and swallow
NTG 0.4 mg SL (if SBP >90 mmHg and DBP >50 mmHg) If no relief,
may repeat NTG every 3-5 minutes up to a total of 4 doses.
Morphine Sulfate 2-5 mg IV
Treat dysrhythmias as appropriate
IV fluid – 300 ml NSS if SBP drops <90mmHg
Reassess lung sounds and vital signs
Dopamine if SBP < 90 mmHg, if patient refractory to fluid challenge (s)
or evidence of pulmonary edema
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Chest Pain Protocol
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Notes
Elderly patients, diabetics and women are more likely
to experience atypical symptoms.
 Do not administer NTG to patients actively taking
medications for Erectile Dysfunction.
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What A Day!
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Within 29 minutes 3 STEMI cases
arrived to UW Cath Lab.
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STEMI case start times:
1) 14:50
2) 15:04
3) 15:19
UW Hospital
15:05 Heart Attack Team activated
 15:16 EMS arrival to UWED
 15:19 Patient on table in Cath Lab
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Door to wire insertion with flow: 18 minutes
Door to balloon inflation: 23 minutes
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UW Cardiac Cath Lab
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Pre procedure
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Staff involved:
2 Physicians
 Minimum of 2 RNs and 1 Cardiovascular Tech
 Consent is obtained
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Patient prep:
ECG, pulse oximetry, BP
 Check pulses in feet
 Remove all clothing
 Table is only 22 inches wide (holds 500 lbs)
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Circumflex artery (on arrival)
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Balloon angioplasty
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Coronary stent deployment
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Stent deployment
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Circumflex artery (post procedure)
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Summary of the procedure
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Stents:
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Sedation:
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Fentanyl 50 mcg & Midazolam 2 mg IV
Uneventful case:
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2 bare-metal stents
No N/V
No arrhythmias
Procedure completed within 48 minutes after arriving
to the Cath Lab.
The patient was pain free post procedure and was
transferred to the CCU in stable condition.
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Discharge Instructions
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Discharged on 3/8/08
follow up with PCP 1-2 weeks
 return for repeat PCI of RCA (3/17/08)
 follow up with Cardiologist 4-6 weeks
 cardiac rehab referral
 nutrition consult
 lab work
 return to work in 2-6 weeks
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The Patient
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Works as a security guard at Allied Automotive
Group.
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“It’s my spending money for Dejope”
Hobbies:
Watching his 9 year old Grandson play baseball
 Will celebrate his 46th Wedding Anniversary in June
 Shoots pool every morning
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How were you doing?
“I was coming out ahead!”
JACKPOT!
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