Transcript Document

CCU Case Studies
The following is a series of case studies to review different patient
types and how they are captured on the form. The information is
provided in sequence to reflect the natural progression of a patient’s
care.
As the case is presented, mark off the required information in the
appropriate fields on your Macstrak form.
At the end of each case study, the form will be reviewed with the
correct answers supplied.
If you have any questions, please refer to your Macstrak manual or
contact us at the Macstrak Project Office.
The Macstrak Project
CCU Case Study
The Macstrak Project
CCU Case Study
ENC is a 49-year-old (DOB: 27/04/56) working mom with no
significant past medical history.
The Macstrak Project
CCU Case Study
On the morning of 02/03/06 ENC awakens at 05:00 with chest
pain. She gets up and gets her children ready for daycare and
drops them off. Rather than going to work she returns home
and her husband calls an ambulance. The ambulance arrives at
07:50. At 08:05, en-route to the hospital, ENC has an ECG
which shows ST elevation in II/IIIaVF. ASA is given to chew.
She arrives at the ER at 08:25. She is seen by the triage RN on
arrival and her vital signs are as follows: BP 130/70, HR 74 and
chest is clear. ENC continues to have chest pain which she rates
at 8/10. The ER MD assesses ENC and finds she has no
contraindications to thrombolytic therapy. At 08:40 the decision
is made to treat ENC (weight 62 kg) with TNK.
The Macstrak Project
CCU Case Study
35 mg of TNK over 5 seconds is given at 08:50. ENC also receives
UF heparin IV and metoprolol IV while in the ER. The pain
resolves shortly after starting the TNK and the ST segments are
normalising.
The Macstrak Project
CCU Case Study
35 mg of TNK over 5 seconds is given at 08:50. ENC also receives
UF heparin IV and metoprolol IV while in the ER. The pain
resolves shortly after starting the TNK and the ST segments are
normalising.
ENC is admitted to your CCU that same morning with a diagnosis
of Acute Myocardial Infarction. She has UF heparin infusing
intravenously on arrival. Clopidogrel is started that evening. ENC
has no further chest pain or complications while in CCU but her CK
and troponin levels remain positive.
The Macstrak Project
CCU Case Study
ENC is transferred to a tertiary centre for a cath on 04/03/06 at
09:00. Her discharge diagnosis is Acute Myocardial Infarction and
her peak CK is 1086, her peak troponin is 24. She is discharged on
the following medications:
ASA
metoprolol
clopidogrel
UF heparin
pravastatin
The Macstrak Project
CCU Case Study
MACSTRAK
Patient Initials: E
F
Birth Date:
CCU
Gender:
N
C
M
L
27
04
Day
Month
Male
Centre:
19 56
Year
X Female
CCU
Date:
ICU
20
Day
Month
Year
ENC is a 49-year-old (DOB: 27/04/56) working mom with no
significant past medical history.
The Macstrak Project
CCU Case Study
MACSTRAK
Patient Initials: E
F
Birth Date:
CCU
Gender:
N
C
M
L
27
04
Day
Month
Male
Centre:
19 56
Year
X Female
Date:
CCU
02
03
Day
Month
ICU
20 06
Year
ENC is a 49-year-old (DOB: 27/04/56) working mom with no
significant past medical history.
On the morning of 02/03/06 ENC awakens at 05:00 with chest
pain. She gets up and gets her children ready for daycare and
drops them off. Rather than going to work she returns home and
her husband calls an ambulance.
The Macstrak Project
CCU Case Study
Past Medical History:
<30 days
MI …………………………….
Angina ………………………..
CABG ………………………..
PCI ……………………………
CHF …………………………..
TIA/CVA ……………………..
Diabetes (oral agents/insulin) ...
None of the Above…………….
>30 days
X
ENC is a 49-year-old
(DOB: 27/04/56)
working mom with no
significant past medical
history.
The Macstrak Project
CCU Case Study
Patient Origin:
X ER
X EMS
Walk In
Dr.’s Office/Clinic (Direct)
Other Hospital
Inpatient
Medical Ward
Surgical Ward
Other ICU
Other: ………………
On the morning of 02/03/06 ENC
awakens at 05:00 with chest pain. She
gets up and gets her children ready for
daycare and drops them off. Rather
than going to work she returns
home and her husband calls an
ambulance. The ambulance arrives at
07:50. At 08:05, en-route to the
hospital, ENC has an ECG which
shows ST elevation in II/IIIaVF. ASA
is given to chew. She arrives at the
ER at 08:25.
The Macstrak Project
CCU Case Study
VS at Presentation: (complete for all patients)
Dyspnea/Rales:
Systolic BP:
Heart Rate:
X None
Mild
Mod/Severe
< 100
X 101-130
131-160
161-190
>190
X < 80
80-100
>100
She arrives at the ER at 08:25. She is
seen by the triage RN on arrival and
her vital signs are as follows: BP
130/70, HR 74 and chest is clear.
ENC continues to have chest pain
which she rates at 8/10. The ER MD
assesses ENC and finds she has no
contraindications to thrombolytic
therapy. At 08:40 the decision is made
to treat ENC (weight 62 kg) with TNK.
The Macstrak Project
CCU Case Study
Admitting Diagnosis: (Check one only)
X Acute AMI (48 hrs)
UA R/O MI
ACS
UA
RSCP NYD
CHF
Arrhythmia
Aortic Dissection
Non ACS
Pericardial Disease
Other: …………………
ENC is admitted to your CCU that
same morning with a diagnosis of
Acute Myocardial Infarction. She
has UF heparin infusing intravenously
on arrival. Clopidogrel is started that
evening. ENC has no further chest
pain or complications while in CCU
but her CK and troponin levels remain
positive.
The Macstrak Project
CCU Case Study
Timeline: (AMI pts only - 24 hr clock or > 24 hrs)
Symptom Onset:
0500
EMS at Scene:
0750
Hospital Arrival:
0825
First ECG: X EMS
0805
Diagnostic ECG:
0805
On the morning of 02/03/06 ENC
awakens at 05:00 with chest pain.
She gets up and gets her children
ready for daycare and drops them off.
Rather than going to work she returns
home and her husband calls an
ambulance. The ambulance arrives
at 07:50. At 08:05, en-route to the
hospital, ENC has an ECG which
shows ST elevation in II/IIIaVF.
ASA is given to chew. She arrives at
the ER at 08:25.
The Macstrak Project
CCU Case Study
Diagnostic ECG: (ACS pts. only)
No ACS ST-T
LBBB
Paced
X Other
ST ST
V1-4 …………..
V5-6 ……….…
IaVL ………...
II/IIIaVF ….. X
V4R..done ...
V7-9 ..done ...
T
Q
…
..…
…...
…
…..
…...
…
.….
……
…
…..
…....
The ambulance arrives at
07:50. At 08:05, en-route to
the hospital, ENC has an
ECG which shows ST
elevation in II/IIIaVF.
ASA is given to chew. She
arrives at the ER at 08:25.
The Macstrak Project
CCU Case Study
Reperfusion Therapy:
No
Not Indicated:
Risk:

ECG Not Diag.
Risk of ICB
ST Up Transient
Risk Other Bleed
Too Late
Given (Other Hosp)
Other: ……………......
EMS
Other Hosp
X Yes X Thrombolysis  X Here
Dose: (mg/units)
Drug: X TNK/rtPA
SK
Duration: (min)
r-PA (reteplase) Pt.Weight: (kg) 62
Other
Adjuvant:
ASA
Heparin
GP2b/3a Inhibitor
 blocker IV
Clopidogrel
Other ...............................
and/or
Primary/Rescue PCI 
Here
Transfer
Reperfusion Therapy Decided by:
X EP
Consultant
The ER MD assesses ENC and finds she has no contraindications
to thrombolytic therapy. At 08:40 the decision is made to treat
ENC (weight 62 kg) with TNK.
The Macstrak Project
CCU Case Study
Reperfusion Therapy:
No
Not Indicated:
Risk:

ECG Not Diag.
Risk of ICB
ST Up Transient
Risk Other Bleed
Too Late
Given (Other Hosp)
Other: ……………......
EMS
Other Hosp
X Yes X Thrombolysis  X Here
Dose: (mg/units)
Drug: X TNK/rtPA
SK
Duration: (min)
r-PA (reteplase) Pt.Weight: (kg) 62
Other
Adjuvant: X ASA
Heparin
GP2b/3a Inhibitor
 blocker IV
Clopidogrel
Other ...............................
and/or
Primary/Rescue PCI 
Here
Transfer
Reperfusion Therapy Decided by:
X EP
Consultant
The ambulance arrives at 07:50. At 08:05, en-route to the hospital,
ENC has an ECG which shows ST elevation in II/IIIaVF. ASA is
given to chew.
The Macstrak Project
CCU Case Study
Reperfusion Therapy:
No
Not Indicated:
Risk:

ECG Not Diag.
Risk of ICB
ST Up Transient
Risk Other Bleed
Too Late
Given (Other Hosp)
Other: ……………......
EMS
Other Hosp
X Yes X Thrombolysis  X Here
35
Dose: (mg/units)
Drug: X TNK/rtPA
1
SK
Duration: (min)
r-PA (reteplase) Pt.Weight: (kg) 62
Other
Adjuvant: X ASA X Heparin
GP2b/3a Inhibitor
Clopidogrel
Other ...............................
X  blocker IV
and/or
Primary/Rescue PCI 
Here
Transfer
Reperfusion Therapy Decided by:
X EP
Consultant
35 mg of TNK over 5 seconds is given at 08:50. ENC also
receives UF heparin IV and metoprolol IV while in the ER. The
pain resolves shortly after starting the TNK and the ST segments
are normalising.
The Macstrak Project
CCU Case Study
TLysis Ordered:
TLysis Started:
GP 2b/3a Started:
Transfer:
0840
The ER MD assesses ENC and finds
she has no contraindications to
thrombolytic therapy. At 08:40 the
decision is made to treat ENC (weight
62 kg) with TNK.
Arrive Lab:
First Inflation:
The Macstrak Project
CCU Case Study
TLysis Ordered:
0840
TLysis Started:
0850
GP 2b/3a Started:
Transfer:
The ER MD assesses ENC and finds
she has no contraindications to
thrombolytic therapy. At 08:40 the
decision is made to treat ENC (weight
62 kg) with TNK.
Arrive Lab:
First Inflation:
35 mg of TNK over 5 seconds is given
at 08:50.
The Macstrak Project
CCU Case Study
02
04
03
Date:
D N D N D
N
Acuity:
Shift:
Diuretics………………………
Inotropes IV…………………..
ETT/Vent……………………..
PA Line……………………….
TTVP…………………………
IABP………………………….
ACS:
RSCP - Ischemia – Definite….
– Probable…
X X
X X
CK (+ve)………………...…… X
X
X
X
X X
Troponin (+ve)………………..
NTG IV……………………….
X X
X X
Heparin – UFH……………..... X
– LMWH…………….
Other Antithrombin………...…
GP 2b/3a Inhibitor IV……...…
X X
X
Clopidogrel (or ticlopidine)..…
Cardiac Cath………………....
PCI…………………………...
Outcomes:
VF/Sustained VT………….…
Infarction (new/repeat)*(1) …...
Thrombolysis (new/repeat)*(2)..
Stroke*(3) …………………….
Major Bleed*(4) ………………
Transfusion…………………..
Crs1: ………………………....
Crs2: ……………………..…..
None of the Above……….…..
RN Initials ………………..…. KD AW KD AW KD
ENC is admitted to your CCU that
same morning with a diagnosis of
Acute Myocardial Infarction. She
has UF heparin infusing
intravenously on arrival.
Clopidogrel is started that
evening. ENC has no further chest
pain or complications while in CCU
but her CK and troponin levels
remain positive.
The Macstrak Project
CCU Case Study
03
Date: 04
Day
Month
06 Time: 0900
20 Year
Discharge Diagnosis:
X Acute MI
Peak CK: 1086
Unstable Angina
Trop: 24
Chest Pain NYD
CHF
Arrhythmia
Other Cardiac Problem: …………..................
Non Cardiac Problem: …..….............……….....
ENC is transferred to a tertiary
centre for a cath on 04/03/06 at
09:00. Her discharge diagnosis
is Acute Myocardial Infarction
and her peak CK is 1086, her
peak troponin is 24. She is
discharged on the following
medications:
ASA
metoprolol
clopidogrel
UF heparin
pravastatin
The Macstrak Project
CCU Case Study
Discharged To:
Discharge Meds:
Cardiac Ward
Med/Surg Ward
Step Down Unit
CV Surgery
Other ICU
X Other Hospital
Home
Death
Other:..............
X ASA
X Clopidogrel (or ticlop.)
X Heparin (UF or LMW)
Nitrates (po/top)
X B Blocker
ACEI
A2 Blocker
X Statin
None of Above
ENC is transferred to a tertiary
centre for a cath on 04/03/06 at
09:00. Her discharge diagnosis is
Acute Myocardial Infarction and her
peak CK is 1086, her peak troponin is
24. She is discharged on the
following medications:
ASA
metoprolol
clopidogrel
UF heparin
pravastatin
The Macstrak Project