Acute Coronary Syndrome

Transcription

1 scenario overview Summary of case Patient is a 68-year-old male who developed chest pain 1 hour ago. His EKG reveals ST elevation. (ACS) treatment is required. End point is disposition to an in-house Cardiac Cath Lab (CCL), receiving CCL or admission to ICU if thrombolytic is administered in ED. Progressive Complexity Experiences ventricular fibrillation Potential Systems Explored Time to EKG and ED Assessment Time to chose and implement reperfusion strategy Door-to-Needle Door-to-Balloon inflation Length 20 minutes Target group Multidisciplinary ED team Physician Primary Nurse 2nd RN ED Tech Respiratory Therapy Confederates Family member (wife) Emergency scenario 1 page 1

2 LEARNING OBJECTIVES General Learning Objectives Communicate effectively with patient/family Communicate effectively with team using crisis resource management skills Demonstrate safety initiatives including medication safety practices Demonstrate safety initiatives including workplace safety practices Maintain infection control standards Scenario Specific Objectives Obtain EKG within 10 minutes of admission to ED Recognize EKG findings for ST segment elevation Activate the ST segment elevation myocardial infarction (STEMI) system of care Implement AHA ACS algorithm in managing a STEMI patient Administer pharmacological agents for pain relief as an aid to reperfusion therapy Perform steps needed to attain treatment goals to treat eligible STEMI patients: > Fibrinolytic therapy within 30 minutes of arrival to the ED > Percutaneous coronary intervention (PCI) within 90 minutes of arrival to the ED Debriefing Overview Review learning objectives Review teamwork skills Review management of patient with Review communication skills including use of SBAR What went well? What might have been done differently/better? Share key assessments and interventions/events What was learned that can be taken back to the real workplace? Emergency scenario 1 page 2

3 learner preparation Pre-session activity Review American Heart Association ACS algorithm Review STEMI course Briefing (patient story) Patient is a 68-year-old male who presents to the ED triage window with complaints of heavy pressure below his breastbone that started 1 hour ago. He rates the pressure at 4 on a scale of 0-10 and also complains of nausea. Additional Information, Medical History Allergies: NKA Medications: Glyburide 10 mg PO BID; Lisinopril 10 PO Daily; Lovastatin 40 mg PO Daily with evening meal; No male enhancement drugs used. Past Wt 81.8 kg; 180 lbs Past Medical History: Hypertension, Type II Diabetes, Hyperlipidemia Past Surgical History: Laser eye surgery 5 ½ weeks ago - cataract surgery Past EKG: normal reading from previous EKG dated 5 years earlier Past Social History: Married; no children, Hx of Smoking 1pk/day - quit 5 yrs ago, ETOH 1 beer daily VS HR 80; RR 22; BP 150/82; SpO2 94% on room air (nurse inputs at bedside) Glucose: 156 (nurse inputs at bedside) Emergency scenario 1 page 3

4 Equipment Preparation Equipment IV supplies IV fluids Medication administration supplies Blood draw equipment O2 source and adjuncts Crash Cart EKG machine Fibrinolytic checklist for STEMI Percutaneous Coronary Intervention (PCI) checklist Medications Aspirin Nitroglycerin Morphine Heparin/Lovenox Clopidogrel/Plavix Thrombolytics Oxygen Integrilin Room Preparation ED Simulator Preparation SimMan 3G dressed in street clothes ID and allergy band Emergency scenario 1 page 4

5 Events / Proposed Correct Treatment Documentation: Electronic Patient Record EKG and read by physician (done and read in five minutes) If positive call Heart Alert and get cardiac consult If negative go to assessment Focused cardiac assessment Obtain cardiac history Vital signs Apply oxygen NC/mask SpO2 Pain assessment Obtain IV/IO access Attach monitor (portable) Communicate effectively with patient/family Communicate effectively with team Call for help Obtain TNK/STEMI Kit Thrombolytic screening Obtain patient weight Shave groin Check peripheral pulses Defibrillator pads on MONA: Morphine, Oxygen, Nitroglycerine, Aspirin Beta-blocker: Metoprolol ordered X 3 doses Clopidogrel Heparin/Enoxaparin Thrombolytics Cardiology consult ordered To in-house or receiving Cardiac Cath Lab To ICU/CCU if TNK administered Cardiac Panel (istat-troponin) CBC CXR (portable) Electrolytes PT/PTT UA Emergency scenario 1 page 5

6 EMERGENCY algorithm Start: HR 80 RR 22 BP 150/82 T 37.5 (98.6) SpO2 94 % Cardiac Monitor: ST elevation and unifocal PVC s Chest pain rated at 4 out of 10 Nauseated and diaphoretic Expected Pathway Caution/review MONA (Morphine, Oxygen, Nitroglycerine, Aspirin NOTE: Nitro x3 Q 5 min followed by Morphine) 12-lead EKG Notify Heart Alert Team CORRECT WITHIN 10 MINUTES OF ADMISSION Trend over 2-4 minutes HR 76 RR 20 BP 146/82 SpO2 98% Pain 4 out of 10 Reassess Repeat Nitroglycerin Diagnostics: CXR, labs Trend over 2 minutes HR 90 RR 26 BP 156/90 Pain 6 out of 10; ST elevation increasing CORRECT WITHIN 2 MINUTES Interventions within 2 minutes MONA CORRECT WITHIN 6 MINUTES Trend over 5 minutes HR 80 RR 18 BP 140/80 Pain 2 out of 10 Ventricular Tachycardia Consider Anticoagulants, Metoprolol, Thrombolytics Consider Morphine if not already given CORRECT ST elevation resolves with Thrombolytics Pain 1 out of 10 Disposition: CCL, CCU, Transfer EmErgEncy scenario 1 page 6