1 BettieACUTE CORONARY SYNDROMES — PRACTICAL, EVIDENCE-BASED GUIDELINES FOR OUTCOME-EFFECTIVE MANAGEMENT Ser Satna ee tar + Pa in ge» Sen = EAD Me ease foe] iain JER, ¥ ¥ “4 Tow Rik ENE pa aR ereAcute Coronary Syndromes “Symptoms suggestive of ischemia or [EMS assessment and care and hospital preparation: * Monitor, 2upeort ABCs, Be prepared to provide CPR and defrition “+ Agmoter asprin and consider onygan,nitegyearn, and morphine i neodes 1 Obtan 12008 ECG ST slouon “Concurrent ED assessment (<10 minutos) * Chock vl elans; evaluate oxygen saturation + Estabion IV access Perl la, targeted history physical exam, Tmmediote ED general treatment WFO, eat <04%, stat oxygen at 4 Limi, trate ++ Aspirin 160 to 325 mg it not given by EMS) ‘suallngual or spray ‘Morphine Ni iscomiort not ewes by trogtyetin + Review/comletefsnayic checks Figure 2) cheat containdeatone Tabi 5) + Obtan intial cariae mark fovel, Intl elecroiye and coagustion todas + Obtain portale hast seray (30 minutes) ST dlovation or new or procumabiy now LBBB; ‘strongly suspicious for injury ‘Stlevation Mi (STEM) ‘ST depression or dynamic “Ewvave invrcion; erongly ‘suspicious for ischemia Highersk unstable anginal rnon-ST-alovation Mi (UANSTEMD) Normal or nondlagnostic changes in ST segment or T wave. Low intormecate-ridk ACS. ‘Consider admission OED choot pain unt or 1 appropriate bed and followe ‘Serial cardiac markors {ietuceg troponin) 1 Repeat ECGeontinous ‘Stsegment monitoring + Consder noninvasive 1 HIG Coa ecciase iniitor (Gtatn therapy Nota ich nie eardotoay to rok eratSuspected Stroke Algorithm: Goals for Management of Stroke nos ‘Supt ABGe: dive anyon freeded ‘ME {be pistetpral ences seeenrent oats + Gabi te ot ynotem eret fat norma) ees 2 Nereepal 2, Chace phcoes pai 0, = poder hurcige sang * Provide ongentitypoxenic ” aneearert Gee eae tee Acie alee {Rberatoy asssomente 1 Orr emergent Tor Mo rin s + Gheckshcese mat Findcalnd + Obi teseed ECO ‘el ae neers + von patent etry eee ee elererer emer etna ae Foceinicbac mares iil Stars tau or Canada Newetogal See) ro ara Probable acute ischemic stroke, sider frinelyc Urerapy + Check for fibrinolytic exclusions + Repeat neurologie exam: ae defi opie improving te nermal? ‘Coneut neutologist or neurosurgeon, ‘oreidar transfer nt avalable ep Aarival min Review risks/benefts with patient © Bogn stoke or andi family. if acceptable: hemomhage pathway + GhenPA + Aalto stoke unit or * No anticoagulants orantpatalet Intensive ca unit Stroke treatrnent for 24 hours “Showre ‘Bagin post-rPA stoke patna * Aggressively mentor: = BP per protocal = For reurclage deteroration + Emergent admasion te stoke uitA Normal Ventricular wall B_ Ischemic area “Injury” ST C_ Ischemic zone Q {y D_ Ischemic zone Zone of “injury” Infarction E Ischemic zone Infarction F Infarct (healed) Scar ta\Vasopressors and Inotropes [Neosynephrine = Alpha | agonist J. Powertul drug! Used when no beta stimulation 's wanted or needed J+ Causes vasoconstriction, bradycardia - t BR TSVR, TPVR, 7 akerioad |. Coronary vatoconetriction J May need to add dopamine to keep HR up |. Used alot in neuro dit che disruption of alpha system in neuro shock J+ Dosing start at 100-180 mcglmin, then 40-60 J. Titrate Smeg q |S-minutes ‘Norepinephrine = Alpha | & agonist + Endogenous catecholamine: has powerful inotrophic and peripheral vasoconstriction feces [Arterial and venous constriction +1 BR.HR may slow, CO unchanged or | dit increased afterload SVR and PVR. Dosing: 2-10 mey/min [Dobutamine = Beta | agonist J+ A syneheve extecholamine Used for © inotropic properties when vasocontvicton undesirable, reduces preload and afterload ‘Commonly used with another catecholamine or vasodiitor 1 coneacility, TCO, 1 BR T myocardial 02 demands, 1 HR {fptis dry it may drop the BF Dosing 25 - 20 meglkg/min Titrate: 1-2 megikg/min q 5-10 min [Dopamine = Beta | & Alpha | agonist First line agent for many shock states ‘Naturally-occurring catechoamine Precursor to norepinephrine 1-3 meg/kg/min -+ renal, coronary, cerebral vayodlation (not renal protective!) T UO - 3-10 mcglkglmin + Beta | stimulation with positive inowopic effect, HR, t BP > 10 meg/kgimin + Aiphs | stimulation with potent vasoconstriction, 1 BR T SVR [Epinephrine = Geta | & Alpha | agonist] Endogenous catecholamine POWERFUL inotropic peripheral and global vatoconstriction Not first line treatment..coo potent! T contractility and T heart O2 demands THR.T MAP 1 CO, 1 SVR and PVR (Causes arehythmias :- Dosing: I-4 meg/min Used in ACLS for pulseless VT and VF Smooth murcle constriction (including bronchioles) + Loss constriction at caranary and renal beds Vasodilates cerebral vasculature + May enhance platelet aggregation in septic shock JT BRT MAR TSVR, T UO Dosing usually 03 oF 04 units/min Positive inotrope and vasodilator (Cleared by the liver Increases CAMP ~* more Ca into calls “+ improves myocardial contractility while inhibiting vasoconstriction +1. CO.LCVR SVR Loading dase: 50 megleg over 10 min Maintenance dese:0.375-0.75 megikg/min