Page 56 - Critical Care Notes

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CV
■ Calculate the HEART Score, a tool for predicting and managing the risk of
heart attack and stroke. Refer to: http://www.escardio.org/communities/
EACPR/toolbox/health-professionals/Pages/SCORE-Risk-Charts.aspx
Calculate in-hospital and 6-mo mortality rate for patients with ACS includ-
ing those with ST elevation or ST depression using the Global Registry
of Acute Coronary Events GRACE) risk model. Refer to: http://www.
outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html
■ Focus on pain radiation, SOB, and diaphoresis.
■ Obtain a 12-lead ECG and lab draw for cardiac markers.
■ MONA: morphine, O 2 , NTG, and 162–325 mg non-enteric coated aspirin
po or chewed. If allergic to aspirin, give ticlopidine (Ticlid) or clopidogrel
(Plavix).
■ Administer supplemental O 2 to maintain SpO 2 >90%.
■ Administer sublingual NTG tablets or spray.
■ Administer IV morphine 4–8 mg initially and then 2-8 mg every 5-15 min until
pain is controlled. (Monitor for hypotension and respiratory depression.)
■ Administer ACE-IS or ARBs.
■ Administer beta blocker.
■ Administer statin.
■ Administer unfractionated heparin, low-molecular-weight heparin.
■ Administer glycoprotein IIb/IIIa antagonists (abciximab, eptifibatide,
tirofiban).
■ Coronary arterial bypass graft (CABG) is warranted in setting of failed PCI
with instability.
ST-Segment Monitoring
■ Continuous ST-segment monitoring is used to detect silent ischemia in
asymptomatic select patients. Monitoring ST changes in a 12-lead ECG is
most accurate. If continuous 12-lead ECG not available, use leads III and V 3 .
Be sure to select patient’s most sensitive monitoring leads (ST fingerprint).
■ Evaluate ST segment with patient in supine position (change in body posi-
tion can alter ST segment and mimic ischemia). If ST alarm sounds with
patient in side-lying position, return patient to supine. If deviation persists
in supine, may indicate ischemia.
■ Measure the ST-segment changes 60 msec beyond the J point (the junction
of the QRS complex with the ST segment).
■ Alarm parameters:
■ Patients at high risk for ischemia: Set ST-segment alarm parameters 1 mm
above and below baseline ST segment.
■ Stable patients: Set segment alarm parameters 2 mm above and below
baseline ST segment.
■ Document actual millimeters of ST-segment depression or elevation.
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