Advanced Cardiac Life Support Acute Coronary Syndromes

Educational Development and Resources The Ohio State University Medical Center

CHEST PAIN
Characteristics Onset Location Radiation Quality STABLE ANGINA Crescendo Mid retrosternal Radiation inside of left arm, both arms Pressing, Squeezing, Tightness, Heaviness UNSTABLE ANGINA Occurs with less exertion than stable or at rest or with exertion Mid retrosternal Radiation inside of left arm, both arms Heaviness (more serve) Severe Pressure Hard pain Choking Short of Breath Nausea & Vomiting Severe Distressing Up to 30 minutes (SL) NTG {May require IV} Rest, Beta Blockers, ASA, Heparin Occurs at rest or minimal exertion less than if stable before Anxious VARIANT ANGINA Occurs early AM or night - cyclic Mid retrosternal MYOCARDIAL INFARCTION Protracted Retrosternal radiates to neck, jaw, shoulder, arm (left > right), back, may be epigastric Crushing Terrible Heaviness (elephant on chest) Pressing Constricting Short of Breath , Tachypnea Nausea, vomiting, Diaphoresis Severe

Squeezing Constricting Heavy

Intensity (Severity) Duration Relieving Factors Precipitating Factors Emotional Response

Mild to Moderate Discomfort Gradual worsening with stress removed 2-5 minutes after precipitating factor removed Rest NTG Effort, Stress, Cold environment Vague anxiety

Severe

Greater than 5 min. (SL) NTG, Calcium Channel Blockers for prevention Occurs at rest or with ordinary activity Anxious

Protracted Thrombolytics, Narcotics, IV NTG, Calcium, Beta Blockers, ASA Often NONE

Severe anxiety Confusion 2

S. Walden, September 1993; Revised June 1999; Edited by M.B. Fontana, MD 3/00

Q- Wave Myocardial Infarction - ECG Changes

Location Arterial Supply Indicative Changes
Leads that face area of damage

Reciprocal Changes
Leads that are opposite the damage (May or May not be present)

8 ST Segments
2mm V Leads > 1mm Frontal Leads Significant Q Waves

9 ST Segments
Tall R Waves

8 Hyperacute T Waves early 9 T Waves - Later

Anterior Septal ! LAD ! Septal Perforating (LAD) ! Posterior Descending (RCA) ! Circumflex ! RCA 90% ! Posterior Descending (RCA 90%) V1 - V4 ! V1 - V3

8 T waves (Early MI)

! II, III, aVF ! None

Lateral Inferior Posterior

! I, aVL, V5 - V6 ! II, III, aVF ! None

! V1 ! I, aVL ! Reciprocal changes only V1 - V3 ! R > S V1 V2 ! Usually associated with Inferior (High incidence of Right Ventricular Involvement) and Lateral Infarctions. ! None

Right Ventricular

! RCA (proximal)

! !

>1mm V4R (ST elevation is greatest in V4R)

8ST

9B/P

+ JVD

+S3

+S4 3

Sandra Walden, February 1999/ Edited by M.B. Fontana, MD 3/00

Acute Myocardial Infarction Drugs

Drug
Oxygen

Why (Action)
O2 supply to ischemic tissues Pain in ischemic tissue Venous dilation Preload & O2 consumption Dilates coronary arteries Collateral flow in MI area Pain of ischemia Anxiety Venous capacitance Systemic vascular resistance Catecholamines leading to in demand and infarction reduction

When (Indications)
Routinely in AMI Suspected ischemic pain Unstable angina Acute Pulmonary Edema Routinely in AMI B/P with AMI Continuing Pain after NTG Evidence of vascular congestion ( preload) B/P > 90mmHg No Hypovolemia

How (Dosing)
Start with 4L/m via nasal cannula & titrate to O2 Sat of 97-98% 0.3- 0.4 mg subling. q 5 min Spray inhaler q 5min 1-2 paste locally IV infusion 12.5-25 mcg bolus 10-20 mcg/min - titrated 2-4 mg titrated to effect Titrate to eliminate pain

Watch Out! (Precautions)

May depress ventilatory drive in patients with COPD but should not withhold O2 from patient who needs it. B/P < 90 mmHg Limit B/P drop 10% in normotensive pts Limit B/P drop 30% in hypertensive pts Instruct patient to sit down Watch for headache, drop in B/P, Tachycardia, syncope, Extreme caution with RV Infarction Drop in B/P Volume depletion Patients with SVR Patients on Beta Blockers RV Infarction Depression of ventilation Nausea & Vomiting Bradycardia Itching & Bronchospasm Relative contraindication with patients with peptic ulcer or asthma Known aspirin hypersensitivity Higher doses are not more effective Active Bleeding Recent intracranial, intraspinal, or eye surgery Severe Hypertension Bleeding tendencies Active GI Bleeding

NTG

Morphine

Aspirin

Heparin

Prevents platelet aggregation by blocking thromboxane A2 Mortality Non-fatal infarction Non-fatal stroke Coronary thrombosis results from ruptured plaque Residual thrombi + vascular injury persists after thrombolysis Maintains patency of infarct-related artery Prevents mural thrombus in anterior MI Automaticity & Dysrhythmias SA Node discharge Heart rate

Routinely in AMI (as soon as possible)

160-325 mg p.o. (Higher doses are not more effective)

PTCA or CABG Fibrin specific lytics High risk for emboli Anterior MI A-Fib LV thrombus

5000 IU IV Bolus 1000 IU/hr IV Infusion x 24-48 hrs Maintain PTT 1.5-2 x nml

Beta Blockers

Any MI unless contraindicated AMI with excessive

Metoprolol 5 mg IVP q 5 min x3 Atenolol 5 mg IV q 10

Contraindicated Severe CHF or PE SBP < 100 mm hg

Drug

Why (Action)
AV Node conduction B/P Myocardial contractility Block catecholamine stimulation Incidence of primary VF

When (Indications)
sympathetic tone Tachycardia or B/P Treat large M.I.s early Refractory chest pain

How (Dosing)
min x2 Propranolol 1 mg IV 1q 5min x5

Watch Out! (Precautions)

Bronchospasm ;Acute Asthma 2nd or 3rd Degree AV Block Caution Mild-moderate CHF HR <60 History asthma IDDM Severe peripheral vascular dis.

ACE Inhibitors

Fibrinolytic Therapy

Reduces BP by inhibiting angiotensin-converting enzyme Alters post-AMI LV remodeling by inhibiting tissue ACE Lowers peripheral vascular resistance by vasodilatation mortality and CHF from AMI Breaks up the fibrin network that binds clots together

ST elevation >1 mm in 2 or more contiguous New LBBB or new BBB that obscures ST Time of symptom onset must be <12 hours ACS with NO ST elevation: NonQ-wave MI Unstable angina managed medically UA undergoing PCI

Antiplatelet Agents

Blocks glycoprotein IIb/IIIa receptors on platelets Blocked receptors cannot attach to fibrinogen Fibrinogen cannot aggregate platelets to platelets

Agents differ in their mechanism of action, ease of preparation and administration; cost; need for heparin! 5 agents currently available: alteplase (tPA, Activase), anistreplase (Eminase), reteplase (Retavase), streptokinase (Streptase), tenecteplase (TNKase) Abciximab (ReoPro), eptifibitide (Integrilin), tirofiban (Aggrastat

Can cause death from brain hemorrhage

Source: American Heart Association 2000 Textbook of Advanced Cardiac Life Support. American Heart Association, Dallas Texas. Educational Development and Resources, The Ohio State University Medical Center, 2001

Ventricular Tachycardia Vs SVT with Aberrancy

Ventricular Tachycardia
! qRs width > 0.16 seconds # qRs > 0.14 sec in V1 positive patterns # qRs > 0.16 sec in V1 negative patterns AV Dissociation ! Non-conducted P Waves ! Independent Atrial Rhythm slower than the Ventricular Rhythm !RR= ! Extreme Axis Deviation between (-)90 and (+)180 ! Left Axis Deviation with positive qRs in V1 ! Tachycardia starts with first abnormal qRs falling R-on-T ! Rosenbaums Normal Pattern # LBBB configuration in V leads + Right Axis Deviation in Frontal Leads # Often initial R wave in Lead V1 is wider than is usual in LBBB ! Capture Complex = Tachycardia interrupted by normal complex ! Fusion Complex = Sinus + Ventricular complex - qRs looks more normal than ventricular complexes surrounding it. ! Concordance of Precordial Leads qRs complexes all positive or all negative ! Rapid, Regular Rhythm in Atrial Fibrillation ! No Concordance of Precordial Leads qRs complexes in the V leads are both negative and positive ! Rapid, Irregular Rhythm in Atrial Fibrillation ! Aberrant complexes with short R-R interval following a long R-R interval (Ashmans Phenomenon) ! Previous Tracings ECG shows LBBB or RBBB; Tachycardia will show similar morphology to the BBB qRs configuration ! Valsalva maneuver slows (even if only temporarily) the Tachycardia

SVT with Aberrancy

! qRs width 0.12 0.16 seconds # qRs < 0.14 sec in V1 positive patterns # qRs < 0.16 sec in V1 negative patterns ! Conducted P Waves ! PRI consistent ! R R = or ! Normal axis except WPW Syndrome ! WPW = Extreme, Left or Right Axis Deviation ! Rate 300 = Atrial Flutter or Atrial Fibrillation with accessory pathway conduction ! Right BBB or Left BBB in V Leads (RBBB more common)

! Previous Tracings - qRs morphology of Tachycardia is similar to PVCs on previous tracings ! Valsalva maneuver does not slow the Tachycardia

S. Walden 1/99; Edited by M.B. Fontana, MD 3/00; Revised 1/01 6

qRs Morphology
Ventricular Tachycardia
! V1 monophasic positive R or ! V1 monophasic notched positive R (2 peaks) with left peak taller than right V1 ! V1 biphasic qR or ! V1 biphasic Rs and ! V6 rS with r<S V1 V1 V1 V6 ! V1 negative rS with narrow r < 0.04 sec & straight downstroke or ! V1 negative QS

SVT with Aberrancy

! V1 positive rR (RBBB) or ! V1 triphasic rSR or ! V6 qRs

V1

V1

V1

V1

V6

! V1 negative QS ! Small r > 0.04 sec ! Notched or slurred S ! S broad and slurred > 0.06 sec on left side V1 ! V1 right peak taller than left occurs with both Ventricular Tachycardia and SVT with aberrancy ! V1 right peak taller than left occurs with both Ventricular Tachycardia and SVT with aberrancy

V1

V1

Sandra Walden January 2001