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::❑ Maintenance dose 0.15 mcg/kg/min </div>}}
::❑ Maintenance dose 0.15 mcg/kg/min </div>}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |!| | | |!| | }}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |!| | | |!| | }}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F01 | | F02 | | F03 | |F01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Consider urgent [[CABG|<span style="color:white;">CABG</span>]] if the coronary anatomy is not amenable to PCI and one of the following:'''<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed?term=15466654 | publisher =  | date =  | accessdate = }}</ref> <br> ❑ Patients with left main or left main equivalent disease <br> ❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction <br> ❑ Diabetic patients </div>|F02=<div style="float: left; text-align: left; width: 25em; padding:1em;"> ❑ Perform an [[angiography|<span style="color:white;">angiography</span>]] </div>|F03=<div style="padding: 5px; background: #FFFFFF; text-align: center;">'''[[Unstable angina/ NSTEMI resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F01 | | F02 | | F03 | |F01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Consider urgent [[CABG|<span style="color:white;">CABG</span>]] if the coronary anatomy is not amenable to PCI and one of the following:'''<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed?term=15466654 | publisher =  | date =  | accessdate = }}</ref> <br> ❑ Patients with left main or left main equivalent disease <br> ❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction <br> ❑ Diabetic patients </div>|F02=<div style="float: left; text-align: left; width: 25em; padding:1em;"> ❑ Perform an [[angiography|<span style="color:white;">angiography</span>]] </div>|F03={{fontcolor|#000000|'''[[Unstable angina/ NSTEMI resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' }}|boxstyle_F03= background-color: #FFFFFF}}
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Revision as of 21:38, 6 April 2015

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red color signify that an urgent management is needed.

 
 
 
Identify cardinal findings of unstable angina/ NSTEMI :

Chest pain or chest discomfort

❑ Sudden onset
❑ Sensation of heaviness, tightness, pressure, or squeezing
❑ Duration> 20 minutes (but usually less than half an hour)
❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium
❑ No relief with medications
❑ No relief with rest
❑ Worse with time
❑ Worse with exertion
❑ Associated symptoms of palpitations, nausea, vomiting, sweating, dyspnea, and

lightheadedness
Characteristic ECG changes consistent with unstable angina/ NSTEMI

❑ No changes
❑ Non specific ST / T wave changes
❑ Flipped or inverted T waves
❑ ST depression (carries the poorest prognosis)
Increase in >99th percentile of upper limit of normal of troponin and / or CK MB , which is consistent with NSTEMI
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out life threatening alternative diagnoses:

Aortic dissection
(suggestive findings: back pain, interscapular pain, aortic regurgitation, pulsus paradoxus, blood pressure discrepancy between the arms)
Pulmonary embolism
(suggestive findings: acute onset of dyspnea, tachypnea, hemoptysis, previous DVT)
Cardiac tamponade
(suggestive findings: hypotension, jugular venous distention, muffled heart sounds, pulsus paradoxus)
Tension pneumothorax
(suggestive findings: sudden dyspnea, tachycardia, chest trauma, unilateral absence of breath sound)

Esophageal rupture
(suggestive findings: vomiting, subcutaneous emphysema)
 
 
 
 
 
 
 
 
 
 
 
 
Begin initial treatment:
❑ Administer aspirin
❑ 162 to 325 mg of non enteric aspirin,orally, crushed or chewed, THEN
❑ 75 to 325 mg/day

❑ Administer 2-4 L/min oxygen via nasal cannula when saturation <90%

❑ Caution in COPD patients: maintain an oxygen saturation between 88% and 92%

❑ Administer beta-blockers (unless contraindicated) and titrate to the heart rate and blood pressure
Contraindicated in heart failure , prolonged or high degree AV block , reactive airway disease , high risk of cardiogenic shock and low cardiac output state

Metoprolol IV, 5 mg every 5 min, up to 3 doses, then 25 to 50 mg orally every 6 hours
Carvedilol IV, 25 mg, two times a day

❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses
Contraindicated in suspected right ventricular MI , recent use of phosphodiesterase inhibitors , decreased blood pressure 30 mmHg below baseline
❑ Administer IV morphine if persistent symptoms or pulmonary edema

❑ Initial dose 4-8 mg
❑ 2-8 mg every 5 to 15 minutes, as needed

❑ Administer 80 mg atorvastatin
❑ Monitor with a 12-lead ECG all the time

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following indications that require immediate angiography and revascularization ?

❑ Hemodynamic instability or cardiogenic shock
❑ Severe left ventricular dysfunction or heart failure
❑ Recurrent or persistent rest angina despite intensive medical therapy
❑ New or worsening mitral regurgitation or new VSD
❑ Sustained VT or VF

❑ Prior PCI within past 6 months or CABG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have negative ECG findings AND negative biomarkers?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat ECG and biomarkers within next 6 hours and 12 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECG and biomarkers are both negative
 
At least one (ECG or biomarkers) is positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to complete diagnostic approach of chest pain to rule out differential diagnoses
 
 
Calculate the risk of future adverse clinical outcomes:

Thrombolysis in Myocardial Infarction (TIMI) risk score, OR

GRACE score
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to angiography
 
High risk
Initial invasive strategy
 
Low risk
Initial conservative strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Administer ONE of the following antiplatelet agents (before or at the time of PCI):
P2Y12 receptor inhibitors

Clopidogrel 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg

Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding
❑ IV GP IIb/IIIa inhibitors

Abciximab
❑ Loading dose 0.25 mg/kg IV bolus
❑ Maintenance dose 0.125 mg/kg/min
Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus
❑ Another 180 mcg/kg IV bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <50 mL/min
❑ Avoid in hemodialysis patients
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <30 mL/min

Administer ONE of the following anticoagulant therapy:
Unfractionated heparin

If GP IIb/IIIa receptor antagonist is planned
❑ 50- to 70-U/kg IV bolus
If no GP IIb/IIIa receptor antagonist is planned
❑ 70- to 100-U/kg bolus

Bivalirudin

❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion
❑ Additional bolus of 0.3 mg/kg if needed
❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min
 
Administer one of the following antiplatelet agents:

Before PCI
P2Y12 receptor inhibitors

Clopidogrel (600 mg), or
Ticagrelor (180 mg), or

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min

At the time of PCI
P2Y12 receptor inhibitors

Clopidogrel (600 mg), or
Ticagrelor (180 mg), or
❑ Prasugrel (60 mg)

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
 
Administer one of the following antiplatelet agents:

Clopidogrel

❑ Loading dose (300 mg)
❑ Maintenance dose for up to 12 months (75 mg)

Ticagrelor

❑ Loading dose (180 mg)
❑ Maintenance dose for up to 12 months (90 mg twice daily)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider urgent CABG if the coronary anatomy is not amenable to PCI and one of the following:[1]
❑ Patients with left main or left main equivalent disease
❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction
❑ Diabetic patients
 
❑ Perform an angiography
 
Continue with the complete diagnostic approach below
 
  1. "ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI".