01
  WINTER


                   2005
                             Circulation
ACLS
  Template




                  Panit...
Effective Chest compression

Goals                          How to achieve

                               Push 100/min
  ...
WINTER


                       2005
                                       Circulation
ACLS     Template

Pulseless Arres...
Pulseless Arrest
•BLS algorithm, Call for help ,give CPR
•Give oxygen when avialable
•Attach moniter/ AED when avialable

...
Pulseless Arrest
        •BLS algorithm, Call for help ,give CPR
        •Give oxygen when avialable
        •Attach monit...
Pulseless Arrest
                        •BLS algorithm, Call for help ,give CPR
                        •Give oxygen when...
Check rhythm. Shockable ?


                VF/VT                                  Asystole/PEA



Give 1 shock
•Manual bi...
Continue CPR while defibrilator is charging
         Give 1 shock
         Resume CPR immediately after shock
         Epi...
Questions



• ชายอายุ 55 ปี เป็นโรคหัวใจอยู่เดิม ถูกนาส่งร.พ ด้วยเรื่องหมดสติ ญาติให้
  ประวัติว่าเป็นขณะออกกาลังกาย แรกร...
Questions



• หญิงอายุ 45 ปี Underlying เป็น CA breat with distance
  metastasis ญาติพบว่าตอนเช้าปลุกไม่ตื่น ตัวเย็น ซีดเ...
Questions



• ขณะที่ทีมกาลัง CPR ผู้ป่วยหญิงอายุ 68 ปี ไม่ทราบประวัติ มาด้วยไม่
  รู้สึกตัว ได้ใส่ ET-Tube , i.v access, ...
Contributing factor
    6H                        5T

•    Hypovolumia          •    Toxin
•    Hypoxia              •    ...
Questions
Route of drug administration


  • ผู้ป่วย cardiac arrest. EKG เป็น VF ซึ่งไม่ตอบสนองต่อการทา
    Defibrillation...
Intraosseous
Site of administration

                         2 cm. above medial
                               condyle
  ...
Questions



•   You are arrive on scene to fine CPR is in progress. Nursing staff
    report that the patient was recover...
Questions
• Following initiation of CPR and one shock for
Questions



• ผู้ป่วยชายอายุ 35 ปี เป็นช่างซ่อมเสาไฟฟ้า นาส่งร.พ เนื่องจากโดนไฟฟ้าแรงสูง
  ช๊อต และตกจากที่สูง 5 เมตร ไม่...
WINTER



                               2005
Brady &
      Template

Tacchycardia
                    Panita Worapratya
 ...
•   35 yr-old woman with palpitation, light headness and stable
    tacchycardia. EKG as picture. An IV has been establish...
WINTER
                             Template



67 Yr-old male ไม่รู้สึกตัวมา 30 min >V/S : BP 64/24,PR 30/min หลังจากท่าน...
WINTER
                            Template



55 Yr-old female บ่นจุกแน่นหน้าอกที่ลิ้นปี่มา 1 ช.ม เป็นขณะพัก ประวัติว่าเค...
WINTER
                       Template



58 Yr-old male บ่นแน่นหน้าอก หน้ามืดจะเป็นลม 30 นาที V/S BP 90/60 PR 33/min
 ,sw...
WINTER
                                 Template


61 Yr-old male หน้ามืด ขณะนั่งรับประทานอาหาร ไม่มจุกแน่นหน้าอก แต่มีใจส...
WINTER
                                Template



66 Yr-old male, underlying CAD with history of coronary bypass
 graft. ...
•   57 yr-old woman with palpitation, chest discomfort and tacchycardia.
    The moniter as picture. She becomes diaphoret...
• 27 ปีผู้ชาย อยู่ ๆ มีอาการใจสั่น หน้ามืด จะเป็นลม เหงื่อแตก ไม่เคยเป็นเช่นนี้มาก่อน
  มาที่ ER ปลายมือปลายเท้าเย็น BP 12...
01
        WINTER
Basic   Template


EKG
                        Panita Worapratya
                  Emergency Department
...
Basic EKG   01
WINTER
Template
Basic EKG Analysis

•   Step 1
                 WINTER
             : Regular or not ?
                    Template
•   St...
Step 1 : Regular or not ?
      WINTER
       Template
Rate & rhythm
                         WINTER
                            Template




• RR interval is 2 large block, rat...
Step 2 : P wave
                    WINTER
• Normal (sinus P wave) present?
                     Template


• Abnormal (no...
Step 2 : P wave
                  WINTER
• No P wave : SVT or junctional
                   Template
Step 2 : P wave
                 WINTER
• Repalcement of P wave by other atrial wave?
                   Template
Step 3 : QRS complex
                 WINTER
                  Template
Stable
                 Wide QRS complex
V/S ?

  ...
Differrentiate Wide QRS
                           WINTER
                               Wide QRS complex
                ...
Wide QRS differrentiation
                                                           Excluded VT and
                     ...
Wide QRS differrentiation
                                                        Excluded VT and
                  Wide Q...
Wide QRS differrentiation
                                                                    Excluded VT and
            ...
Wide QRS differrentiation
                                              Excluded VT and
        Wide QRS complex          ...
Wide QRS differrentiation
                                              Excluded VT and
        Wide QRS complex          ...
Wide QRS differrentiation
                                              Excluded VT and
        Wide QRS complex          ...
Differrentiate Wide QRS
                           WINTER
                               Wide QRS complex
                ...
Step 4 : Analysis rhythm
Narrow complex
tacchycardia
                           WINTERWide QRS complex
                   ...
Step 4 : Analysis rhythm
Narrow complex tacchycardia

• Measure rate and rhythm
• Look for P wave & QRS relationship
   – ...
Step 4 : Analysis rhythm
Narrow complex tacchycardia

                     P > QRS
= Atrial arrythmia
Narrow complex tacchycardia
                                                                                P in QRS
     ...
Narrow complex tacchycardia
                                                                                   P fused wit...
Narrow complex tacchycardia

                           P < QRS
= Junctional taccycardia
Wide complex tacchycardia




.   Monomorphic VT      Polymorphic VT
Narrow complex Bradycardia
Narrow complex Bradycardia
2nd degree AV
                                   Group of beat ?
                 block




            PR segment
   PR  ...
WINTER



                               2005
Brady &
      Template

Tacchycardia
                    Panita Worapratya
 ...
Tacchycardia



                           •Assess & support ABCD
                           •Given oxygen
               ...
Stable patient


                                       •Establish AV access
                                       •Obtai...
Regular-narrow complex
                    •Attempt vagal maneuver
                    •Adenosine 6 mg iv push
           ...
Wide QRS complex



              Regular                                              Irregular




                     ...
•   35 yr-old woman with palpitation, light headness and stable
    tacchycardia. EKG as picture. An IV has been establish...
WINTER
                             Template



67 Yr-old male ไม่รู้สึกตัวมา 30 min >V/S : BP 64/24,PR 30/min หลังจากท่าน...
WINTER
                            Template



55 Yr-old female บ่นจุกแน่นหน้าอกที่ลิ้นปี่มา 1 ช.ม เป็นขณะพัก ประวัติว่าเค...
WINTER
                       Template



58 Yr-old male บ่นแน่นหน้าอก หน้ามืดจะเป็นลม 30 นาที V/S BP 90/60 PR 33/min
 ,sw...
WINTER
                                 Template


61 Yr-old male หน้ามืด ขณะนั่งรับประทานอาหาร ไม่มจุกแน่นหน้าอก แต่มีใจส...
WINTER
                                Template



66 Yr-old male, underlying CAD with history of coronary bypass
 graft. ...
•   57 yr-old woman with palpitation, chest discomfort and tacchycardia.
    The moniter as picture. She becomes diaphoret...
• If the patient is monomorphic, unstable VT
  but has pulse, treat with synchronized
  cardioversion initial dose is 100J...
• 27 ปีผู้ชาย อยู่ ๆ มีอาการใจสั่น หน้ามืด จะเป็นลม เหงื่อแตก ไม่เคยเป็นเช่นนี้มาก่อน
  มาที่ ER ปลายมือปลายเท้าเย็น BP 12...
WINTER



                                  2005
Coronary
      Template

Syndrome
                       Panita Worapraty...
WINTER



                               2005
Basic EKG for
      Template

ACS
                    Panita Worapratya
    ...
EKG change during ischemia
        WINTER
         Template
EKG change during ischemia
        WINTER
         Template
EKG change during ischemia
        WINTER
         Template
         LCA origin : Lt. sinus of
              aortic valve
EKG change during ischemia
                WINTER
                  Template
                          LAD : Anteroseptal
...
EKG change during ischemia
                  WINTER
                    Template




   LCx : Anterolateral wall
EKG change during ischemia
                          WINTER
                          Template
RCA : RV, inferior wall
Basic Leads group
                           WINTER
                                Template




       Wall              ...
Basic Leads group
                        WINTER Template




     Wall               EKG                Blood supply
Infe...
Basic Leads group
               WINTER
                   Template




     Wall          EKG         Blood supply
Anteri...
Basic Leads group
                  WINTER
                     Template




     Wall            EKG           Blood supp...
Basic Leads group
                 WINTER
                     Template




    Wall             EKG        Blood supply
A...
Basic Leads group
                 WINTER
                     Template




    Wall             EKG        Blood supply
A...
Basic Leads group
                  WINTER
                     Template




    Wall             EKG          Blood suppl...
Basic Leads group
                         WINTERTemplate



      Wall               EKG                   Blood supply
I...
RCA or RCx
                        WINTER
                          Template




RCA occlusion                  RCx occlus...
Various cause of ST segment Deviation

ST elevation
                        WINTER ST depression
                         ...
EKG Evolution in non-reperfused MI
           WINTER
             Template
Morphology of ST elevate
LVH    LBB
                   WINTER
             Pericarditis   Hyper K+

                      ...
Morphology of ST elevate
LVH    LBB
                   WINTER
             Pericarditis    Hyper K+

                     ...
Morphology of ST elevate
LVH    LBB
                   WINTER
             Pericarditis   Hyper K+

                      ...
Morphology of ST elevate
LVH    LBB
                   WINTER
             Pericarditis   Hyper K+

                      ...
Morphology of ST elevate
LVH    LBB
                   WINTER
             Pericarditis   Hyper K+

                      ...
Morphology of ST elevate
LVH    LBB
                   WINTER
             Pericarditis   Hyper K+

                      ...
Morphology of ST elevate
LVH    LBB
                   WINTER
             Pericarditis   Hyper K+

                      ...
Morphology of ST elevate
      WINTER
       Template
1                Chest comfort
                                          suggest of ischemia

2
     EMS careand Hosp. pre...
4
                                         Review 12 Leads EKG


  5                                      9               ...
4
                                         Review 12 Leads EKG


  5                                      9               ...
7
         Time form onset of
          symptoms ≤ 12 hr




 8
Reperfusion therapy
•Reperfusion goal
     •Door to balloo...
4
                            Review 12 Leads EKG


5                           9                                  13

   ...
11

          Admit to moniter and
          risk assessment (Table
                    3,4)



12


High risk patient (ta...
4
                            Review 12 Leads EKG


5                           9                                       13...
15

     Consider admission to ED
        chest pain unit or
          monitered bed
     • Serial cardiac marder
     • R...
Check list for STEMI fibrinolytic therapy

Step 1                Chest discomfort > 15 min, < 12 hr
                      ...
Check list for STEMI fibrinolytic therapy



                    Are there contraindication for fibrinolysis ?
Step 2
    ...
Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment change
       ...
Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment change
       ...
Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment change
       ...
Table 3 : Likely hood of ischemic etiology (short term risk)
Part II : Risk of death or non fatal MI over the short term i...
Table 3 : Likely hood of ischemic etiology (short term risk)
Part II : Risk of death or non fatal MI over the short term i...
Table 3 : Likely hood of ischemic etiology (short term risk)
Part II : Risk of death or non fatal MI over the short term i...
Table 4 : TIMI risk score for patient with UA and NSTEMI

                                         Risk factor of CAD
    ...
Table 4 : TIMI risk score for patient with UA and NSTEMI

Calculated        Risk of ≥ 1        Risk status
TIMI risk      ...
Case Presentation
                               WINTER
• ชายอายุ 42 ปี : 3 วันมีอาการใจสั่น แน่นหน้าอก ไม่สัมพันธ์กับการอ...
Case Presentation
A : Anxiousness.
                WINTER
                     Template
B : Lung is clear . O2 sat วัดไม่ไ...
Case Presentation
  WINTER
   Template
Case Presentation
  WINTER
   Template
Case Presentation
  WINTER
   Template
Case Presentation
Initial management
                       WINTER
                         Template
    A : None
    B : ...
Case Presentation
                    WINTER
                       Template
หลัง Load fluid ครบ 300 ml และให้ atropine 1 ...
Case Presentation
                       WINTER
หลัง Load fluid ครบ 300 ml และให้ atropine 1 amp
                         ...
Case Presentation
  WINTER
   Template
Case Presentation

  ท่านจะทาอย่างไรต่อไป
                        WINTER
• At 19.37 หลังใส่ ET-Tube คนไข้เริ่ม unconscious...
Case Presentation
                        WINTER
• หลังจาก CPRไปได้ 2 นาที ให้ adrenaline run q 3 min คลื่นไฟฟ้า
         ...
Case Presentation
                           WINTER
• ได้ทา defibrillation x 3 ครั้ง EKG ยังคงเป็นเช่นนี้ ท่านจะทาอย่างไรต...
Case Presentation

  ท่านจะทาอย่างไรต่อไป
                         WINTER
• หลังจากท่าน ได้ check lead, ขยาย amplitude แล้...
Case Presentation
                                WINTER
                                   Template



หลังจากท่านได้ Def...
WINTER



                              2005
Thank You
   Template




                   Panita Worapratya
             E...
Common cause of ST depression
03




PowerPoint picture page
04
 Bullet points are like this
Text and lines are like this
Hyperlinks like this
Visited hyperlinks like this


         ...
05
You are free to use these templates for your personal
and business presentations.

We have put a lot of work into devel...
4
                                         Review 12 Leads EKG


  5                                      9               ...
Updates in ACLS 2005
Updates in ACLS 2005
Updates in ACLS 2005
Updates in ACLS 2005
Updates in ACLS 2005
Updates in ACLS 2005
Updates in ACLS 2005
Updates in ACLS 2005
Upcoming SlideShare
Loading in …5
×

Updates in ACLS 2005

4,184 views

Published on

Published in: Health & Medicine, Technology
3 Comments
6 Likes
Statistics
Notes
No Downloads
Views
Total views
4,184
On SlideShare
0
From Embeds
0
Number of Embeds
719
Actions
Shares
0
Downloads
677
Comments
3
Likes
6
Embeds 0
No embeds

No notes for slide

Updates in ACLS 2005

  1. 1. 01 WINTER 2005 Circulation ACLS Template Panita Worapratya Emergency Department Prince of Songkhla University
  2. 2. Effective Chest compression Goals How to achieve Push 100/min Push hard & Deep 1/3 of chest wall fast Fully recoil Fully Don’t let hands off the chest wall recoil Minimized interruption Avoid fatique Resume CPR No pause for check pulse
  3. 3. WINTER 2005 Circulation ACLS Template Pulseless Arrest Panita Worapratya Emergency Department Prince of Songkhla University
  4. 4. Pulseless Arrest •BLS algorithm, Call for help ,give CPR •Give oxygen when avialable •Attach moniter/ AED when avialable Check rhythm. Shockable ?
  5. 5. Pulseless Arrest •BLS algorithm, Call for help ,give CPR •Give oxygen when avialable •Attach moniter/ AED when avialable Check rhythm. Shockable ? VF/VT Asystole/PEA Resume CPR immediately I.V/I.O access, given vasopressor • Epinephrine 1 mg I.V/ I.O q 3-5 min •Vasopressin 40 U I.V/I.O to replace epinerphine •Consider atropine 1 mg I.V/I.O for asystole or slow PEA
  6. 6. Pulseless Arrest •BLS algorithm, Call for help ,give CPR •Give oxygen when avialable •Attach moniter/ AED when avialable Check rhythm. Shockable ? VF/VT Asystole/PEA Give 1 shock •Manual biphasic 200J •Monophasic 300 J •AED when avialable Resume CPR immediately Check rhythm. Shockable ?
  7. 7. Check rhythm. Shockable ? VF/VT Asystole/PEA Give 1 shock •Manual biphasic 200J •Monophasic 300 J •AED when avialable Resume CPR immediately Check rhythm. Shockable ? Continue CPR while defibrilator is charging Give 1 shock •Manual biphasic 200J •Monophasic 300 J •AED when avialable Resume CPR immediately after shock When I.V or I.O access give vasopress Epinephrine 1 mg I.V/I.O q 3-5 min Or one dose of vasopressin 40 U I.V/I.O
  8. 8. Continue CPR while defibrilator is charging Give 1 shock Resume CPR immediately after shock Epinephrine 1 mg I.V/I.O q 3-5 min Check rhythm. Shockable ? Continue CPR while defibrilator is charging Give 1 shock Resume CPR immediately after shock Epinephrine 1 mg I.V/I.O q 3-5 min Consider antiarrythmic drug •Amiodarone 300 mg I.V/I.O then 150 mg I.V •Lidocaine 1-1.5 mg/kg I.V/I.O then 0.5-7.5 mg/kg I.V/I.O •Consider MgSO4 1-2 g I.V/I.O •After 5 cycle of CPR , look for 6H,5T
  9. 9. Questions • ชายอายุ 55 ปี เป็นโรคหัวใจอยู่เดิม ถูกนาส่งร.พ ด้วยเรื่องหมดสติ ญาติให้ ประวัติว่าเป็นขณะออกกาลังกาย แรกรับ Unconsciousness, no pulse. EKG เป็นดังรูป ท่านจะให้การรักษาอย่างไร a. Chest compression b. Atropine 1 amp iv stat c. Synchronized cardioversion 100 J d. Defibrillation 200 J e. Search for 6H, 5T pulseless VF : Defibrillation 200 J
  10. 10. Questions • หญิงอายุ 45 ปี Underlying เป็น CA breat with distance metastasis ญาติพบว่าตอนเช้าปลุกไม่ตื่น ตัวเย็น ซีดเขียว ไม่หายใจ ไม่ทราบว่าตั้งแต่เมื่อใด แรกรับ Unconsciousness, no pulse. EKG เป็นดังรูป ท่านจะให้การรักษาอย่างไร a. Chest compression 5 cycle b. Atropine 1 amp iv stat c. Synchronized cardioversion 100 J d. Defibrillation 200 J Asystole : CPR 5 cycle e. Search for 6H, 5T
  11. 11. Questions • ขณะที่ทีมกาลัง CPR ผู้ป่วยหญิงอายุ 68 ปี ไม่ทราบประวัติ มาด้วยไม่ รู้สึกตัว ได้ใส่ ET-Tube , i.v access, adrenaline 1 amp iv q 3-5 min และ High quality CPR แล้วไม่ดขึ้น EKG ยังคงเป็น ี ดังรูป หลังจากท่านได้ทา Defibrillation ไปแล้ว 3 ครั้ง ท่านจะให้การ รักษาอย่างไรต่อ ? (อาจเลือกได้มากกว่า 1 ข้อ) a. Antiarrhythmic drug Refractory VT : b. NaHCO3 50 mEq •Amiodarone 300 mg i.v/i.o c. Escalating dose epinephrine 3 mg •6H, 5T d. Search for 6H, 5T
  12. 12. Contributing factor 6H 5T • Hypovolumia • Toxin • Hypoxia • Temponade (cardiac) • Hydrogen ion • Tension pneumothorax • Hypo/hyper kalemia • Thrombosis • Hypoglycemia • Trauma • Hypothermia
  13. 13. Questions Route of drug administration • ผู้ป่วย cardiac arrest. EKG เป็น VF ซึ่งไม่ตอบสนองต่อการทา Defibrillation. พยาบาลได้พยายามเปิดเส้นเลือด 2 ครั้ง แต่ไม่เป็นผล ผู้ป่วยได้ใส่ ET-Tube แล้ว ท่านคิดว่าจะให้ยากู้ชีพทางใดดีที่สด ุ a. Endotracheal b. Femeral vein c. Intraosseous d. External jugular vein Intraosseous
  14. 14. Intraosseous Site of administration 2 cm. above medial condyle 2 cm. above medial maleolous 2 cm. below medial tuberosity
  15. 15. Questions • You are arrive on scene to fine CPR is in progress. Nursing staff report that the patient was recovering form pulmonary embolism and suddenly collapsed. There is no pulse or spontaneous respiration. High quallity CPR is in progress and effetive circulation is being provided with bag mask. An i.v is establish, you would now…? a. Give atropine 1 mg i.v b. Give NaHCO3 1 amp iv c. Immediate CPR d. Immediate endotracheal intubation e. Initiate transcutaneous pacing
  16. 16. Questions • Following initiation of CPR and one shock for
  17. 17. Questions • ผู้ป่วยชายอายุ 35 ปี เป็นช่างซ่อมเสาไฟฟ้า นาส่งร.พ เนื่องจากโดนไฟฟ้าแรงสูง ช๊อต และตกจากที่สูง 5 เมตร ไม่รู้สกตัว แรกรับไม่มีสัญญาณชีพ Moniter ึ EKG เป็นดังรูป จงให้การรักษา a. Give atropine 1 mg i.v b. Give epineprhine 1 mg i.v c. Give Synchronized cardioversion 100 J d. Immediate Defibrillation 200J e. Initiate transcutaneous pacing
  18. 18. WINTER 2005 Brady & Template Tacchycardia Panita Worapratya Emergency Department Prince of Songkhla University
  19. 19. • 35 yr-old woman with palpitation, light headness and stable tacchycardia. EKG as picture. An IV has been established. What drug should be administered IV? o Atropine 0.5 mg o Lidocaine 1 mg/kg o Epinephrine 2-10 µg/kg/min o Adenosine 6 mg
  20. 20. WINTER Template 67 Yr-old male ไม่รู้สึกตัวมา 30 min >V/S : BP 64/24,PR 30/min หลังจากท่านได้ใส่ ท่อช่วยหายใจ เปิดเส้นเลือด ติด monitor EKG แล้ว คลื่นไฟฟ้าหัวใจเป็นดังรูปท่านคิดว่าการกระทาใด เหมาะสมที่สุด o On external pacing o Atropine 0.6 mg iv stat o 7.5 % NaHCO3 1 amp iv stat o 10% Ca-gluconate 1 amp iv stat
  21. 21. WINTER Template 55 Yr-old female บ่นจุกแน่นหน้าอกที่ลิ้นปี่มา 1 ช.ม เป็นขณะพัก ประวัติว่าเคยไปตรวจที่คลินิค แพทย์บอกว่าหัวใจโต V/S : BP 140/86 PR 87/min ,regular-full peripheral pulse. EKG เป็นดังรูป ท่านจะทาอย่างไร o ให้ ASA, ISDN, Morphine o ให้ serial EKG ไปก่อน รอ cardiac enzyme o Consult cardiologist ทันที สงสัย AMI
  22. 22. WINTER Template 58 Yr-old male บ่นแน่นหน้าอก หน้ามืดจะเป็นลม 30 นาที V/S BP 90/60 PR 33/min ,sweating, look anxiousness. EKG เป็นดังรูป ท่านจะทาอย่างไร o ให้ atropine 1 amp iv. stat o ให้ serial EKG รอ cardiac enzyme o Consult cardiologist ทันที สงสัย AMI o ใส่ Transcutaneous pacing
  23. 23. WINTER Template 61 Yr-old male หน้ามืด ขณะนั่งรับประทานอาหาร ไม่มจุกแน่นหน้าอก แต่มีใจสั่น V/S แรกรับ ี BP 95/57 PR 42/min , irregular, sweating ถามตอบไม่รู้เรื่อง o ให้ atropine 1 amp iv. stat o ให้ serial EKG รอ cardiac enzyme o Consult cardiologist ทันที o ใส่ Transcutaneous pacing
  24. 24. WINTER Template 66 Yr-old male, underlying CAD with history of coronary bypass graft. มาด้วยเป็นลมหมดสติ ไม่รู้สึกตัว BP วัดไม่ได้ ปลายมือปลายเท้าซีด เย็น o ให้ adenosine 6 mg iv stat o ให้ synchronized cardioversion 100 J o ให้ cordarone 150 mg iv stat o ให้ Defib 200 J
  25. 25. • 57 yr-old woman with palpitation, chest discomfort and tacchycardia. The moniter as picture. She becomes diaphoretic and BP 80/60 mmHg. The next action is o Obtain 12 lead EKG o Perform immediate electrical cardioversion o Establish IV and give sedation for electrical cardioversion o Give amiodarone 300 mg IV push
  26. 26. • 27 ปีผู้ชาย อยู่ ๆ มีอาการใจสั่น หน้ามืด จะเป็นลม เหงื่อแตก ไม่เคยเป็นเช่นนี้มาก่อน มาที่ ER ปลายมือปลายเท้าเย็น BP 120/84 PR 210 EKG เป็นดังรูป จงให้การรักษา o Adenosine 6 mg iv stat o Give amiodarone 300 mg IV push o Perform immediate Defibrillation o Establish IV and give sedation for synchronized cardioversion
  27. 27. 01 WINTER Basic Template EKG Panita Worapratya Emergency Department Prince of Songkhla University
  28. 28. Basic EKG 01 WINTER Template
  29. 29. Basic EKG Analysis • Step 1 WINTER : Regular or not ? Template • Step 2 : P wave ? • Step 3 : QRS ? (wide/narrow) • Step 4 : ST-segment elevation • Step 5 : QT segment
  30. 30. Step 1 : Regular or not ? WINTER Template
  31. 31. Rate & rhythm WINTER Template • RR interval is 2 large block, rate = 150 beats/min (300/2) • RR interval is 3 large block, rate = 100 beats/min (300/3) • RR interval is 4 large block, rate = 75 beats/min (300/4)
  32. 32. Step 2 : P wave WINTER • Normal (sinus P wave) present? Template • Abnormal (non sinus P wave) present ?
  33. 33. Step 2 : P wave WINTER • No P wave : SVT or junctional Template
  34. 34. Step 2 : P wave WINTER • Repalcement of P wave by other atrial wave? Template
  35. 35. Step 3 : QRS complex WINTER Template Stable Wide QRS complex V/S ? Unstable Stable Immediate Cardioversion Consider common cause •VT : Most common, especially underlying heart disease •SVT with pre-existing RBBB •SVT with aberrant conduction
  36. 36. Differrentiate Wide QRS WINTER Wide QRS complex Template Excluded VT and WPW !! Typical RBB Typical LBB IVCD RBB LBB •QRS wide > 0.11 s. •QRS wide > 0.11 s •QRS wide > 0.12 s •Neither typical RBB nor •rSR' or rsR' in V1 •Upright (monophasic) LBB present •Wide terminal S wave in QRS in Lead I, V6 (เป็นตุด ไม่ใช่ LBB ก็ไม่ใช่ RBB ก็ไม่ ๊ Lead I, V6 •Negative QRS in V1 เชิง)
  37. 37. Wide QRS differrentiation Excluded VT and Wide QRS complex WPW !! Modified Brugada Criteria for VT Question Answer 1. Is there AV dissociation? Yes = VT ( independent P/QRS, capture beats, fusion beat) 2. Is there an RS in any No = VT precordial lead? 3. Is there QRS onset to nadir of Yes = VT S wave > 100 msec in any precordial lead? WPW 4. Are there morphologic criteria Yest = VT •Short PR for VT in both V1 or V6? • Delta wave 5. If no, SVT • Wide QRS complex
  38. 38. Wide QRS differrentiation Excluded VT and Wide QRS complex WPW !! Modified Brugada Criteria for VT Question Answer 1. Is there AV dissociation? Yes = VT ( independent P/QRS, capture beats, fusion beat) 2. Is there an RS in any No = VT precordial lead? AV dissociation 3. Is there QRS onset to nadir of Yes = VT S wave > 100 msec in any precordial lead? 4. Are there morphologic criteria Yest = VT for VT in both V1 or V6? 5. If no, SVT
  39. 39. Wide QRS differrentiation Excluded VT and Wide QRS complex WPW !! Modified Brugada Criteria for VT Question Answer 1. Is there AV dissociation? Yes = VT ( independent P/QRS, capture beats, fusion beat) 2. Is there an RS in any No = VT precordial lead? 3. Is there QRS onset to nadir of Yes = VT S wave > 100 msec in any 100 % specific for VT precordial lead? Sensitivity 26% 4. Are there morphologic criteria Yest = VT for VT in both V1 or V6? No RS wave in any precordial leads 5. If no, SVT
  40. 40. Wide QRS differrentiation Excluded VT and Wide QRS complex WPW !! Modified Brugada Criteria for VT Question Answer 1. Is there AV dissociation? Yes = VT ( independent P/QRS, capture beats, fusion beat) 2. Is there an RS in any No = VT precordial lead? 3. Is there QRS onset to nadir of Yes = VT S wave > 160 msec in any precordial lead? 4. Are there morphologic criteria Yest = VT for VT in both V1,2 or V6? 5. If no, SVT
  41. 41. Wide QRS differrentiation Excluded VT and Wide QRS complex WPW !! Modified Brugada Criteria for VT Question Answer 1. Is there AV dissociation? Yes = VT ( independent P/QRS, capture beats, fusion beat) 2. Is there an RS in any No = VT precordial lead? 3. Is there QRS onset to nadir of Yes = VT S wave > 100 msec in any precordial lead? 4. Are there morphologic criteria Yest = VT for VT in both V1,2 or V6? 5. If no, SVT
  42. 42. Wide QRS differrentiation Excluded VT and Wide QRS complex WPW !! Modified Brugada Criteria for VT Question Answer 1. Is there AV dissociation? Yes = VT ( independent P/QRS, capture beats, fusion beat) 2. Is there an RS in any No = VT precordial lead? 3. Is there QRS onset to nadir of Yes = VT S wave > 100 msec in any precordial lead? 4. Are there morphologic criteria Yest = VT for VT in both V1,2 or V6? 5. If no, SVT
  43. 43. Differrentiate Wide QRS WINTER Wide QRS complex Template Excluded VT and WPW !! Typical RBB Typical LBB IVCD RBB LBB •QRS wide > 0.11 s. •QRS wide > 0.11 s •QRS wide > 0.12 s •Neither typical RBB nor •rSR' or rsR' in V1 •Upright (monophasic) LBB present •Wide terminal S wave in QRS in Lead I, V6 (เป็นตุด ไม่ใช่ LBB ก็ไม่ใช่ RBB ก็ไม่ ๊ Lead I, V6 •Negative QRS in V1 เชิง)
  44. 44. Step 4 : Analysis rhythm Narrow complex tacchycardia WINTERWide QRS complex tacchycardia Template • Sinus tacchycardia • Ventricular tacchycardia • Atrial fibrillation • SVT with aberrancy • Atrial flutter • Pre-excited tacchycardia • AV nodal reentry • Accessory pathway-mediated tachycardia • Atrial tacchycardia (ectopic or reentrance) • Multifocal atrial tacchycardia (MAT) • Junctional tacchycardia
  45. 45. Step 4 : Analysis rhythm Narrow complex tacchycardia • Measure rate and rhythm • Look for P wave & QRS relationship – If P > QRS : Atrial arrythmia – If P = QRS : Look for timing of P-wave • P in QRS = AVRT • P fused with QRS = AVNRT – If P < QRS : Junctional arrythmia
  46. 46. Step 4 : Analysis rhythm Narrow complex tacchycardia P > QRS = Atrial arrythmia
  47. 47. Narrow complex tacchycardia P in QRS P = QRS = AVRT WPW : Normal electrical conduction through AV AVRT with reentrance circuit consisting of 2 limbs, node and accessory pathway cause slurred the antrograde limb involve the normal QRS and upstoke of QRS wave (delta wave retrograde limbs involve accessory pathway
  48. 48. Narrow complex tacchycardia P fused with QRS P = QRS = AVNRT AVNRT :Reentrance circuit around AV These AV nodal reentry beats stimulate both the atrium and the nodeleading to rapid stimulation of ventricle ventricles rapidly in typically a 1 to 1 fashion with a strip of the EKG and tacchycardia. shown at the bottom.
  49. 49. Narrow complex tacchycardia P < QRS = Junctional taccycardia
  50. 50. Wide complex tacchycardia . Monomorphic VT Polymorphic VT
  51. 51. Narrow complex Bradycardia
  52. 52. Narrow complex Bradycardia
  53. 53. 2nd degree AV Group of beat ? block PR segment PR PR equal Prolonger prolong Morbitz I Morbitz II
  54. 54. WINTER 2005 Brady & Template Tacchycardia Panita Worapratya Emergency Department Prince of Songkhla University
  55. 55. Tacchycardia •Assess & support ABCD •Given oxygen •Moniter EKG, BP, oxymetry •Identify & treat reversible cause Is patient stable ? Yes Yes •Establish AV access Immediate Synchronized •Obtain 12 Leads EKG cardioversion Is QRS narrow? (<0.12 s) Immediate I.V access Expert consultation If pulseless arrest develop, follow guideline
  56. 56. Stable patient •Establish AV access •Obtain 12 Leads EKG Is QRS narrow? (<0.12 s) Narrow QRS complex Wide QRS complex Regular or not? Regular-narrow complex Irregular –narrow complex •Attempt vagal maneuver Possible AF, atrial flutter or MAT •Adenosine 6 mg iv push Consider expert consultation then 12 mg iv push Controle rate : Diltiazem, B-blocker may repeat 12 mg iv push at once Caution B-blocker in CHF, Hypotension
  57. 57. Regular-narrow complex •Attempt vagal maneuver •Adenosine 6 mg iv push then 12 mg iv push may repeat 12 mg iv push at once Does rhythm convert ? Rhythm Convert Rhythm Dose not Convert = Possible SVT = Possible atrial flutter, ectopic atrial •Observe for recurrent tacchycardia, or junctional tacchycardia •Treat recurrent with adenosine or AV • Controle rate (diatiazem, b-blocker) blocking agent (diltiazem/B-blocker) • Treat underlying cause • Expert consultation During evaluation consider =6H= =5T= Hypovolumia Toxin Hypoxia Temponade Hydrogen ion Thrombosis Hypoglycemia Tension pneumothorax Hypo/hyper kalemia Trauma Hypothermia
  58. 58. Wide QRS complex Regular Irregular If atrial fibrillation with aberrency If ventricular tacchycardia or uncertain • Treat as irregular narrow complex rhythm tacchycardia •Amiodarone 150 mg i.v over 10 min If preexite atrial fibrillation (AF with Repeat as needed to maximum dose 2.2 WPW) g/24 hr • Expert consultation •Prepare for synchronized cardioversion • Avoid AV nodal blocking agent If SVT with aberrency , (adenosine, digoxin, diltiazem, •Give adenosine verapamil) • Consider antiarrhythmic drug (amiodarone 150 mg iv over 10 min) If recurrent polymorphic VT • Expert consultation If torsade de point give •MgSO4 1-2 g over 5-60 min then infusion
  59. 59. • 35 yr-old woman with palpitation, light headness and stable tacchycardia. EKG as picture. An IV has been established. What drug should be administered IV? o Atropine 0.5 mg o Lidocaine 1 mg/kg o Epinephrine 2-10 µg/kg/min o Adenosine 6 mg Answer : SVT =Adenosine 6 mg
  60. 60. WINTER Template 67 Yr-old male ไม่รู้สึกตัวมา 30 min >V/S : BP 64/24,PR 30/min หลังจากท่านได้ใส่ ท่อช่วยหายใจ เปิดเส้นเลือด ติด monitor EKG แล้ว คลื่นไฟฟ้าหัวใจเป็นดังรูปท่านคิดว่าการกระทาใด เหมาะสมที่สุด o On external pacing o Atropine 0.6 mg iv stat o 7.5 % NaHCO3 1 amp iv stat o 10% Ca-gluconate 1 amp iv stat
  61. 61. WINTER Template 55 Yr-old female บ่นจุกแน่นหน้าอกที่ลิ้นปี่มา 1 ช.ม เป็นขณะพัก ประวัติว่าเคยไปตรวจที่คลินิค แพทย์บอกว่าหัวใจโต V/S : BP 140/86 PR 87/min ,regular-full peripheral pulse. EKG เป็นดังรูป ท่านจะทาอย่างไร o ให้ ASA, ISDN, Morphine o ให้ serial EKG ไปก่อน รอ cardiac enzyme o Consult cardiologist ทันที สงสัย AMI
  62. 62. WINTER Template 58 Yr-old male บ่นแน่นหน้าอก หน้ามืดจะเป็นลม 30 นาที V/S BP 90/60 PR 33/min ,sweating, look anxiousness. EKG เป็นดังรูป ท่านจะทาอย่างไร o ให้ atropine 1 amp iv. stat o ให้ serial EKG รอ cardiac enzyme o Consult cardiologist ทันที สงสัย AMI o ใส่ Transcutaneous pacing
  63. 63. WINTER Template 61 Yr-old male หน้ามืด ขณะนั่งรับประทานอาหาร ไม่มจุกแน่นหน้าอก แต่มีใจสั่น V/S แรกรับ ี BP 95/57 PR 42/min , irregular, sweating ถามตอบไม่รู้เรื่อง o ให้ atropine 1 amp iv. stat o ให้ serial EKG รอ cardiac enzyme o Consult cardiologist ทันที o ใส่ Transcutaneous pacing
  64. 64. WINTER Template 66 Yr-old male, underlying CAD with history of coronary bypass graft. มาด้วยเป็นลมหมดสติ ไม่รู้สึกตัว BP วัดไม่ได้ ปลายมือปลายเท้าซีด เย็น o ให้ adenosine 6 mg iv stat o ให้ synchronized cardioversion 100 J o ให้ cordarone 150 mg iv stat o ให้ Defib 200 J
  65. 65. • 57 yr-old woman with palpitation, chest discomfort and tacchycardia. The moniter as picture. She becomes diaphoretic and BP 80/60 mmHg. The next action is o Obtain 12 lead EKG o Perform immediate electrical cardioversion o Establish IV and give sedation for electrical cardioversion o Give amiodarone 300 mg IV push Answer : VT with pulse Immediate electrical cardioversion
  66. 66. • If the patient is monomorphic, unstable VT but has pulse, treat with synchronized cardioversion initial dose is 100J. and stepwise (200J, 300J, 360J)
  67. 67. • 27 ปีผู้ชาย อยู่ ๆ มีอาการใจสั่น หน้ามืด จะเป็นลม เหงื่อแตก ไม่เคยเป็นเช่นนี้มาก่อน มาที่ ER ปลายมือปลายเท้าเย็น BP 120/84 PR 210 EKG เป็นดังรูป จงให้การรักษา o Adenosine 6 mg iv stat o Give amiodarone 300 mg IV push o Perform immediate Defibrillation o Establish IV and give sedation for synchronized cardioversion
  68. 68. WINTER 2005 Coronary Template Syndrome Panita Worapratya Emergency Department Prince of Songkhla University
  69. 69. WINTER 2005 Basic EKG for Template ACS Panita Worapratya Emergency Department Prince of Songkhla University
  70. 70. EKG change during ischemia WINTER Template
  71. 71. EKG change during ischemia WINTER Template
  72. 72. EKG change during ischemia WINTER Template LCA origin : Lt. sinus of aortic valve
  73. 73. EKG change during ischemia WINTER Template LAD : Anteroseptal Distal LAD : Anastomosis with posterior diagonal branch of RCA
  74. 74. EKG change during ischemia WINTER Template LCx : Anterolateral wall
  75. 75. EKG change during ischemia WINTER Template RCA : RV, inferior wall
  76. 76. Basic Leads group WINTER Template Wall EKG Blood supply Inferior wall II, III, aVF RCA or LCA RV infarction II, III, aVF, V4R Prox. RCA
  77. 77. Basic Leads group WINTER Template Wall EKG Blood supply Inferior wall II, III, aVF RCA or LCA RV infarction II, III, aVF, V4R Prox. RCA Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA
  78. 78. Basic Leads group WINTER Template Wall EKG Blood supply Anterior V2-4 Mid LAD
  79. 79. Basic Leads group WINTER Template Wall EKG Blood supply Anterior V2-4 Mid LAD Ant-Lat-Sep V1-6, aVL Prox LAD Lateral I, aVL,V5,6 Diagonal branch of LAD
  80. 80. Basic Leads group WINTER Template Wall EKG Blood supply Anterior V2-4 Mid LAD Ant-Lat-Sep V1-6, aVL Prox LAD
  81. 81. Basic Leads group WINTER Template Wall EKG Blood supply Anterior V2-4 Mid LAD Ant-Lat-Sep V1-6, aVL Prox LAD
  82. 82. Basic Leads group WINTER Template Wall EKG Blood supply Anterior V2-4 Mid LAD Ant-Lat-Sep V1-6, aVL Prox LAD Lateral I, aVL,V5,6 Diagonal branch of LAD
  83. 83. Basic Leads group WINTERTemplate Wall EKG Blood supply Inferior wall II, III, aVF RCA or LCA RV infarction II, III, aVF, V4R Prox. RCA Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA Anterior V2-4 Mid LAD Ant-Lat-Sep V1-6, aVL Prox LAD Lateral I, aVL,V5,6 Diagonal branch of LAD
  84. 84. RCA or RCx WINTER Template RCA occlusion RCx occlusion • ST elevation III > II • ST elevation II > III • ST depression in Lead I • ST elevate in Lead I • Isoelectric V4R • Negative V4R
  85. 85. Various cause of ST segment Deviation ST elevation WINTER ST depression Template Suggest MI Symmetric ST inversion in contiguous leads Asymmetric ST Early “Scooping or strain depression in repolarization like pattern lateral leads
  86. 86. EKG Evolution in non-reperfused MI WINTER Template
  87. 87. Morphology of ST elevate LVH LBB WINTER Pericarditis Hyper K+ Template • Deep S wave in V1,V2 MI MI + RBBB Brugada • Tall R in V5,V6
  88. 88. Morphology of ST elevate LVH LBB WINTER Pericarditis Hyper K+ Template MI MI + RBBB Brugada • Predominate negative QRS in V1 • QRS widening > 0.12 s • Upright QRS in Lead I, V6
  89. 89. Morphology of ST elevate LVH LBB WINTER Pericarditis Hyper K+ Template MI MI + RBBB Brugada
  90. 90. Morphology of ST elevate LVH LBB WINTER Pericarditis Hyper K+ Template MI MI + RBBB Brugada
  91. 91. Morphology of ST elevate LVH LBB WINTER Pericarditis Hyper K+ Template MI MI + RBBB Brugada
  92. 92. Morphology of ST elevate LVH LBB WINTER Pericarditis Hyper K+ Template MI MI + RBBB Brugada
  93. 93. Morphology of ST elevate LVH LBB WINTER Pericarditis Hyper K+ Template MI MI + RBBB Brugada
  94. 94. Morphology of ST elevate WINTER Template
  95. 95. 1 Chest comfort suggest of ischemia 2 EMS careand Hosp. preparation • Moniter, ABC support, prepare for CPR & defibrillation • Administer MONA (morphine,oxygen,nitroglycerine, ASA) as needed • Obtain EKG, if ST-elevation • Notify receiving hospital • Begin fibrinolytic check list • Notify hospital to response MI. 3 Immediate ED assessment < 10 min Immediate ED general treatment • Check V/S, evaluate oxygen saturation Start O2 4 L/min, maintain O2 sat > 90% • Obtain 12 leads EKG ASA 160-325 mg (if not given by EMS) • Brief target Hx & PE NTG sublingual,spray or i.v • Review fibrinolytic check list Morphine i.v if not improved by NTG • Obtain initial cardiac marker level, E-lyte and coagulopathy • Obtain portable CXR < 30min
  96. 96. 4 Review 12 Leads EKG 5 9 13 ST depression or dynamic T- Normal or nondiagnostic ST- ST elevation or new LBBB wave, strongly suspected wave change Strongly suspected STEMI ischemia Intermediate or low risk UA high risk /NSTEMI 6 10 14 Start adjunctive treatment Start adjunctive treatment as indicated as indicated Develop High or Intermediate • B-adrenergic receptor block • Nitroglycerine risk criteria (Table 3,4) • Clopidogrel • B-adrenergic blocker or • Heparin • Clopidogrel Troponin positive • Glycoprotein Iib/IIIa YES No ≥ 12hr 7 11 15 Admit to moniter and Consider admission to ED Time form onset of risk assessment (Table chest pain unit or symptoms ≤ 12 hr 3,4) monitered bed • Serial cardiac marder • Repeate EKG < 12hr • consider stress test
  97. 97. 4 Review 12 Leads EKG 5 9 13 ST depression or dynamic T- Normal or nondiagnostic ST- ST elevation or new LBBB wave, strongly suspected wave change Strongly suspected STEMI ischemia Intermediate or low risk UA high risk /NSTEMI 6 Start adjunctive treatment as indicated • B-adrenergic receptor block • Clopidogrel • Heparin ≥ 12hr 7 11 Admit to moniter and Time form onset of risk assessment (Table symptoms ≤ 12 hr 3,4) < 12hr
  98. 98. 7 Time form onset of symptoms ≤ 12 hr 8 Reperfusion therapy •Reperfusion goal •Door to balloon (PCI) < 90 min •Door to needle (fibrinolysis) 30min •Continue adjuctive therapy and.. • ACE-I or ARB < 24 of onset • HMG co A reductase inhibitor
  99. 99. 4 Review 12 Leads EKG 5 9 13 ST depression or dynamic T- Normal or nondiagnostic ST- ST elevation or new LBBB wave, strongly suspected wave change Strongly suspected STEMI ischemia Intermediate or low risk UA high risk /NSTEMI 10 Start adjunctive treatment as indicated • Nitroglycerine • B-adrenergic blocker • Clopidogrel • Glycoprotein Iib/IIIa 11 Admit to moniter and risk assessment (Table 3,4)
  100. 100. 11 Admit to moniter and risk assessment (Table 3,4) 12 High risk patient (table 3,4 for risk stratification) • Refractory ischemic chest pain • Recurrent persistent STE • Ventricular tacchycardia • Hemodynamic instability • Early invasive strategy, including PCI and revascularization for shock ≤ 48 hr. of AMI Continue ASA, heparin and other therapy as indicated • ACE-I/ ARB • HMG co A reductase inhibitor
  101. 101. 4 Review 12 Leads EKG 5 9 13 ST depression or dynamic T- Normal or nondiagnostic ST- ST elevation or new LBBB wave, strongly suspected wave change Strongly suspected STEMI ischemia Intermediate or low risk UA high risk /NSTEMI 14 Start adjunctive treatment as indicated Develop High or Intermediate • Nitroglycerine risk criteria (Table 3,4) • B-adrenergic blocker or • Clopidogrel Troponin positive • Glycoprotein Iib/IIIa YES No 15 Admit to moniter and Consider admission to ED risk assessment (Table chest pain unit or 3,4) monitered bed • Serial cardiac marder • Repeate EKG • consider stress test
  102. 102. 15 Consider admission to ED chest pain unit or monitered bed • Serial cardiac marder • Repeate EKG • consider stress test 16 Develop High or Intermediate risk criteria (Table 3,4) or Troponin positive 17 If no evidence of ischemia or infarction, can discharge with F/U
  103. 103. Check list for STEMI fibrinolytic therapy Step 1 Chest discomfort > 15 min, < 12 hr YES EKG show STEMI or new LBBB ? stop YES Are there contraindication for fibrinolysis ? Step 2 SBP > 180 mm Hg □ YES □ NO DBP > 110 mmHg □ YES □ NO ∆ Rt. VS Lt. arm SBP > 15 mmHg □ YES □ NO History of structural CNS disease □ YES □ NO Significant closed head or facial trauma < 3 mo □ YES □ NO Recent major surgery or trauma or GU/GI bleed < 6 wk □ YES □ NO Bleeding or clotting problem □ YES □ NO CPR > 10 min □ YES □ NO Pregnant female □ YES □ NO Serious systemic disease □ YES □ NO
  104. 104. Check list for STEMI fibrinolytic therapy Are there contraindication for fibrinolysis ? Step 2 NO Step 3 Is a pateint any high risk ? If any of following check “YES” , consider PCI HR ≥ 100/min and SBP < 100 mmHg □ YES □ NO Pulmonary edmema (rale) □ YES □ NO Sign of shock (cool, clamy) □ YES □ NO Contraindication for fibrinolytid therapy □ YES □ NO
  105. 105. Table 3 : Likely hood of ischemic etiology (short term risk) Part I : Chest pain patient without ST segment change Likelihood of ischemic etiology A : High likelihood B : Intermediate likelihood C : Low likelihood Any of following No A with any of following No A & B with any of following History • Chief complaint of Lt. arm pain or discomfort plus Current pain reproduce pain of prior pain document angina and Known CAD including MI Physical Exam • Transient MR • Hypotension • Diaphoresis • Pulmonary edema or rale EKG • New (or persume new) transient ST deviation (>0.5 mm) or T wave inversion (> 2 mm) with symptoms Cardiac marker • Elevate troponin I or T • Elevate CK-MB
  106. 106. Table 3 : Likely hood of ischemic etiology (short term risk) Part I : Chest pain patient without ST segment change Likelihood of ischemic etiology A : High likelihood B : Intermediate likelihood C : Low likelihood Any of following No A with any of following No A & B with any of following History • Chief complaint of Lt. arm • Chief complaint is Lt. arm pain pain or discomfort plus or dyscomfort Current pain reproduce pain • Age > 70 yr. of prior pain document • Male sex angina and Known CAD • Diabetic mellitus including MI Physical Exam • Transient MR • Extravascular disease • Hypotension • Diaphoresis • Pulmonary edema or rale EKG • New (or persume new) • Fixd Q wave transient ST deviation (>0.5 • Abnormal ST segment or T mm) or T wave inversion (> 2 wave that are not new mm) with symptoms Cardiac marker • Elevate troponin I or T • Normal • Elevate CK-MB
  107. 107. Table 3 : Likely hood of ischemic etiology (short term risk) Part I : Chest pain patient without ST segment change Likelihood of ischemic etiology A : High likelihood B : Intermediate likelihood C : Low likelihood Any of following No A with any of following No A & B with any of following History • Chief complaint of Lt. arm • Chief complaint is Lt. arm pain • Probable ischemic symptoms pain or discomfort plus or dyscomfort • Recent cocaine use Current pain reproduce pain • Age > 70 yr. of prior pain document • Male sex angina and Known CAD • Diabetic mellitus including MI Physical Exam • Transient MR • Extravascular disease • Chest discomfort reproduce • Hypotension by palpation • Diaphoresis • Pulmonary edema or rale EKG • New (or persume new) • Fixd Q wave • Normal EKG or T wave transient ST deviation (>0.5 • Abnormal ST segment or T flattening or T wave inversion mm) or T wave inversion (> 2 wave that are not new in leads which dominant R mm) with symptoms wave Cardiac marker • Elevate troponin I or T • Normal • Normal • Elevate CK-MB
  108. 108. Table 3 : Likely hood of ischemic etiology (short term risk) Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high or intermediate likelihood of ischemia (column A, B in Part I) High risk Intermediate risk Low risk Any of the following Any of the following Any of the following History • Accelerating tempo of ischemic symptoms over prior 48 hr. Character of pain • Prolong continue > 20 min of rest pain Physical exam • Age > 75 yr • Pulmonary edema secondary to ischemia • New or worse MR • Hypotension, brady/tacchycardia • S3 gallops or new or worsening rale EKG • Transient ST segment deviation (≥ 0.5 mm with rest agina) • Persume new LBBB • Sustain VT Cardiac marker • Elevate cardiac troponin • Elevate CK-MB
  109. 109. Table 3 : Likely hood of ischemic etiology (short term risk) Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high or intermediate likelihood of ischemia (column A, B in Part I) High risk Intermediate risk Low risk Any of the following Any of the following Any of the following History • Accelerating tempo of ischemic • Prior MI or symptoms over prior 48 hr. • Peripheral artery disease or • Cerebrovascular disease or • CABG, prior ASA use Character of pain • Prolong continue > 20 min of rest • Prolong > 20 min rest angina is now pain resolved (moderate to high likely hood of CAD) • Rest angina (<20 min) or relieved by rest or sublingual nitroglycerine Physical exam • Age > 75 yr • Age > 70 yr • Pulmonary edema secondary to ischemia • New or worse MR • Hypotension, brady/tacchycardia • S3 gallops or new or worsening rale EKG • Transient ST segment deviation (≥ • T wave inversion ≥ 2 mm. 0.5 mm with rest agina) • Pathologic T wave or Q wave that • Persume new LBBB are not new • Sustain VT Cardiac marker • Elevate cardiac troponin • Any or above , plus normal • Elevate CK-MB
  110. 110. Table 3 : Likely hood of ischemic etiology (short term risk) Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high or intermediate likelihood of ischemia (column A, B in Part I) High risk Intermediate risk Low risk Any of the following Any of the following Any of the following History • Accelerating tempo of ischemic • Prior MI or symptoms over prior 48 hr. • Peripheral artery disease or • Cerebrovascular disease or • CABG, prior ASA use Character of pain • Prolong continue > 20 min of rest • Prolong > 20 min rest angina is now • New onset functional angina (Class pain resolved (moderate to high likely III or IV) in past 2 wk. without hood of CAD) prolong rest pain (but with • Rest angina (<20 min) or relieved moderate to high likelihood of CAD) by rest or sublingual nitroglycerine Physical exam • Age > 75 yr • Age > 70 yr • Pulmonary edema secondary to ischemia • New or worse MR • Hypotension, brady/tacchycardia • S3 gallops or new or worsening rale EKG • Transient ST segment deviation (≥ • T wave inversion ≥ 2 mm. • Normal or unchanged EKG during 0.5 mm with rest agina) • Pathologic T wave or Q wave that an episode of chest discomfort • Persume new LBBB are not new • Sustain VT Cardiac marker • Elevate cardiac troponin • Any or above , plus normal • Normal • Elevate CK-MB
  111. 111. Table 4 : TIMI risk score for patient with UA and NSTEMI Risk factor of CAD • Family Hx of CAD Predictor variable • HT • Hypercholesteralemia • D.M Age > 65 year • Current smoker ≥ 3 risk factor of CAD ASA used in Last 7 days ≥ 2 angina event in last 24 hr Recent , severe symptoms of angina Elevated cardiac marker ST deviation ≥ 0.5 mm. Prior coronary a. stenosis > 50% •ST depression > 0.5 mm is significant •Transient ST deviation > 0.5 mm < 20 min is high risk •STE > 1 mm (>20 min) = STEMI
  112. 112. Table 4 : TIMI risk score for patient with UA and NSTEMI Calculated Risk of ≥ 1 Risk status TIMI risk primary end score point in 14 days 0-2 5-8% Low 3-4 13-20% Intermediate 5 26% High 6 or 7 41% High Predictor variable Age > 65 year ≥ 3 risk factor of CAD ASA used in Last 7 days Recent , severe symptoms of angina Elevated cardiac marker ST deviation ≥ 0.5 mm. Prior coronary a. stenosis > 50%
  113. 113. Case Presentation WINTER • ชายอายุ 42 ปี : 3 วันมีอาการใจสั่น แน่นหน้าอก ไม่สัมพันธ์กับการออกกาลัง Template ก่อนมาร.พ เพื่อนนาส่งร.พ อาการเป็น ๆ หาย ๆ เจ็บหน้าอกครั้งสุดท้าย 45 นาที V/S : BT 36 c PR 40/min , RR 20/min, BP 69/37 mmHg Consciousness พูดเป็นคา ทาตามสั่งบ้าง ไม่ทาตามสั่งบ้าง เหงื่อแตก มือเท้าเย็น บ่นแน่นหน้าอก
  114. 114. Case Presentation A : Anxiousness. WINTER Template B : Lung is clear . O2 sat วัดไม่ได้ C : PR 40/min,irregular rate, no murmur. Poor peripheral pluse, acrocyanosis. D : E3V5M5-6 No moter weakness.
  115. 115. Case Presentation WINTER Template
  116. 116. Case Presentation WINTER Template
  117. 117. Case Presentation WINTER Template
  118. 118. Case Presentation Initial management WINTER Template A : None B : O2 cannular 3 LPM C : Moniter EKG, I.V access ส่ง Lab + cardiac enzyme 0.9 % NSS iv load 1000 ml iv freee flow 300 ml Atropine 1 amp iv stat On External pacemaker
  119. 119. Case Presentation WINTER Template หลัง Load fluid ครบ 300 ml และให้ atropine 1 amp V/S : PR 65/min BP 72/47 , O2 sat 100% เริ่มถามตอบไม่รู้เรื่อง มองไม่สื่อความหมาย Mx : ET-Tube No 7.5 ขีด 23 cm. EKG เป็นดังรูป (next slide)
  120. 120. Case Presentation WINTER หลัง Load fluid ครบ 300 ml และให้ atropine 1 amp Template V/S : PR 65/min BP 72/47 , O2 sat 100% เริ่มถามตอบไม่รู้เรื่อง มองไม่สื่อความหมาย Mx : ET-Tube No 7.5 ขีด 23 cm.
  121. 121. Case Presentation WINTER Template
  122. 122. Case Presentation ท่านจะทาอย่างไรต่อไป WINTER • At 19.37 หลังใส่ ET-Tube คนไข้เริ่ม unconsciousness , คลา pulse ไม่ได้ Template
  123. 123. Case Presentation WINTER • หลังจาก CPRไปได้ 2 นาที ให้ adrenaline run q 3 min คลื่นไฟฟ้า Template หัวใจเป็นดังรูป ท่านจะทาอย่างไรต่อไป
  124. 124. Case Presentation WINTER • ได้ทา defibrillation x 3 ครั้ง EKG ยังคงเป็นเช่นนี้ ท่านจะทาอย่างไรต่อไป Template
  125. 125. Case Presentation ท่านจะทาอย่างไรต่อไป WINTER • หลังจากท่าน ได้ check lead, ขยาย amplitude แล้ว EKG เป็นดังนี้ Template
  126. 126. Case Presentation WINTER Template หลังจากท่านได้ Defibrillation แล้ว EKG เป็นดังนี้ ท่านจะทาอย่างไร o Atropine 1 amp iv stat o External pacemaker o Transfer to ICU o Load 0.9% NSS
  127. 127. WINTER 2005 Thank You Template Panita Worapratya Emergency Department Prince of Songkhla University
  128. 128. Common cause of ST depression
  129. 129. 03 PowerPoint picture page
  130. 130. 04 Bullet points are like this Text and lines are like this Hyperlinks like this Visited hyperlinks like this Text box PowerPoint styles
  131. 131. 05 You are free to use these templates for your personal and business presentations. We have put a lot of work into developing all these templates and retain the copyright in them. You can use them freely providing that you do not redistribute or sell them. Do Don’t  Use these templates for your  Resell or distribute these templates or presentations include the graphics in your work for re-  Display your presentation on a web sale site provided that it is not for the  Put these templates on a website for purpose of downloading the template. download. This includes uploading  If you like these templates, we would them onto file sharing networks like always appreciate a link back to our Slideshare, Myspace, Facebook, bit website. Many thanks. torrent etc  Pass off any of our created content as your own work You can find many more free PowerPoint templates on the Presentation Helper website www.presentationhelper.co.uk
  132. 132. 4 Review 12 Leads EKG 5 9 13 ST depression or dynamic T- Normal or nondiagnostic ST- ST elevation or new LBBB wave, strongly suspected wave change Strongly suspected STEMI ischemia Intermediate or low risk UA high risk /NSTEMI 6 10 14 Start adjunctive treatment Start adjunctive treatment as indicated as indicated Develop High or Intermediate • B-adrenergic receptor block • Nitroglycerine risk criteria (Table 3,4) • Clopidogrel • B-adrenergic blocker or • Heparin • Clopidogrel Troponin positive • Glycoprotein Iib/IIIa YES No ≥ 12hr 7 11 15 Admit to moniter and Consider admission to ED Time form onset of risk assessment (Table chest pain unit or symptoms ≤ 12 hr 3,4) monitered bed • Serial cardiac marder • Repeate EKG < 12hr • consider stress test

×