Myocardial Ischemia
ADU-14
Diagnosis
Chest Pain, Shortness of Breath, ST Elevation or Depression, Ventricular Arrhythmias
Call for help
- Ask: "Who will be the crisis manager?"
- Crisis manager designates checklist reader
Increase oxygen delivery and decrease oxygen demand
- Increase Supply:
- 100% FiO2
- Correct anemia (goal hgb 7-9 g/dL)
- Correct hypotension (see ADU-10)
- Decrease Demand:
- Correct tachycardia - caution in RCA ischemia (II, III, aVF)
- Correct hypertension
- Restore sinus rhythm (see ADU-16)
- Increase Supply:
Obtain 12-lead EKG and send troponin levels
Consult cardiology
- Consideration of anticoagulation and/or antiplatelet therapy
- Consideration of thrombolysis or cardiac catheterization
Discuss clinical condition with surgical team
- Safe to abort surgery?
- Safe to consider anticoagulation and/or antiplatelet therapy?
Consider hemodynamic monitoring
- If ongoing hemodynamic instability, arterial line
- If persistent vasopressor requirement, central line
- If evidence of cardiogenic shock, non-invasive cardiac output monitor or PA catheter
Consider TEE or TTE if ongoing hemodynamic instability
Consider ICU admission
Drugs
| Nitroglycerin | 0.5 - 5 MICROgrams/kg/min |
|---|---|
| Aspirin | 325 mg PO/PR x1 dose |
| Heparin | 4000 - 5000 units IV push |
| Norepinephrine | BOLUS: 5 - 20 MICROgrams IV |
| Norepinephrine | INFUSION: 0.05 - 0.5 MICROgrams/kg/min |
| EPINEPHrine | BOLUS: 4 - 10 MICROgrams IV |
| EPINEPHrine | INFUSION: 0.01 - 0.1 MICROgrams/kg/min |
| Esmolol | 50 - 300 MICROgrams/kg/min |
| Metoprolol | 5 - 20 mg IV |
DIFFERENTIAL diagnosis
- Coronary artery disease with acute thrombus
- Coronary artery disease with demand ischemia
- Coronary artery embolism
- Local Anesthetic Systemic Toxicity (ADU-12)
- Severe hypoxia (ADU-11)
Critical CHANGES
If PEA develops, go to ADU-04
If VF/VT develops, go to ADU-05