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Jackpot!

Jackpot!. Brenda Larson RN, BSN Chest Pain Clinical Program Coordinator University of Wisconsin Hospital. Historical Perspective. Coronary artery disease remains the leading killer in the U.S.

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Jackpot!

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  1. Jackpot! Brenda Larson RN, BSN Chest Pain Clinical Program Coordinator University of Wisconsin Hospital

  2. Historical Perspective • Coronary artery disease remains the leading killer in the U.S. • Heart attacks occur when a blood clot forms in a blood vessel in the heart – starving the downstream muscle of oxygen. • Time is critical! Every minute the artery is blocked, heart muscle is damaged. Time is muscle!!

  3. 3/6/2008Dispatched - 14:39 • Dejope Casino • 71 year old male • pale, c/o chest pain, difficulty breathing

  4. Initial EMS Assessment • Arrived on scene: 14:49 • 71 year old male • sitting in a wheelchair • Chief Complaint: • “Arms and legs hurt bad and terrible pains in the chest.” • “Didn’t feel like himself”

  5. Primary Assessment • Mentation: A&O x4 • Airway/Breathing: • Regular • Circulation: • Skin • color: pink • temperature: normal • moisture: dry • Cap Refill: <2 seconds • No major bleeds • Determine Priority: Vital signs: BP: 142/100 HR: 68 RR: 18 SaO2: 98% ECG: NSR

  6. History • Signs/symptoms: • O: playing slots • P: walking made pain worse • Q: dull pain, substernal • R: left arm and jaw/neck • S: 5/10 • T: 2:00 PM

  7. History • Allergies: NKDA • Medications: Glipizide • Pertinent past medical history: Type II DM • Last oral intake:Unknown • Events: • playing slots • chest pain is getting worse • asks wife to take him home

  8. Interventions 10 minute scene time!

  9. Interventions

  10. Chest Pain Protocol • General • Assess ABCs • IV NSS, oxygen, pulse oximetry and ECG monitor • Vital signs • Obtain a severity value of chest pain (1 to 10) • Obtain and interpret 12 Lead ECG if patient condition permits • Do not delay transport for 12 Lead ECG. Obtain ECG during transport and transmit to receiving hospital if possible. Communicate your impression of ECG during report.

  11. Chest Pain Protocol • Medications • Aspirin 324 mg PO - chew and swallow • NTG 0.4 mg SL (if SBP >90 mmHg and DBP >50 mmHg) If no relief, may repeat NTG every 3-5 minutes up to a total of 4 doses. • Morphine Sulfate 2-5 mg IV • Treat dysrhythmias as appropriate • IV fluid – 300 ml NSS if SBP drops <90mmHg • Reassess lung sounds and vital signs • Dopamine if SBP < 90 mmHg, if patient refractory to fluid challenge (s) or evidence of pulmonary edema

  12. Chest Pain Protocol • Notes • Elderly patients, diabetics and women are more likely to experience atypical symptoms. • Do not administer NTG to patients actively taking medications for Erectile Dysfunction.

  13. What A Day! Within 29 minutes 3 STEMI cases arrived to UW Cath Lab. STEMI case start times: 1) 14:50 2) 15:04 3) 15:19

  14. UW Hospital • 15:05 Heart Attack Team activated • 15:16 EMS arrival to UWED • 15:19 Patient on table in Cath Lab Door to wire insertion with flow: 18 minutes Door to balloon inflation: 23 minutes

  15. UW Cardiac Cath Lab

  16. Pre procedure • Staff involved: • 2 Physicians • Minimum of 2 RNs and 1 Cardiovascular Tech • Consent is obtained • Patient prep: • ECG, pulse oximetry, BP • Check pulses in feet • Remove all clothing • Table is only 22 inches wide (holds 500 lbs)

  17. Circumflex artery (on arrival)

  18. Balloon angioplasty

  19. Coronary stent deployment

  20. Stent deployment

  21. Circumflex artery (post procedure)

  22. Summary of the procedure • Stents: • 2 bare-metal stents • Sedation: • Fentanyl 50 mcg & Midazolam 2 mg IV • Uneventful case: • No N/V • No arrhythmias • Procedure completed within 48 minutes after arriving to the Cath Lab. • The patient was pain free post procedure and was transferred to the CCU in stable condition.

  23. Discharge Instructions • Discharged on 3/8/08 • follow up with PCP 1-2 weeks • return for repeat PCI of RCA (3/17/08) • follow up with Cardiologist 4-6 weeks • cardiac rehab referral • nutrition consult • lab work • return to work in 2-6 weeks

  24. The Patient • Works as a security guard at Allied Automotive Group. • “It’s my spending money for Dejope” • Hobbies: • Watching his 9 year old Grandson play baseball • Will celebrate his 46th Wedding Anniversary in June • Shoots pool every morning

  25. How were you doing? “I was coming out ahead!” JACKPOT!

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