Develop a one-page clinical reference which reinforces educational content from NURS 640.
Develop a one-page clinical reference which reinforces educational content from NURS 640.
· The structure of the reference is determined by the student based on the content presented. Formats that can be considered for representing a reference include diagrams or tables.
· The reference is limited to the space of one standard letter-sized (8.5 x 11 inches) document.
· Please add your reference list as a second page to your assignment (use APA format).
Clinical Reference: 12 Lead EKG Evaluation
Prepare a clinical reference/reference that describes the 12 lead EKG findings for cardiac ischemia and infarction.
Within your reference:
1. Specify the EKG changes associated with the various coronary arteries.
2. Identify the anatomic areas of the heart muscle supplied by the coronary arteries.
3. List the EKG criteria for STEMI (ST elevation and other EKG changes).
4. List the EKG findings in non-STEMI.
List the cardiac biomarkers commonly used in conjunction with 12-lead EKG to identify acute myocardial infarction, identify when these biomarkers peak and the length of time until they normalize
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Aspirin 160–325 mg
Oxygen (If O2 sat< 94% or O2 Sat>90% with COPD)
12–Lead ECG Pain Control
Cardiac Marker Levels
Pain Control
Nitroglycerin Sublingual or spray
ECG Interpretation**
ST-elevation MI (STEMI) High-risk unstable angina/non-ST-elevation MI (UA/NSTEMI)
Low-/Intermediate-risk ACS
Consider admission to ED chest pain unit or to appropriate bed and follow:
Start adjunctive therapies as indicated Do not delay reperfusion
Troponin elevated or high-risk patient Consider early invasive strategy if: Refractory ischemic chest discomfort Recument/persistent ST deviation Ventricular tachycardia Hemodynamic instability Signs of heart failure
Serial cardiac markers (including troponin) Repeat ECG/continuous ST-segment monitoring Consider noninvasive diagnostic test
Time from onset of symptoms ≤ 12 hours?
>12 hours
≤12 hours
Start adjunctive treatments as indicated Nitroglycerin Heparin (UFH or LMWH) Consider: PO β-blockers
Clopidogrel Glycoprotein llb/llla inhibitor
Reperfusion goals: Door-to-balloon inflation (PCI)*** goal of 90 minutes Door-to-needle (fibrinolysis) goal of 30 minutes
Admit to monitored bed Assess risk status Continue ASA heparin, and other therapies as indicated
ACE inhibitor/ARB; HMG CoA reductase inhibitor (statin therapy) Not at high risk: cardiology to risk stratity
Abnormal diagnostic noninvasive imaging or physiologic testing?
If no evidence of ischemia or infarction by testing, can discharge with follow-up
Consider: Consider:
EMS assessment and care and hospital preparation*
* O’Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O’Neil BJ, Travers AH, Yannopoulos D. “Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S787-S817. http://circ.ahajoumals.org/content/122/18_suppl_3/S787 **Afolabi BA, Novaro GM, Pinski SL, Fromkin KR, Bush HS. Use of the prehospital ECG improves door to balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. Emerg Med J. 2007;24:588-591 *** O’Connor, RE AL, Ali, Brady , WJ, Ghaemmaghami CA, Menon V, Welsford M, Shuster M. Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132(suppl2):S483-S500
Syndromes Suggestive of Ischemia or Infarction
Check Vital Signs IV Access
Physical Exam
Activate Cardiac Cath Lab
Chest X-ray (<30 mins) 12–Lead ECG
If O2 sat<94% Start Oxygen
Aspirin 160–325 mg (If not already taken)
Activate Cardiac Cath Lab
Dynamic ECG changes consistent with ischemia
Clinical high-risk features
Troponin elevated
Develops 1 or more:
Concurrent ED assessment (<10 minutes)
Immediate ED general treatment
Acute Coronary Syndromes Algorithm