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Lytics - to use or not to use

Lytics - to use or not to use. CNS II Case Presentation by Tania Randell , RN-BC, BSN. Objectives. Discuss the standards for diagnosis and treatment of both pulmonary embolism (PE) and acute myocardial infarction (AMI)

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Lytics - to use or not to use

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  1. Lytics- to use or not to use CNS II Case Presentation by Tania Randell, RN-BC, BSN

  2. Objectives • Discuss the standards for diagnosis and treatment of both pulmonary embolism (PE) and acute myocardial infarction (AMI) • Practice clinical reasoning by exploring possibilities that explain this patient scenario • Explore the roles of the CNS related to a complicated patient case from the emergency department (ED)

  3. Patient Summary 68 y/o male hospital employee who collapsed in a building near the ED HPI: Patient found down but still breathing, foaming at the mouth, brought by EMS to ED VS: HR- 48, Rhythm- CHB, BP 60/palp, O2- UTA, RR- 12, GCS- 5, BG- 163 PMH: DM, Htn, dyslipidemia, obesity, asthma, former smoker quit ‘04

  4. Clinical Course Once in the ED… • Rhythm: CHB -> PEA arrest -> Tachycardic -> HR 35 -> PEA • Hemodynamics: 60/palp -> undetectable • Oxygenation: hypoxic, undetectable • Family Report: pt c/o SOB & RLE pain for several wks, right LE is edematous • Family Report: No c/o chest pain

  5. Diagnostics Other ECG: ST ^ II, III, AVF, Rt BBB- V2, V3, Inf Q waves CXR: (-) pneumothorax, (-) infiltrates Cardiac Cath: Large distal LAD thrombus Later Diagnostics Echo: Severe pulmonary Htn & RV failure Duplex RLE: + occulsive DVT CT Scan: (-) intracranial hemm Labs Initial ABG: 6.93/58/80/11 (primary respiratory acidosis w/ metabolic acidosis) All other labs within normal limits (Chemistry, Hematology & coags) Later..PeakTroponin I: 27.1 (normal 0-0.1 ng/mL)

  6. Diagnostic Picture • Patient has risk factors for both PE & CAD • CHB & ECG indicate RCA infarct • Cardiac Cath shows LAD thrombus and clean RCA • Recent SOB & RLE swelling raise suspicion for PE • Later Echo shows RV infarct and Pulmonary Htn indicating PE • PE can mimic MI, Inferior ECG changes may have been related to PE & lack of forward flow • Final diagnosis “Likely massive PE & RV failure”

  7. Interventions/Treatments in ED Nursing CPR Initial lines Fluids Drugs: Atropine, Epi, Bicarb, Levo & Dopa Medical Intubation Central Line Transvenous Pacer Cardiology consult

  8. Evidence Based Guidelines Diagnosis & Treatment for AMI ECG Cardiac enzymes Angiography PCI Thrombectomy Thrombolytics Diagnosis & Treatment for PE • VQ scan or Spiral CT • D-Dimer • Angiography • Anticoagulants • Thrombolytics • Pulmonary Embolectomy • IVC filter for prevention

  9. Clinical Reasoning Things to ponder on this case… • No anterior ECG changes • Atrial communication? • Inferior ECG changes r/t RV failure caused by PE • Consider thrombolytics versus PCI • Did PCI interrupt his PE intervention? • Standard- patients w/ AMI treated w/ PCI when available

  10. Genetic Information For MI 33 genetic risk variants for CAD identified 10 associated with Htn or lipids Alleles have not yet been linked to treatments- not used therapeutically For PE • inherited thrombophilia- usually occurs in those < 50 y/o • factor V Leiden or the prothrombin gene mutation can occur at any age • Factor II Mutation drawn- normal for this patient

  11. Clinical Competency I Synthesizes, interprets, makes decisions and recommendations, and evaluates responses based on complex, sometimes conflicting sources of data.

  12. Clinical Competency II Identifies and prioritizes clinical problems based on education, research and experiential knowledge.

  13. Clinical Competency III Develops proactive interventions. Implements and/or directs others to act on actual or potential clinical problems

  14. Clinical Competency IV Facilitates development of clinical judgment in healthcare team members (e.g., nursing staff, medical staff, other healthcare providers) through role modeling, teaching, coaching and/or mentoring.

  15. Clinical Competency V Formally and informally evaluates the clinical practice of other healthcare team members (e.g., nursing staff, medical staff, and other healthcare providers).

  16. CNS Roles Expert Clinician CNS contributes expert judgment & past experience to synthesize data during a complex patient presentation Education CNS uses her role to debrief the staff and lead them through thought process of evaluating the care they provided May prepare educational material for knowledge gaps that are noted Communication CNS can serve as a liaison between teams, for example giving the ED resident an update from the cath lab

  17. CNS Spheres of Influence Patient/Family Provide emotional support Utilize healthcare team- chaplain & SW Nurse Presence gives moral support Codes- CNS can lend physical support System CNS involvement in RCA Opportunity to improve practices, multi-disciplinary

  18. Questions for Discussion • Would the outcome for this patient have been different if he received treatment for PE instead of MI? • How would you use this case scenario for furthering the knowledge of the ED staff? • How would you prepare to participate in a Root Cause Analysis (RCA) related to this patient case?

  19. References Akay, T.H., Sezgin, A., & Aslamaci, S. (2006). Successful Surgical Treatment of Massive Pulmonary Embolism after Coronary Bypass Surgery. Texas Heart Institute Journal, 33(4), 498-500. Dirks, J.L., Howland-Gradman, J. (2009). Vascular Emergencies. In Carlson, K.K. (Ed.). Advanced Critical Care Nursing. (pp.347-383). St. Louis, MO: Saunders/Elsevier. Goslar, T., & Podbregar, M. (2010). Acute ECG ST-segment elevation mimicking myocardial infarction in a patient with pulmonary embolism. Cardiovascular Ultrasound, 1-7. Kang, D.K., Thilo, C., Schoepf, J., Barraza, J.M., Nance, J.W., Bastarrika, G., Abro, J.A., Ravenel, J.G., Costello, P., & Goldhaber, S.Z. (2011). CT Signs of Right Ventricular Dysfunction Prognostic Role in Acute Pulmonary Embolism. JACC: Cardiovascular Imaging, 4(8), 841-849. Reeder, G.S., Kennedy, H.L, & Rosenson, R.S. (2013). Overview of the acute management of ST elevation myocardial infarction. Up to Date website, Retrieved 7/14/13 from uptodate.com Roberts, R., & Stewart, A.F.R. (2012). Genes and Coronary Artery Disease: Where are we? Journal of the American College of Cardiology, 60(18), 1715-1721. Sareyyupoglu, B., Greason, K.L., Suri, R.M., Keegan, M.T., Dearani, J.A., & Sundt, T.M. (2010). A More Aggressive Approach to Emergency Embolectomy for Acute Pulmonary Embolism. Mayo Clinic Proceedings, 85(9), 785-790. Thompson, B.T., Hales, C.A. (2012). Patient information: Pulmonary embolism (Beyond the Basics). Up to Date website, Retrieved 7/14/13 from uptodate.com Thygesen, K., Alpert, J.S., Jaffe, A.S., Simoons, M.L., Chaitman, B.R., & White, H.D. (2012). Third Universal Definition of Myocardial Infarction. Circulation: Journal of the AHA, 126, 2020-2035.

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