Adult 2: Acute Mi

Front 1

What are the different names for an MI?

Back 1

MI- myocardial infarction
ACS- Acute coronary syndrome (if unsure whether MI)
NSTMI- Non ST elevation MI
STEMI- ST Elevation MI
AMI- Acute MI

Front 2

Risk factors for Coronary heart disease

Back 2

age, gender, cigarette smoke, hyptertension, cholesterol over 240, HDL below 35, LDL above 130, diabetes, stress, homocysteine, menopause, obesity, physical inactivity

Front 3

How many nitros should a heart patient take before going into the hospital?

Back 3

3

Front 4

What may be sigsn of MI?

Back 4

chest pain that is not relieved by sublingual nitroglycerin
Pain in neck, jaw, back, epigastrium, or arms
Diaphoresis, restlessness, pallor, N/V, SOB, signs and symptoms of low cardiac output

Front 5

S/S low CO

Back 5

Nausea, shortness of breath, sense of impending doom

Front 6

MI is shown by pain coupled with?

Back 6

signs of decreased CO

Front 7

Findings on an EKG during MI

Back 7

bradycardia or tachycardia (depending on MI location), Ventricular ectopy (PVC), ST segment changes (ST elevation= acute MI), T wave inversion, Q wave presence

Front 8

What is an early sign of an MI that indicates ischemia?

Back 8

ST elevation

Front 9

When will MI have bradycardia?

Back 9

if blocked SA node

Front 10

When is MI tachycardia?

Back 10

decreased Cardiac output, so the HR increases for compensation

Front 11

What do you do if you think you see MI evidence on a 2 lead?

Back 11

get a 12 lead for follow up

Front 12

What is ST segment elevation

Back 12

QRS when S does not return to baseline, but goes up with T wave

Front 13

Lab findings in an MI

Back 13

creatinine kinase MB (rises 3-6 hours, greater than 6%)
Myoglobin (rises in 2 hours, greater than 110 ng/mL)
Cardiac troponin T (rises 3-5 hours, greater than 1.5 ng/mL)
Cardiac Troponin I (rises in 3 hours, greater than 0.1-0.2 ng/mL)

Front 14

What do rises in cardiac markers show?

Back 14

acute events, because they rise in a short period, then fall

Front 15

What are specific to cardiac?

Back 15

CPK M bands

Front 16

What is the one lab finding in an MI that they will definitely look for

Back 16

Troponin

Front 17

What is done on all cardiac patients, even if it's not definitive?

Back 17

CPK- M bands

Front 18

What is a LATE sign of MI

Back 18

LDH

Front 19

What would you look for if the patient had an MI a while ago?

Back 19

LDH

Front 20

What is emergency treatment for MI?

Back 20

CALL 911!! First and fast! Don't delay!
Chew an aspirin (if enteric)
Be aware that it may not "feel" like an MI
Remember ABCD (airway, breathing, circulation, Defib)

Front 21

What does ASA do for an MI patient

Back 21

stops platelets from sticking to the clot, which will allow blood to pass through

Front 22

What dysrhythmias are a person with an MI at risk for?

Back 22

V. Tach and V. Fib

Front 23

What do you do for a patient with V Fib?

Back 23

Shock!

Front 24

What do you do for a patient with V tach if they're alert?

Back 24

Lidocaine

Front 25

What do you do for a patient with V tach if they're unresponsive

Back 25

shock

Front 26

What are the 4 D's once in the ER?

Back 26

door, data, decision, drug

Front 27

What is the data for the 4D

Back 27

cardiac markers, electrolyte panel, coagulation studies

Front 28

what do you do once the patient is in the ER?

Back 28

4 Ds (door, data, decision, drug)
Oxygen, ECG monitor, IV, labs, 12 lead EKG, IV morphine for pain if tolerable, MONA

Front 29

What is MONA

Back 29

for all MI's
Morphine
Oxygen
Nitroglycerin
Aspirin

Front 30

When should you NOT give morphine for heart attack?

Back 30

if BP is too low!!

Front 31

what is one the first things you do in every patient with an MI?

Back 31

get an IV in!

Front 32

What order do you do MONA?

Back 32

Aspirin should have been done at home.

Oxygen, then Nitroglycerin, then Morphine (if BP can handle it)

Front 33

What is pharm treatment for an MI?

Back 33

anti-ischemic therapy, Nitroglycerin IV, Beta blockade

Front 34

Why do you use anti-ischemic therapy for MI?

Back 34

to treat the clot or blockage

Front 35

Why do you use Nitroglycerin IV for MI

Back 35

it's a coronary vasodilator
If there's a clot, you'll dilate enough to get the blood through

Front 36

Why do you give Beta blockade for MI?

Back 36

it decreases sympathetic and decreases HR
It increases survival in MI's

Front 37

Examples of anti-thrombotic therapy commonly used

Back 37

aspirin, heparin

Front 38

What are some thrombolytics

Back 38

streptokinase, urokinase, t-PA, APSAC, reteplase, UPA

Front 39

After thrombolytic is given to a person with an MI, what are they maintained with?

Back 39

heparin or a glycoprotein II/III inhibitor (Abciximab)

Front 40

How do you give anti-thrombotic therapy or thrombolytics?

Back 40

IV

Front 41

what do thrombolytics do?

Back 41

dissolve clots everywhere

Front 42

What do thrombolytics put you at risk for?

Back 42

hemorrhagic stroke/bleed

Front 43

What do you do if patient passes out and they're being treated with thrombolytics

Back 43

check the monitor for any life threatening dysrhythmia and check the neuro status for unequal pupils

Front 44

what do you do it patient has unequal pupils and they're on thrombolytics

Back 44

STOP thrombolytics and shut off IV
Prepare to give platelets, blood, do CT scan, and prepare to intubate

Front 45

What would you do with thrombolytics if BP is down?

Back 45

give a bolus

Front 46

Who cannot have thrombolytic therapy?

Back 46

Pregnant women
history of CVA
recent surgery
person already on anticoagulants

Front 47

What are some complications of thrombolytics?

Back 47

bleeding, allergic reaction, hemorrhagic stroke, etc.

Front 48

How can you tell if reperfusion after an MI is successful?

Back 48

ECG ST segment and T wave return to normal
Chest pain is relieved
Presence of reperfusion dysrhythmias (PVCs)
Cardiac enzymes decrease

Front 49

What is the number treatment for an MI according to AHA?

Back 49

angioplasty and stent

Front 50

When do you need to have an angio done by if you had and MI?

Back 50

less than 90 minutes

Front 51

What are some alternatives for MI treatment if patient cant have thrombolytics?

Back 51

angioplasty, stent, directional coronary atherectomy, laser ablation, bypass surgery

Front 52

What do you need to do if patients having angio?

Back 52

sign consent for bypass

Front 53

When do you need an angio and stent by?

Back 53

within 90 minutes of hitting ER

Front 54

When do you give thrombolytics for MI?

Back 54

if not able to get angio and stent

Front 55

What should you check before doing angiography?

Back 55

allergies, any problems eating shellfish

Front 56

what to do before angiography

Back 56

check allergies, prep groin site, and check distal pulses

Front 57

What do you do if patient says have allergy to fish

Back 57

CALL CATH LAB! HAVE PERSON TO PERSON CONTACT!
Then band, call the MD, and document!

Front 58

What do you do after angiography?

Back 58

check for bleeding, pulses, reperfusion, dysrhythmias, kidneys, neuro changes, and lie flat for at least 4 hours! (check hospital policy)

Front 59

What is FIRST thing you do after angiography?

Back 59

check groin site!

Front 60

What do you do if arterial bleed in groin after angio?

Back 60

turn back, put on gloves and eyewear, then put pressure on the groin

Front 61

Why would you do a brachial angio instead of femoral?

Back 61

need no bed rest
outpatient
just keep arm straight

Front 62

What occurs in angioplasty?

Back 62

balloon tipped cath into artery, filled, and compresses plaque and restores flow

Front 63

Why is arterial sheath left in after angio?

Back 63

in case they have to emergently reopen the vessel

Front 64

When do you do thrombolytics?

Back 64

if can't do angio with stent, it is an acceptable alternative

Front 65

What are risks of angioplasty?

Back 65

bleeding, MI, tearing of vessel

Front 66

Why do you need consent for open heart with angio?

Back 66

in case vessel cannot be opened or if accidentally torn

Front 67

What is a stent

Back 67

introduced like angio, but self expandable tubing is put in narrowed region to maintain vessel open

Front 68

What must a person stay on if they have a stent?

Back 68

antiplatelets for life!

Front 69

What are some complications of stents?

Back 69

thrombus, vessel dissection, bleeding

Front 70

What is directional coronary atherectomy?

Back 70

rotating blade shaves off plaque and deposits in nose of housing

Front 71

Complications with a directional coronary angioplasty?

Back 71

embolus, vessel occlusion, perforation, spasm

Front 72

What is laser ablation?

Back 72

vaporize the plaque, usually right after PCTA to fully remove plaque

Front 73

Complications of laser ablation

Back 73

vessel dissection, occlusion, perforation, embolism

Front 74

What are 3 types of coronary artery bypass grafting?

Back 74

traditional
minimally invasive
octopus

Front 75

what is octopus CABG?

Back 75

done on a beating heart; don't need bypass so you don't have to worry about clots or impaired flow

Front 76

Two arteries preferred for CABG?

Back 76

internal mammary artery or radial artery

Front 77

Other sites that may be used for CABG?

Back 77

saphenous, xenograft (pig), cadaver, or synthetic graft

Front 78

Why are internal mammary artery and radial artery best choices for CABG?

Back 78

better elasticity and strength, since they're arteries
Plus, they have no valves like veins
Tend to last over 10 years

Front 79

Why might you use a pig xenograft for CABG?

Back 79

if Diabetic and you can't use mammary due to high risk for infection, can't use radial because they have positive Allen's test and can't use saphenous because they have leg ulcers

Front 80

What is bypass?

Back 80

blood is redirected to go through a machine that oxygenates it

Front 81

Why do people with CABG need ventilated if they're having bypass?

Back 81

ventilate to prevent atelectasis

Front 82

Some alternatives if the person cannot have CABG

Back 82

transmyocardial revascularization (TMR)
Percutaneous myocardial revascularization (PMR)
using short bursts of laser beams to burn holes in myocardium to allow blood to enter the channels to feed the heart oxygenated blood

Front 83

Why might they do TMR or PMR?

Back 83

if not strong enough for open heart and CABG

Front 84

After initial treatment for MI (TPA, angio, open heart), what will they be given?

Back 84

antiarrhythmics
stool softeners
ACE inhibitors
Cardiac Rehab

Front 85

Why should a patient get antiarrhythmics after initial MI treatment?

Back 85

prophylaxis to prevent many dysrhythmias

many patients get afib on day 3 post open heart

Front 86

When do patients commonly get afib after open heart?

Back 86

post op day 3

Front 87

How can you tell if patient has afib on the 3rd day post op?

Back 87

clots and a change in cardiac output (SOB and decrease in oxygen)
look at monitor

Front 88

What is common after MI

Back 88

denial

Front 89

Why are stool softeners given after initial MI treatment?

Back 89

prevent vagal stimulation

Front 90

What do ACE inhibitors end in?

Back 90

-pril

Front 91

What is important after MI?

Back 91

Cardiac rehab and education

Front 92

What are some things that can increase mortality from an MI?

Back 92

old age (over 80: comorbidity)
evidence of other diseases
Anterior MI
hypotension on admission (Systolic below 55 mm Hg on admission)

Front 93

Why is hypotension (systolic below 55 on admission) a sign of MI mortality?

Back 93

cardiogenic shock shows that you have hardly any stroke volume

Front 94

Why is anterior MI so fatal?

Back 94

because it's in the left ventricle

Front 95

Why do you only have a 90 minute window to treat MI?

Back 95

tissue becomes ichemic: It is DEAD! and nonfunctional

Front 96

What are some problems that arise with an MI

Back 96

pain (chest, procedure)
impaired tissue perfusion (decrease SV and CO)
dysrhythmias
decreased C.O
impaired gas exchange
risk for bleeding
powerlessness/anxiety/fear
activity intolerance
heart failure
fluid volume excess
skin breakdown
potential for infection
knowledge deficit

Front 97

What dysrhythmias are people with an MI at risk for?

Back 97

V tach and V fib right away and a fib day three

Front 98

When might a person develop heart failure

Back 98

especially if not treated in 90 minute window

Front 99

Who are at higher risk for skin breakdown with MI

Back 99

elderly, open heart

Front 100

Why are post MI at risk for fluid volume excess

Back 100

decreased stroke volume, poor perfusion

Front 101

Door to balloon window

Back 101

90 minutes

Front 102

Door to needle for TPA/ fibrinolytics window

Back 102

30 minutes

Front 103

What is timeline for MI

Back 103

chest pain, cause to monitor ABC, prepare CPR and defib, give Oxygen, ASA, Nitrogen, Morphine, get 12 lead, Fibrinolytic checklist, notify hospital that may have MI

Within 10 minutes at hospital, must be FINISHED with: vitals, Oxygen, 12 lead, IV put in, history, fibronlytic check list, electrolyte panel, cardiac markers, portable chest xray, coagulation studies

Then review 12 lead for ST elevation or new MI, Give Beta blockers and Heparin, check time frame for reperfusion, give ACE inhibitors and Statin therapy