Sandbox Rim: Difference between revisions
Rim Halaby (talk | contribs) |
Rim Halaby (talk | contribs) |
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{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |,|-|-|^|.| | }} | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |,|-|-|^|.| | }} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | D01 | | D02 | | D03 | |D01=<div style="float: left; text-align: center; width: 20em; padding:1em;"> '''Proceed to [[angiography|<span style="color:white;">angiography </span>]]'''<br></div> | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | D01 | | D02 | | D03 | |D01=<div style="float: left; text-align: center; width: 20em; padding:1em;"> '''Proceed to [[angiography|<span style="color:white;">angiography </span>]]'''<br></div> | ||
| D02= <div style="float: left; text-align: center; width: 20em; padding:1em;"> ''' | | D02= <div style="float: left; text-align: center; width: 20em; padding:1em;"> '''High risk''' <br> '''Initial invasive strategy''' </div>}}| D03= <div style="float: left; text-align: center; width: 20em; padding:1em;"> '''Low risk''' <br> '''Initial conservative strategy''' </div> | ||
| D03= <div style="float: left; text-align: center; width: 20em; padding:1em;"> ''' | |||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |!| | | |!| | }} | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |!| | | |!| | }} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | E01 | | E02 | | E03 |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> | ||
'''Administer ONE of the following antiplatelet agents (before or at the time of PCI):''' <br> | '''Administer ONE of the following antiplatelet agents (before or at the time of PCI):''' <br> | ||
❑ [[P2Y12|<span style="color:white;">P2Y12</span>]] receptor inhibitors <br> | ❑ [[P2Y12|<span style="color:white;">P2Y12</span>]] receptor inhibitors <br> | ||
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::❑ Additional bolus of 0.3 mg/kg if needed | ::❑ Additional bolus of 0.3 mg/kg if needed | ||
::❑ Decrease infusion to 1 mg/kg/h when [[creatinine|<span style="color:white;">creatinine</span>]] clearance <30 mL/min | ::❑ Decrease infusion to 1 mg/kg/h when [[creatinine|<span style="color:white;">creatinine</span>]] clearance <30 mL/min | ||
</div>| | </div>|E03=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Administer one of the following antiplatelet agents:'''<br> | ||
❑ [[Clopidogrel|<span style="color:white;">Clopidogrel </span>]]<br> | ❑ [[Clopidogrel|<span style="color:white;">Clopidogrel </span>]]<br> | ||
:❑ Loading dose (300 mg)<br> | :❑ Loading dose (300 mg)<br> | ||
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❑ [[Ticagrelor|<span style="color:white;">Ticagrelor </span>]] | ❑ [[Ticagrelor|<span style="color:white;">Ticagrelor </span>]] | ||
:❑ Loading dose (180 mg)<br> | :❑ Loading dose (180 mg)<br> | ||
:❑ Maintenance dose for up to 12 months (90 mg twice daily)</div>| | :❑ Maintenance dose for up to 12 months (90 mg twice daily)</div>|E02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Administer one of the following antiplatelet agents:'''<br> | ||
'''Before [[PCI|<span style="color:white;">PCI </span>]]'''<br> | '''Before [[PCI|<span style="color:white;">PCI </span>]]'''<br> | ||
❑ [[P2Y12|<span style="color:white;">P2Y12 </span>]] receptor inhibitors <br> | ❑ [[P2Y12|<span style="color:white;">P2Y12 </span>]] receptor inhibitors <br> | ||
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::❑ Maintenance dose 0.15 mcg/kg/min </div>}} | ::❑ Maintenance dose 0.15 mcg/kg/min </div>}} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |!| | | |!| | }} | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | |!| | | |!| | | |!| | }} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F01 | | F02 | | F03 | |F01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Consider urgent [[CABG|<span style="color:white;">CABG</span>]] if the coronary anatomy is not amenable to PCI and one of the following:'''<ref name="www.ncbi.nlm.nih.gov">{{Cite web | last = | first = | title = ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed?term=15466654 | publisher = | date = | accessdate = }}</ref> <br> ❑ Patients with left main or left main equivalent disease <br> ❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction <br> ❑ Diabetic patients </div>|F02=<div style="float: left; text-align: left; width: 25em; padding:1em;"> ❑ Perform an [[angiography|<span style="color:white;">angiography</span>]] </div>|F03=<div style="padding: 5px; background: #FFFFFF; text-align: center;">'''[[Unstable angina/ NSTEMI resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}} | ||
{{familytree/end}} | {{familytree/end}} |
Revision as of 20:53, 6 April 2015
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Boxes in the red color signify that an urgent management is needed.
| D03=Initial conservative strategy
Identify cardinal findings of unstable angina/ NSTEMI : ❑ Chest pain or chest discomfort
lightheadedness ❑ Characteristic ECG changes consistent with unstable angina/ NSTEMI
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Rule out life threatening alternative diagnoses: ❑ Aortic dissection (suggestive findings: vomiting, subcutaneous emphysema) | |||||||||||||||||||||||
Begin initial treatment: ❑ Administer aspirin
❑ Administer 2-4 L/min oxygen via nasal cannula when saturation <90%
❑ Administer beta-blockers (unless contraindicated) and titrate to the heart rate and blood pressure
❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses
❑ Administer 80 mg atorvastatin | |||||||||||||||||||||||
Does the patient have any of the following indications that require immediate angiography and revascularization ?
❑ Hemodynamic instability or cardiogenic shock | |||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||
Does the patient have negative ECG findings AND negative biomarkers? | |||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||
Repeat ECG and biomarkers within next 6 hours and 12 hours | |||||||||||||||||||||||
Both negative | At least one positive | ||||||||||||||||||||||
Calculate the risk of patients: ❑ Thrombolysis in Myocardial Infarction (TIMI) risk score, OR ❑ GRACE score | |||||||||||||||||||||||
Proceed to angiography | High risk Initial invasive strategy | {{{ D03 }}} | |||||||||||||||||||||
Administer ONE of the following antiplatelet agents (before or at the time of PCI):
Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding
Administer ONE of the following anticoagulant therapy:
| Administer one of the following antiplatelet agents: Before PCI
❑ IV GP IIb/IIIa inhibitors
At the time of PCI
❑ IV GP IIb/IIIa inhibitors
| Administer one of the following antiplatelet agents:
| |||||||||||||||||||||
❑ Perform an angiography | |||||||||||||||||||||||