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CCU Case Studies The following is a series of case studies to review different patient types and how they are captured on the form. The information is provided in sequence to reflect the natural progression of a patient’s care. As the case is presented, mark off the required information in the appropriate fields on your Macstrak form. At the end of each case study, the form will be reviewed with the correct answers supplied. If you have any questions, please refer to your Macstrak manual or contact us at the Macstrak Project Office. The Macstrak Project CCU Case Study The Macstrak Project CCU Case Study ENC is a 49-year-old (DOB: 27/04/56) working mom with no significant past medical history. The Macstrak Project CCU Case Study On the morning of 02/03/06 ENC awakens at 05:00 with chest pain. She gets up and gets her children ready for daycare and drops them off. Rather than going to work she returns home and her husband calls an ambulance. The ambulance arrives at 07:50. At 08:05, en-route to the hospital, ENC has an ECG which shows ST elevation in II/IIIaVF. ASA is given to chew. She arrives at the ER at 08:25. She is seen by the triage RN on arrival and her vital signs are as follows: BP 130/70, HR 74 and chest is clear. ENC continues to have chest pain which she rates at 8/10. The ER MD assesses ENC and finds she has no contraindications to thrombolytic therapy. At 08:40 the decision is made to treat ENC (weight 62 kg) with TNK. The Macstrak Project CCU Case Study 35 mg of TNK over 5 seconds is given at 08:50. ENC also receives UF heparin IV and metoprolol IV while in the ER. The pain resolves shortly after starting the TNK and the ST segments are normalising. The Macstrak Project CCU Case Study 35 mg of TNK over 5 seconds is given at 08:50. ENC also receives UF heparin IV and metoprolol IV while in the ER. The pain resolves shortly after starting the TNK and the ST segments are normalising. ENC is admitted to your CCU that same morning with a diagnosis of Acute Myocardial Infarction. She has UF heparin infusing intravenously on arrival. Clopidogrel is started that evening. ENC has no further chest pain or complications while in CCU but her CK and troponin levels remain positive. The Macstrak Project CCU Case Study ENC is transferred to a tertiary centre for a cath on 04/03/06 at 09:00. Her discharge diagnosis is Acute Myocardial Infarction and her peak CK is 1086, her peak troponin is 24. She is discharged on the following medications: ASA metoprolol clopidogrel UF heparin pravastatin The Macstrak Project CCU Case Study MACSTRAK Patient Initials: E F Birth Date: CCU Gender: N C M L 27 04 Day Month Male Centre: 19 56 Year X Female CCU Date: ICU 20 Day Month Year ENC is a 49-year-old (DOB: 27/04/56) working mom with no significant past medical history. The Macstrak Project CCU Case Study MACSTRAK Patient Initials: E F Birth Date: CCU Gender: N C M L 27 04 Day Month Male Centre: 19 56 Year X Female Date: CCU 02 03 Day Month ICU 20 06 Year ENC is a 49-year-old (DOB: 27/04/56) working mom with no significant past medical history. On the morning of 02/03/06 ENC awakens at 05:00 with chest pain. She gets up and gets her children ready for daycare and drops them off. Rather than going to work she returns home and her husband calls an ambulance. The Macstrak Project CCU Case Study Past Medical History: <30 days MI ……………………………. Angina ……………………….. CABG ……………………….. PCI …………………………… CHF ………………………….. TIA/CVA …………………….. Diabetes (oral agents/insulin) ... None of the Above……………. >30 days X ENC is a 49-year-old (DOB: 27/04/56) working mom with no significant past medical history. The Macstrak Project CCU Case Study Patient Origin: X ER X EMS Walk In Dr.’s Office/Clinic (Direct) Other Hospital Inpatient Medical Ward Surgical Ward Other ICU Other: ……………… On the morning of 02/03/06 ENC awakens at 05:00 with chest pain. She gets up and gets her children ready for daycare and drops them off. Rather than going to work she returns home and her husband calls an ambulance. The ambulance arrives at 07:50. At 08:05, en-route to the hospital, ENC has an ECG which shows ST elevation in II/IIIaVF. ASA is given to chew. She arrives at the ER at 08:25. The Macstrak Project CCU Case Study VS at Presentation: (complete for all patients) Dyspnea/Rales: Systolic BP: Heart Rate: X None Mild Mod/Severe < 100 X 101-130 131-160 161-190 >190 X < 80 80-100 >100 She arrives at the ER at 08:25. She is seen by the triage RN on arrival and her vital signs are as follows: BP 130/70, HR 74 and chest is clear. ENC continues to have chest pain which she rates at 8/10. The ER MD assesses ENC and finds she has no contraindications to thrombolytic therapy. At 08:40 the decision is made to treat ENC (weight 62 kg) with TNK. The Macstrak Project CCU Case Study Admitting Diagnosis: (Check one only) X Acute AMI (48 hrs) UA R/O MI ACS UA RSCP NYD CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………… ENC is admitted to your CCU that same morning with a diagnosis of Acute Myocardial Infarction. She has UF heparin infusing intravenously on arrival. Clopidogrel is started that evening. ENC has no further chest pain or complications while in CCU but her CK and troponin levels remain positive. The Macstrak Project CCU Case Study Timeline: (AMI pts only - 24 hr clock or > 24 hrs) Symptom Onset: 0500 EMS at Scene: 0750 Hospital Arrival: 0825 First ECG: X EMS 0805 Diagnostic ECG: 0805 On the morning of 02/03/06 ENC awakens at 05:00 with chest pain. She gets up and gets her children ready for daycare and drops them off. Rather than going to work she returns home and her husband calls an ambulance. The ambulance arrives at 07:50. At 08:05, en-route to the hospital, ENC has an ECG which shows ST elevation in II/IIIaVF. ASA is given to chew. She arrives at the ER at 08:25. The Macstrak Project CCU Case Study Diagnostic ECG: (ACS pts. only) No ACS ST-T LBBB Paced X Other ST ST V1-4 ………….. V5-6 ……….… IaVL ………... II/IIIaVF ….. X V4R..done ... V7-9 ..done ... T Q … ..… …... … ….. …... … .…. …… … ….. ….... The ambulance arrives at 07:50. At 08:05, en-route to the hospital, ENC has an ECG which shows ST elevation in II/IIIaVF. ASA is given to chew. She arrives at the ER at 08:25. The Macstrak Project CCU Case Study Reperfusion Therapy: No Not Indicated: Risk: ECG Not Diag. Risk of ICB ST Up Transient Risk Other Bleed Too Late Given (Other Hosp) Other: ……………...... EMS Other Hosp X Yes X Thrombolysis X Here Dose: (mg/units) Drug: X TNK/rtPA SK Duration: (min) r-PA (reteplase) Pt.Weight: (kg) 62 Other Adjuvant: ASA Heparin GP2b/3a Inhibitor blocker IV Clopidogrel Other ............................... and/or Primary/Rescue PCI Here Transfer Reperfusion Therapy Decided by: X EP Consultant The ER MD assesses ENC and finds she has no contraindications to thrombolytic therapy. At 08:40 the decision is made to treat ENC (weight 62 kg) with TNK. The Macstrak Project CCU Case Study Reperfusion Therapy: No Not Indicated: Risk: ECG Not Diag. Risk of ICB ST Up Transient Risk Other Bleed Too Late Given (Other Hosp) Other: ……………...... EMS Other Hosp X Yes X Thrombolysis X Here Dose: (mg/units) Drug: X TNK/rtPA SK Duration: (min) r-PA (reteplase) Pt.Weight: (kg) 62 Other Adjuvant: X ASA Heparin GP2b/3a Inhibitor blocker IV Clopidogrel Other ............................... and/or Primary/Rescue PCI Here Transfer Reperfusion Therapy Decided by: X EP Consultant The ambulance arrives at 07:50. At 08:05, en-route to the hospital, ENC has an ECG which shows ST elevation in II/IIIaVF. ASA is given to chew. The Macstrak Project CCU Case Study Reperfusion Therapy: No Not Indicated: Risk: ECG Not Diag. Risk of ICB ST Up Transient Risk Other Bleed Too Late Given (Other Hosp) Other: ……………...... EMS Other Hosp X Yes X Thrombolysis X Here 35 Dose: (mg/units) Drug: X TNK/rtPA 1 SK Duration: (min) r-PA (reteplase) Pt.Weight: (kg) 62 Other Adjuvant: X ASA X Heparin GP2b/3a Inhibitor Clopidogrel Other ............................... X blocker IV and/or Primary/Rescue PCI Here Transfer Reperfusion Therapy Decided by: X EP Consultant 35 mg of TNK over 5 seconds is given at 08:50. ENC also receives UF heparin IV and metoprolol IV while in the ER. The pain resolves shortly after starting the TNK and the ST segments are normalising. The Macstrak Project CCU Case Study TLysis Ordered: TLysis Started: GP 2b/3a Started: Transfer: 0840 The ER MD assesses ENC and finds she has no contraindications to thrombolytic therapy. At 08:40 the decision is made to treat ENC (weight 62 kg) with TNK. Arrive Lab: First Inflation: The Macstrak Project CCU Case Study TLysis Ordered: 0840 TLysis Started: 0850 GP 2b/3a Started: Transfer: The ER MD assesses ENC and finds she has no contraindications to thrombolytic therapy. At 08:40 the decision is made to treat ENC (weight 62 kg) with TNK. Arrive Lab: First Inflation: 35 mg of TNK over 5 seconds is given at 08:50. The Macstrak Project CCU Case Study 02 04 03 Date: D N D N D N Acuity: Shift: Diuretics……………………… Inotropes IV………………….. ETT/Vent…………………….. PA Line………………………. TTVP………………………… IABP…………………………. ACS: RSCP - Ischemia – Definite…. – Probable… X X X X CK (+ve)………………...…… X X X X X X Troponin (+ve)……………….. NTG IV………………………. X X X X Heparin – UFH……………..... X – LMWH……………. Other Antithrombin………...… GP 2b/3a Inhibitor IV……...… X X X Clopidogrel (or ticlopidine)..… Cardiac Cath……………….... PCI…………………………... Outcomes: VF/Sustained VT………….… Infarction (new/repeat)*(1) …... Thrombolysis (new/repeat)*(2).. Stroke*(3) ……………………. Major Bleed*(4) ……………… Transfusion………………….. Crs1: ……………………….... Crs2: ……………………..….. None of the Above……….….. RN Initials ………………..…. KD AW KD AW KD ENC is admitted to your CCU that same morning with a diagnosis of Acute Myocardial Infarction. She has UF heparin infusing intravenously on arrival. Clopidogrel is started that evening. ENC has no further chest pain or complications while in CCU but her CK and troponin levels remain positive. The Macstrak Project CCU Case Study 03 Date: 04 Day Month 06 Time: 0900 20 Year Discharge Diagnosis: X Acute MI Peak CK: 1086 Unstable Angina Trop: 24 Chest Pain NYD CHF Arrhythmia Other Cardiac Problem: ………….................. Non Cardiac Problem: …..….............………..... ENC is transferred to a tertiary centre for a cath on 04/03/06 at 09:00. Her discharge diagnosis is Acute Myocardial Infarction and her peak CK is 1086, her peak troponin is 24. She is discharged on the following medications: ASA metoprolol clopidogrel UF heparin pravastatin The Macstrak Project CCU Case Study Discharged To: Discharge Meds: Cardiac Ward Med/Surg Ward Step Down Unit CV Surgery Other ICU X Other Hospital Home Death Other:.............. X ASA X Clopidogrel (or ticlop.) X Heparin (UF or LMW) Nitrates (po/top) X B Blocker ACEI A2 Blocker X Statin None of Above ENC is transferred to a tertiary centre for a cath on 04/03/06 at 09:00. Her discharge diagnosis is Acute Myocardial Infarction and her peak CK is 1086, her peak troponin is 24. She is discharged on the following medications: ASA metoprolol clopidogrel UF heparin pravastatin The Macstrak Project