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ACLS Acute Coronary Syndrome

ACLS 2010
Earl Purtell
Age: 67 years
Weight: 100.0 kg
Base: Stan D. Ardman II

Overview

Synopsis

Prehospital Setting: You have been called to the home of a 67-year-old male who is complaining of
tightness in his chest that began while he was resting and watching television. He reports that he took
three nitroglycerin tablets sublingually without any relief. His history includes angina, congestive heart
failure and hypertension. When asked about his compliance with medications, he admits to "only taking
them when he remembers to." He also states that over the past couple of nights he has been sleeping with
a lot of pillows propping him up because the shortness of breath "is too much if I lay flat." As time moves
on, he becomes very agitated and states it is getting "harder to breathe."

Emergency Department Setting: You are the triage nurse at a local emergency room when a 67-year-old
male walks into the lobby and is complaining of tightness in his chest. He states the discomfort started
while he was resting and watching TV at home.

He reports that he took three nitroglycerin tablets sublingually without any relief. His history includes
angina, congestive heart failure and hypertension. When asked about his compliance with medications, he
admits to "only taking them when he remembers to." He also states that over the past couple of nights he
has been sleeping with a lot of pillows propping him up because the shortness of breath "is too much if I
lay flat." As time moves on, he becomes very agitated and states it is getting "harder to breathe."

This SCE consists of seven states that automatically and manually transition. With manual transitions,
instructors should advance to the applicable state when appropriate interventions are performed.

In State 1 Chest Pain, the patient presents with a HR in the 70s, BP in the 110s/70s, RR in the upper
teens and SpO2 in the 90s on room air. The patient's lungs are clear and equal bilaterally, the cardiac
rhythm is sinus with mild myocardial ischemia. The patient is alert and oriented to person, place and
time. The patient complains of his chest being tight. The learner is expected to place the patient on 4LPM
of oxygen via nasal cannula before transitioning to next state.If the time in this state is greater than 180
seconds, the state automatically progresses to State 2 Chest Pain Increases.

In State 2 Chest Pain Increases, the patient's pain increases with a HR in the 70s to 80s, BP in the
110s/70s, RR in the teens to 20s and SpO2 in the 90s on oxygen by nasal cannula at 4 LPM. Other
clinical findings include a cardiac rhythm of sinus with ST elevations. The patient states "I can't breathe."

ACLS Acute Coronary Syndrome Page 1


Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
If the time in this state is greater than 180 seconds, the scenario automatically progresses to State 3 Chest
Pain Without Relief. If 300 mL or more of crystalloids are infused, manually transition to State 5 Acute
Myocardial Infarction. The learner is expected to note the ST wave elevation on the monitor and obtain
a 12 lead ECG and continue with treatment. The 12 lead shows ST elevation in leads II, III and AVF.

In State 3 Chest Pain Without Relief, the patient's condition worsens with a HR in the 80s to 90s, BP in
the 70s/40s, RR in the 30s and SpO2 in the 90s on oxygen by nasal cannula at 4 LPM. The patient also
has a cardiac rhythm of sinus with ST elevations. The patient is alert, oriented to person and place and
extremely anxious. The patient states, "My chest is tight!" If the time in this state is greater than 180
seconds, the scenario automatically progresses to State 4 Low Blood Pressure. If 300 mL or more of
crystalloids are infused, manually transition to State 5 Acute Myocardial Infarction.

In State 4 Low Blood Pressure, the patient's condition continues to deteriorate with a HR in the 110s, BP
in the 60s/40s to 50s, RR in the 30s and SpO2 undetectable. Lungs now have crackles throughout and
patient is mumbling. If 300 mL or more of crystalloids are infused, manually transition to State 5 Acute
Myocardial Infarction. If time in this state is greater than 300 seconds, the SCE automatically
progresses to State 6 Premature Ventricular Contractions. The learner is expected to respond
appropriately to the falling blood pressure.

In State 5 Acute Myocardial Infarction, the patient's condition stabilizes with a HR in the 100s, BP in
the 100s/50s and a RR in the 20s. Cardiac rhythm is sinus with ST elevations and lung sounds are
dimished. The learners should be preparing the patient for the cardiac catheterization lab or to begin
Thrombolytic therapy. This state is a possible endpoint of the SCE.

In State 6 Premature Ventricular Contractions, the patient's condition continues to deteriorate with a
HR in the 110s-130s, BP in the 50s-70s/30s-50s and RR in the 30-40s. Lung sounds are crackles and
other clinical findings include cyanosis of the fingertips and toes. The learner is expected to recognize the
presence of cyanosis and PVCs and respond appropriately. If the learner fails to intervene appropriately,
manually transition to State 7 Death. If the learner responds appropriately, this would be the end of the
SCE. If the learner reaches this state, it is recommended to repeat the simulation until a positive outcome
occurs.

In State 7 Death, the patient's condition deteriorates to ventricular fibrillation. Other clinical findings
include absent breath sounds and cyanosis is present. The learner is expected to begin CPR. If the learner
gets to this state, it is recommended to repeat the simulation until a positive outcome occurs.

Background

Patient History

Past Medical History: Past history includes angina, congestive heart failure and hypertension

Allergies: Penicillin and sulfa drugs

ACLS Acute Coronary Syndrome Page 2


Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
Medications: Nitroglycerin, furosemide and captopril. The patient was noncompliant with his
medications for the past three weeks

Code Status: Full Code

Social/Family History: Smokes two packs of cigarettes a day

Secondary Assessment: Weight is 100 kg, height is 5'7"; jugular vein distention (JVD) at a 45-degree
angle. The lungs have bibasilar crackles and poor air exchange. The abdomen is soft with no pain on
palpation, the lower extremities have pitting pedal edema, and pedal pulses are present bilaterally. The
upper extremities have equal and strong pulses

Handoff Report

The learner is expected to give a report to the receiving facility that includes patient history, treatment
administered in the field, the patient's response to interventions and status upon arrival. This report should
be given at the conclusion of the SCE.

Orders

The learner is expected to follow all regional and local protocols.

Preparation

Learning Objectives

Demonstrates proficiency in the steps of the Advanced Cardiac Life Support (ACLS) approach utilizing
the Primary Survey.
Demonstrates the application of the Secondary Survey.
Effectively applies skills for advanced management of the airway, effective ventilation, continued chest
compressions and appropriate IV drug therapy.
Calls for a defibrillator/monitor, uses quick look paddles or attaches leads correctly.
Performs immediate general treatment with MONA (morphine, oxygen, nitroglycerine, aspirin).
Demonstrates correct technique in establishing IV access to deliver fluid and medications.
Administers medications in the correct sequence and dosage.
Demonstrates the ability to provide leadership to a resuscitation team with multiple available
interventions.
Demonstrates observation of electrical safety principles.
ACLS Acute Coronary Syndrome Page 3
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
Considers family presence during resuscitative attempts and offers that option to appropriate family
members.
Discusses use of fibrolytic and revascularization approaches to care.
Follows local protocols.

Learning Performance Measures

State 1 Chest Pain Begins:


Demonstrates proficiency in the steps of the ACLS approach utilizing the Primary Survey
Initiates cardiac and oxygen saturation monitoring
Obtains a history
Establishes IV access

State 2 Chest Pain Increases:


Performs immediate general treatment using MONA

State 3 Chest Pain Without Relief:


Continues a focused assessment
Initiates vasopressor(s) infusion

State 4 Low Blood Pressure:


Continues a focused assessment
Responds to the falling blood pressure
Considers conscious sedation prior to pacing
Titrates vasopressor(s) to maintain systolic BP

State 5 Acute Myocardial Infarction:


Reassesses the patient

State 6 Premature Ventricular Contractions:


Continues an ongoing assessment
Considers administration of appropriate medications for premature ventricular contractions (PVCs)

State 7 Death:
Begins CPR
Protects the airway

Preparation Questions

Describe the pathophysiology of acute myocardial infarction (AMI).


What are modifiable and non-modifiable risk factors for AMI?
ACLS Acute Coronary Syndrome Page 4
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
What assessments should be performed for a patient with AMI?
How can the learner determine what type of oxygen device is needed for this patient?
What other means can the learner use if there is no pulse oximeter available?
What assessment information would the learner be looking for that would indicate treatment is effective?
How does stress affect AMI?
Identify three priority-teaching points related to health promotion for the patient with AMI.

Equipment & Supplies

IV Supplies
20 or 22-gauge IV catheter (2 each)
Alcohol pads (8-10)
Tourniquets (2)
Transparent dressing
1" Roll of medical tape
IV tubing (4)
IV extension sets (4)
Needleless adapters (4)
Distilled water 500 mL or 1000 mL (labeled as 0.9% normal saline)
Medication Supplies
Distilled water 10 mL pre-filled syringe (labeled as 0.9% Normal Saline Flush) (6)
Distilled water 1 mL vial (labeled as Morphine Sulfate 5 mg/mL)
Distilled water 10 mL vial (labeled as Amiodarone 50 mg/mL)
Distilled water 250 mL (labeled as Dopamine 200 mg in 250 mL D5W)
Distilled water 100 mL (labeled as D5W)
Distilled water 500 mL (labeled as D5W)
Simulated pills (labeled as Aspirin 325 mg and Nitroglycerine 0.4 mg)
Oxygen, Airway and Ventilation Supplies
Oxygen source
Oxygen flowmeter
Nasal cannula
Venturi-mask
Non-rebreather mask
Bag valve mask
Pocket facemask
Laryngoscope with Miller and Mac blades (#3 or #4)
Endotracheal tube (sizes 6.5-7.5) with stylet (2 each)
Silicone lubricant
Endotracheal tube securing device
CO2 detector
Laryngeal Mask Airway size #3
37 Fr combitube
10 mL syringe
Silicone spray
ACLS Acute Coronary Syndrome Page 5
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
Suction Equipment and Supplies
Suction source
Suction setup with canister and tubing
Suction catheter kit
Gastrointestinal Supplies
14-16 Fr nasogastric tube
Miscellaneous
Stethoscope
BP cuff adapted for use with simulator
Non-sterile gloves (1 box)
Sharps container 12-lead ECG tracing depicting myocardial ischemia
Run report or Code Blue record
Communication radios
External pacemaker
Defibrillator/External pacer
Code cart
Ventilator
X-ray films
Printed lab reports
Patient identification band
Patient chart with appropriate forms and order sheets
Goggles
Gown
Mask
Audio and visual recording devices
Monitors Required
ECG
NIBP
SpO2

Notes

Facilitator Notes

This SCE was created with the patient Earl Purtell, and only this patient can be used. The physiological
values documented indicate appropriate and timely interventions. Differences will be encountered when
care is not appropriate or timely.

If using the Muse platform, don't hit Run until you are ready to start the scenario. If using the HPS6
platform, open the patient and scenario directory. Do not open the scenario until you are ready to start the
simulated clinical experience.

Learners should perform an appropriate physical exam, and the facilitator or patient should verbalize
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Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
physical findings the learner is seeking but not enabled by the simulator (such as pain on palpation). The
facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to respond to
learner questions if present on your simulator.

Where appropriate, do not provide information unless specifically asked by the learner. In addition,
ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them.

If the patient becomes unconscious in the SCE, remember the patient stops speaking.

It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinical
experience. For this patient, dress the simulator in casual clothing and place the simulator in a sitting
position.

For simulators without the diaphoresis feature, spray the face and other appropriate body areas with
water.

For simulators without the cyanosis feature, use a thin coating of mortician's wax or petroleum jelly as a
base, then apply moulage paints or ordinary cosmetics (e.g., blue eyeshadow) to the lips and nail beds as
indicated.

When the learner initiates cardiac monitoring, the tracing and heart rate appear on a real ECG monitor for
those simulators with this feature. For simulators without ECG monitoring, have the learner apply ECG
electrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the TouchPro
or Waveform display ECG tracing.

Place a code cart either outside of the room or away from the patient area in the room to allow the
secondary nurse to retrieve it and bring it to the bedside, if needed. Have a code cart and either an
automated external defibrillator or a defibrillator with the code cart.

For simulators without the jugular venous distention or trismus feature, the facilitator should verbalize the
presence of these conditions to learners as approprate.

Simulation center personnel should play the following roles:


Healthcare provider
EMTs
Paramedics

Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learners
to utilize. The chart should include the specific patient identification information.

Have the learners roleplay inter-professional communication by reporting the patient's response to
interventions. If the data presented is disorganized or missing vital components, have the healthcare
provider become inappropriate in response. Emphasize the importance of data organization and
completeness when communicating.

Roleplay intra-professional communication by having the learner hand off to the admitting or transferring
ACLS Acute Coronary Syndrome Page 7
Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
unit or have the learner hand off to the next shift.

When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option or
Treatment Scenario and choose the appropriate flow rate. If using the HPS, no software command is
necessary when real oxygen is applied.

When learners provide pharmaceutical interventions, the facilitator should open the Medication
Intervention Option or Treatment Scenario and choose the appropriate medication. If using the drug
recognition feature of the HPS, no software command is necessary when a drug is administered using that
system.

When learners provide IV fluid interventions, the facilitator should open the Intervention Option or
Treatment Scenario and choose the appropriate fluid and volume to be administered.

Debriefing and instruction after the scenario are critical. Learners and instructors may wish to view a
videotape of the scenario afterward for instructional and debriefing purposes.

Debriefing Points

The facilitator should begin by introducing the process of debriefing:


Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safe environment for
discussion
Personal Reactions: Allow learners to recognize and release emotions, explore learner reactions
Discussion of Events: Analyze what happened during the SCE, using video playback if available
Summary: Review what went well and what did not, identify areas for improvement and evaluate the
experience

Questions to be asked during debriefing:


What was the experience like for you?
What happened and why?
What did you do and was it effective?
Discuss your interventions (technical and non-technical). Were they performed appropriately and in a
timely manner?
How did you decide on your priorities for care and what would you change?
How did patient safety concerns influence your care? What did you overlook?
In what ways did you personalize your care (recognition of culture, concerns, anxiety) for this patient and
family members?
Discuss your teamwork. How did you communicate and collaborate? What worked, what didn't work and
what you will do differently next time?
What are you going to take away from this experience?

ACLS Acute Coronary Syndrome Page 8


Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
Teaching Q & A

State 1 Chest Pain Begins:

What is causing the patient to have chest pain?


Plaque has ruptured in a coronary artery. The plaque releases its contents into the bloodstream resulting
in platelet aggregation and thrombus development within the artery.

State 2 Chest Pain Increases:

What is the reason for the patient's chest pain to be increasing despite the care being delivered?
If the thrombus partially occludes a coronary vessel, the patient may experience unstable angina. But if it
totally occludes the vessel, an AMI is likely.

State 3 Chest Pain Without Relief:

Why can't this patient get relief, even if the correct treatment is being performed?
A myocardial infarction may compromise the function of the heart; therefore, the pump is damaged
causing the patient to have heart failure.

State 4 Low Blood Pressure:

What is causing this patient's blood pressure to continue to fall?


Inadequate cerebral perfusion is causing the blood pressure to fall, which may lead to cardiogenic shock.
If this continues without proper treatment, the patient can go into cardiac arrest.

State 5 Acute Myocardial Infarction:

Why is the patient having an AMI?


The occlusion of the coronary artery is interrupting the blood flow to the heart causing ischemia to the
heart cells. The myocardium is being deprived of oxygen.

State 6 Premature Ventricular Contractions:

Why is the patient having PVCs?


Because a part of the heart is damaged, the conduction in that area is functioning slower than the
conduction in the healthy portions of the heart. This difference in electrical conduction causes
arrhythmias.

State 7 Death:

Why do you think the patient went into cardiac arrest?


The prognosis for patients with myocardial infarction varies greatly, depending on the patient, the
condition itself and the given treatment. The outcome can be traced back to the learner.

ACLS Acute Coronary Syndrome Page 9


Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011
ACLS Acute Coronary Syndrome
References

American Heart Association. (2010). Handbook of emergency cardiovascular care for healthcare
providers. Dallas, TX: American Heart Association.

ACLS Acute Coronary Syndrome Page 10


Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-
Sarasota, FL 2011