The Macstrak Project 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 KFD is a 62-year-old (DOB:09/09/43) woman with no significant past medical history.

The Macstrak Project CCU Case Study KFD is a 62-year-old (DOB:09/09/43) woman with no significant past medical history. On the afternoon of 08/02/06 KFD is brought to the ER at 13:30 by her husband. She reports chest pain for the past 3 hours associated with nausea and diaphoresis. She is seen by the triage RN on arrival and her vital signs are as follows: BP 145/80, HR 96 and chest is clear. KFD continues to have chest pain which she rates at 9/10. An ECG is done at 13:43 showing ST elevation in II/IIIaVF and ST depression in V 1 -V 4. The ER MD assesses KFD and finds she has no contraindications to reperfusion therapy. At 13:50 the decision is made to treat KFD (weight 59 kg) with TNK.

The Macstrak Project CCU Case Study 30 mg of TNK over 5 seconds is given at 14:00. KFD also receives UF heparin IV and metoprolol IV.

The Macstrak Project CCU Case Study 30 mg of TNK over 5 seconds is given at 14:00. KFD also receives UF heparin IV and metoprolol IV. By 15:00 the pain remains and an ECG shows persistent ST segment elevation.

The Macstrak Project CCU Case Study 30 mg of TNK over 5 seconds is given at 14:00. KFD also receives UF heparin IV and metoprolol IV. By 15:00 the pain remains and an ECG shows persistent ST segment elevation. At 15:15, KFD is transferred from your hospital to a tertiary hospital for a rescue PCI. She arrives at the cath lab at 16:00 and angiography confirms a persistent occlusion of the right coronary artery. She has a successful angioplasty with her first inflation at 16:35.

The Macstrak Project CCU Case Study KFD arrives back at your hospital at 23:00 and is admitted to your CCU with a diagnosis of Acute Myocardial Infarction. She has eptifibitide (Integrilin ® ) infusing intravenously on arrival. She was loaded with clopidogrel 600 mg at the other hospital and is now on 75 mg per day. The eptifibitide is discontinued the next morning. Her CK and troponins are positive. KFD has no further chest pain or complications while in CCU.

The Macstrak Project CCU Case Study KFD is discharged to the cardiac ward on 11/02/06 at 09:00. Her discharge diagnosis is Acute Myocardial Infarction and her peak CK is 2206 and peak troponin is 32. She is discharged on the following medications: ASA clopidogrel bisoprolol ramipril atorvastatin

The Macstrak Project Centre: CCU ICU Date: 20 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female CCU Case Study KFD is a 62-year-old (DOB:09/09/43) woman with no significant past medical history. K F D CCU MACSTRAK X

The Macstrak Project Centre: CCU ICU Date: 20 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female CCU Case Study KFD is a 62-year-old (DOB:09/09/43) woman with no significant past medical history. CCU MACSTRAK On the afternoon of 08/02/06 KFD is brought to the ER at 13:30 by her husband. She reports chest pain for the past 3 hours associated with nausea and diaphoresis X K F D

The Macstrak Project Past Medical History : 30 days MI ……………………………. Angina ……………………….. CABG ……………………….. PCI …………………………… CHF ………………………….. TIA/CVA …………………….. Diabetes (oral agents/insulin)... None of the Above……………. CCU Case Study KFD is a 62-year-old (DOB:09/09/43) woman with no significant past medical history. X

The Macstrak Project Patient Origin: ER EMS Walk In Dr.’s Office/Clinic (Direct) Other Hospital Inpatient Medical Ward Surgical Ward Other ICU Other: ……………… CCU Case Study On the afternoon of 08/02/06 KFD is brought to the ER at 13:30 by her husband. She reports chest pain for the past 3 hours associated with nausea and diaphoresis. X X

The Macstrak Project VS at Presentation: (complete for all patients) Dyspnea/Rales: None Mild Mod/Severe Systolic BP: < >190 Heart Rate: < >100 CCU Case Study On the afternoon of 08/02/06 KFD is brought to the ER at 13:30 by her husband. She reports chest pain for the past 3 hours associated with nausea and diaphoresis. She is seen by the triage RN on arrival and her vital signs are as follows: BP 145/80, HR 96 and chest is clear. KFD continues to have chest pain which she rates at 9/10. X X X

The Macstrak Project CCU Case Study KFD arrives back at your hospital at 23:00 and is admitted to your CCU with a diagnosis of Acute Myocardial Infarction. She has eptifibitide (Integrilin ® ) infusing intravenously on arrival. She was loaded with clopidogrel 600 mg at the other hospital and is now on 75 mg per day. The eptifibitide is discontinued the to next morning. Her CK and troponins are positive. KFD has no further chest pain or complications while in CCU. Admitting Diagnosis: (Check one only) Acute AMI (48 hrs) UA R/O MI UA RSCP NYD CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………… ACS X

The Macstrak Project CCU Case Study Symptom Onset : EMS at Scene: Timeline: (AMI pts only - 24 hr clock or > 24 hrs) Hospital Arrival: First ECG: EMS Diagnostic ECG: 1030 On the afternoon of 08/02/06 KFD is brought to the ER at 13:30 by her husband. She reports chest pain for the past 3 hours associated with nausea and diaphoresis. She is seen by the triage RN on arrival and her vital signs are as follows: BP 145/80, HR 96 and chest is clear. KFD continues to have chest pain which she rates at 9/10. An ECG is done at 13:43 showing ST elevation in II/IIIaVF and ST depression in V 1 -V

The Macstrak Project Diagnostic ECG: (ACS pts. only) ST  ST  T  Q No ACS ST-TV 5-6 ……….… … ….. …... PacedII/IIIaVF ….. … ….. ….... OtherV 4 R..done... V 7-9..done... CCU Case Study V 1-4 ………….. …..… …... LBBB IaVL ………... ….…. …… KFD continues to have chest pain which she rates at 9/10. An ECG is done at 13:43 showing ST elevation in II/IIIaVF and ST depression in V 1 -V 4. X X X

The Macstrak Project Reperfusion Therapy: No  Not Indicated:  ECG Not Diag. ST Up Transient Too Late Given (Other Hosp) Risk:  Risk of ICB Risk Other Bleed Other: …………… Drug:TNK/rtPA SK r-PA ( reteplase ) Other Adjuvant: ASA Heparin GP2b/3a Inhibitor  blocker IV Clopidogrel Other and/or Primary/Rescue PCI  Here Transfer Reperfusion Therapy Decided by:EP Consultant CCU Case Study Yes  Thrombolysis  Here EMS Other Hosp Dose: (mg/units) Duration: (min) Pt.Weight: (kg) The ER MD assesses KFD and finds she has no contraindications to reperfusion therapy. At 13:50 the decision is made to treat KFD (weight 59 kg) with TNK. X X X X X 59

The Macstrak Project Reperfusion Therapy: No  Not Indicated:  ECG Not Diag. ST Up Transient Too Late Given (Other Hosp) Risk:  Risk of ICB Risk Other Bleed Other: …………… Drug:TNK/rtPA SK r-PA ( reteplase ) Other Adjuvant: ASA Heparin GP2b/3a Inhibitor  blocker IV Clopidogrel Other and/or Primary/Rescue PCI  Here Transfer Reperfusion Therapy Decided by:EP Consultant CCU Case Study Yes  Thrombolysis  Here EMS Other Hosp Dose: (mg/units) Duration: (min) Pt.Weight: (kg) 30 mg of TNK over 5 seconds is given at 14:00. KFD also receives UF heparin IV and metoprolol IV. X X X X X X X

The Macstrak Project Reperfusion Therapy: No  Not Indicated:  ECG Not Diag. ST Up Transient Too Late Given (Other Hosp) Risk:  Risk of ICB Risk Other Bleed Other: …………… Drug:TNK/rtPA SK r-PA ( reteplase ) Other Adjuvant: ASA Heparin GP2b/3a Inhibitor  blocker IV Clopidogrel Other and/or Primary/Rescue PCI  Here Transfer Reperfusion Therapy Decided by:EP Consultant CCU Case Study Yes  Thrombolysis  Here EMS Other Hosp Dose: (mg/units) Duration: (min) Pt.Weight: (kg) At 15:15, KFD is transferred from your hospital to a tertiary hospital for a rescue PCI. She arrives at the cath lab at 16:00 and angiography confirms a persistent occlusion of the right coronary artery. X X X X X X X X X

The Macstrak Project CCU Case Study At 13:50 the decision is made to treat KFD (weight 59 kg) with TNK. TLysis Started: Arrive Lab: First Inflation: TLysis Ordered: GP 2b/3a Started: Transfer: mg of TNK over 5 seconds is given at 14:

The Macstrak Project CCU Case Study At 13:50 the decision is made to treat KFD (weight 59 kg) with TNK. TLysis Started: Arrive Lab: First Inflation: TLysis Ordered: GP 2b/3a Started: Transfer: mg of TNK over 5 seconds is given at 14: At 15:15, KFD is transferred from your hospital to a tertiary hospital for a rescue PCI. She arrives at the cath lab at 16:00 and angiography confirms a persistent occlusion of the right coronary artery. She has a successful angioplasty with her first inflation at 16:

The Macstrak Project Acuity: Shift: Diuretics……………………… Inotropes IV………………….. ETT/Vent…………………….. PA Line………………………. TTVP………………………… IABP…………………………. ACS: RSCP - Ischemia – Definite…. – Probable… CK (+ve)………………...…… Troponin (+ve)……………….. NTG IV………………………. Heparin – UFH……………..... – LMWH……………. Other Antithrombin………...… GP 2b/3a Inhibitor IV……...… 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 ………………..…. Date: CCU Case Study DNDNN D KFD arrives back at your hospital at 23:00 and is admitted to your CCU with a diagnosis of Acute Myocardial Infarction. She has eptifibitide (Integrilin ® ) infusing intravenously on arrival. She was loaded with clopidogrel 600 mg at the other hospital and is now on 75 mg per day. The eptifibitide is discontinued the next morning. Her CK and troponins are positive. KFD has no further chest pain or complications while in CCU SG AW D N 11 PJ CS X XX XX XXX X XX X X X

The Macstrak Project Discharge Diagnosis: Acute MI Unstable Angina Chest Pain NYD CHF Arrhythmia Other Cardiac Problem: ………… Non Cardiac Problem: …..… ………..... Date: 20 Time: CCU Case Study KFD is discharged to the cardiac ward on 11/02/06 at 09:00. Her discharge diagnosis is Acute Myocardial Infarction and her peak CK is 2206 and peak troponin is 32. She is discharged on the following medications: ASA clopidogrel bisoprolol ramipril atorvastatin Day Month Year Peak CK: Trop: X

The Macstrak Project CCU Case Study KFD is discharged to the cardiac ward on 11/02/06 at 09:00. Her discharge diagnosis is Acute Myocardial Infarction and her peak CK is 2206 and peak troponin is 32. She is discharged on the following medications: ASA clopidogrel bisoprolol ramipril atorvastatin Discharged To: Cardiac Ward Med/Surg Ward Step Down Unit CV Surgery Other ICU Other Hospital Home Death Other: Discharge Meds: ASA Clopidogrel (or ticlop.) Heparin (UF or LMW) Nitrates (po/top) B Blocker ACEI A2 Blocker Statin None of Above X X X X X X