Your Patient Is Going to the Cath Lab!!! Part 1 w/Markus Dela Cruz, RN

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Markus dela Cruz, RN

Mark is an ED Nurse extraordinaire who turned into a Cath Lab RN. He is also found working in PACU units and still works some ED shifts. Mark also considers himself a foodie and likes exploring Queens, NY. Mark works at a Level 1 Trauma Center that is also a STEMI receiving center in Queens, NY.

Fun fact: When I first started working, there were rumors that Mark can get an IV line with a full set of labs on sick patients with NO tourniquet! To this day, I believe this may be more truth than fiction.

Disclaimer: This is how Mark and I manage our STEMI patients going to the Cardiac Cath lab for PCI. These are suggestions. Follow your institution’s policies.

Your Patient’s Going to the Cath Lab!

How can we ensure the fastest and smoothest transition from the moment your patient is identified as a STEMI and accepted to the Cardiac Cath lab?

PCI (Percutaneous Coronary Intervention) is the treatment of choice for a repercussion of a patient having an active MI. It is a life-saving procedure.

  • You may be a receiving facility getting transfers.
  • If your facility does not have a Cath lab, you will transfer to a facility that does.
  • 3 Sites of Entry: Right Radial Artery and Bilaterally Femoral
  • This is a CMS reportable event and the door to balloon time is within 90 minutes.
  • Preferably, you get your patient into the Cath lab WELL before the 90 minute mark because your Cath lab team have a lot to do.

Prepping Your Patient

  • Get your patient butt naked! Seriously, no underwear! (A running theme!)
  • IV Medlocks
    • Minimum 2 IV medlocks. 3 is super!
    • Avoid Right Wrist and Right Hand.
    • Left arm preferred
  • Vitals also include:
    • Weight All medications given in the Cath lab are weight-based.
    • Height intra-aortic balloon pump is sized by height
  • EKGs (just leave the leads on! You’ll be repeating these!)
  • Defibrillator Monitoring (use radiolucent pads)
  • Telemonitoring & transport monitoring (esp. your cardiogenic shock pts)
    • Not all facilities have fancy defibrillator monitors that also have BP and Pulse Ox. If you do, obviously use it!
  • History Ask the patient and/or EMS what meds were given (esp. aspirin dose)
  • Consent
    • Can we trust the Cath fellow with the original?
    • If we have time, I usually make copies and tape it to the top of the stretcher and get it scanned in the ED Chart.
  • Secure all property and jewelry with family member or security – label and seal the property bags.
    • Keep left chest wall and right wrist clear of all jewelry.
    • Document in chart where property went.

Medications

All Patients with STEMI

Aspirin 325mg PO
  • If EMS gave 2 baby aspirins (81mg each), give another 2 for a full dose of 325mg
Heparin Bolus IV
  • Most facilities are weight-based, but some still give the standard 5000 units IV

Heparin IV Myth-Buster!

  • Always administer bolus dose heparin by IV. Never subcutaneous!
  • IV Heparin helps prevent the existing clot to not get larger and prevents new clots
  • aPTT in anticoagulated therapeutic range is the goal!
  • Don’t wait for an aPTT/INR result before administering Heparin IV.
  • Pts need to be anticoagulated because PCI attracts clot formation.
  • Cath labs have fancy machines that measure aPTT and INR in real time and can adjust heparin as needed.
    • ACT (Activated Clotting Time) Machine
  • Worse case, heparin’s antidote (protamine sulfate) is readily available in the Cath lab.

If PCI w/Stents

Loading doses of clopidogrel (Plavix) and ticagrelor (Brilinta)

Additional Medications

Heparin Drip
  • When did you start it?
  • What’s the current dosage/rate?
  • If the pt received thrombolytics and you are a receiving hospital, pt should most likely be on a heparin drip to prevent further clots. Speak with Cath fellow/cardiology/EM MD.
  • NSTEMI patients boarding in your ED may be on a heparin drip. Check aPTT every 6 hours and adjust drip as needed for anticoagulated therapeutic levels – goal.
Nitroglycerin
  • Ask your patient if they are taking sildenafil (Viagra) or tadalafil (Cialis) for erectile dysfunction.
  • Tell the Cath Lab nurse how much nitro you administered and in what form
  • Preferred route is SL tabs versus paste. Works faster.
  • Nitro paste can cause an accidental overdose in the Cath lab.

eptifibatide (Integrillin) Drip

  • May be used for pts with elective PCI

Metformin or Sitagliptin (Januvia)

  • Let your Cath lab nurse know that pt is on metformin or other DM medications.
  • metformin can interact with the dye used in PCI – may cause nausea, dizziness, or vomiting. Concern for airway.
  • If the patient is having an elective PCI, hold DM meds for 24 hours.

Transfer Patients

  • Pt may have received thrombolytics prior to transferring to a STEMI receiving center.
    • Need to know when it was given and how much
  • What other medications were given (see above for pertinent list)
  • Are they on a heparin drip?

Now Listen to the Episode!

 

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