Markus dela Cruz, RN

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!

• 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

• If EMS gave 2 baby aspirins (81mg each), give another 2 for a full dose of 325mg

• 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

Additional Medications

• 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.

• 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?

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