Development of Clinical Guidelines
A 59-year-old white woman is working at her office when she experiences the sudden onset of chest pain, and then falls to the floor. Coworkers find that she is pulseless and apneic. Basic life support is instituted with positioning for proper airway, rescue breathing, chest compressions, and notification of the city’s emergency medical system. An ambulance arrives, and the paramedics find that the pulse and respirations have been restored by the prompt and proper application of CPR. After intravenous access is established, she is transported to the hospital where electrocardiogram and cardiac enzymes show evidence of acute myocardial infarction. Intravenous streptokinase and nitroglycerine are administered. The cardiology fellow, the emergency room physician, and her family physician begin a discussion of management, with disagreement as to the appropriate subsequent medications, monitoring, imaging studies, length of stay in the coronary care unit, exercise testing, and rehabilitation planning. They differ over the use of calcium channel blockers and beta blockers in the acute phase, and over the use of nitrates for long-term therapy. The family physician believes that she needs to have only a monitor for cardiac rhythm and that her blood pressure should be taken manually, while the ER physician wants an intermittent automatic blood pressure device, and the cardiology fellow wants to place an arterial line for continuous blood pressure monitoring and a central line to monitor central venous pressure. The need for coronary angiography, nuclear imaging, and magnetic resonance imaging are discussed.
KeywordsFamily Physician Preventive Service Task Basic Life Support Advance Cardiac Life Support Specialty Society
Unable to display preview. Download preview PDF.