ER & CCU Protocol Ahmed Abdelmageed Alfarra

ER & CCU Protocol

Prepared by
Dr. Ahmed Abdelmageed Alfarra, MSc

Version 1.0
March 2024

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

Before use
This protocol is prepared for junior cardiologists or non-cardiologists dealing with acute
cardiac cases at ER & CCU or intermediate ICU in hospitals with limited resources.

This protocol suitable for a hospital with following criteria (many hospitals in
Egypt like this):

 Limited resources CCU (with beds and telemetry monitors only).

 Limited medications.
 No catheterization Lab (the nearest cath lab > 90 min away).
 No cardiothoracic surgery backup.

So this place is capable to deal with:

 Acute coronary syndrome (medically managed).

 Tachyarrhythmias.
 Hypertensive crisis.
 Acute decompensated heart failure or pulmonary edema.
 Cardiac arrest (resuscitation and first aids).

And these are not your cases (refer immediately to an equipped hospital):

 Symptomatic bradycardia and heat block.

 Advance management of cardiac arrest.
 Suspected pulmonary embolism.
 Suspected aortic dissection.
 Cardiac tamponade.
 MHV dysfunctions.
 Cardiac drugs toxicity.

More details and recommendations of are cardiac cases are provided in CARDIO-NOTES book
(Part I: cardiac emergencies), a printed book available in all medical book stores that simplifies
acute therapy of cardiac cases in a step-by-step approach based on ESC and ACC guidelines.

Any suggestions or comments are welcomed and don’t hesitate to contact me through
WhatsApp (0201090697989).

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

Table of contents
No Topic Page
1 Acute coronary syndrome 4
2 Tachyarrhythmias 7
3 Hypertensive crisis 10
4 ADHF and pulmonary edema 11
5 Cardiac arrest 12

Abbreviation and acronyms IHD: ischemic heart disease

INR: international normalized ratio
AC: anticoagulant
IV: intravenous
ACC: American college of cardiology
K: potassium
ACEIs: angiotensin converting enzyme inhibitors
LA: left atrium
ACS: acute coronary syndrome
ADHF: acute decompensated heart failure LAA: left atrial appendage
AF: atrial fibrillation LAVI: left atrial volume index
AFL: atrial flutter LVEF: left ventricle ejection fraction
AHA: American heart association MAP: mean arterial pressure
ARBs: angiotensin receptors blockers min: minute
BBs: beta blockers mo: month
Bid: bis in die (twice daily) MRA: mineralocorticoid receptors antagonists
BP: blood pressure MVT: monomorphic ventricular tachycardia
CCBs: calcium channels blockers Na: sodium
CCU: cardiac care unit NCT: narrow complex tachycardia
CPR: cardiopulmonary resuscitation NDCCBs: non-dihydropyridine calcium channels
CS: cardiogenic shock blockers
CV: cardioversion NS: normal saline/ normal rhythm
DAPT: dual antiplatelets therapy NSTE-ACS: non-ST elevation acute coronary syndrome
DBP: diastolic blood pressure OAC: oral anticoagulant
DC: direct current Od/qd: once daily
DCCBs: dihydropyridine calcium channels blockers PO: per mouth/ orally
ECG: electrocardiogram PPCI: primary precautious intervention.
ESC: European society of cardiology PVT: polymorphic ventricular tachycardia
h/hr: hour Qid: quaque in die (4 times a day)
HD: hemodynamic ROSC: return of spontaneous circulation
HFpEF: heart failure with preserved ejection fraction RR: respiratory rate
HFrEF: heart failure with reduced ejection fraction s/sec: second
HR: hear rate SAPT: single antiplatelet therapy
HQ: high quality
SBP: systolic blood pressure
ICA: invasive coronary angiography
SC: subcutaneous
ICH: intracranial hemorrhage

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

SCr: serum creatinine Tid: ter in die (3 times a day)

SHD: structural heart disease
TOD: target organ damage
STE: ST elevation
TSH: thyroid stimulating hormone
STEMI: ST elevation myocardial infarction
WCT: wide complex tachycardia
SVT: supraventricular tachycardia
y/yr: year
TIA: transient ischemic attack

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

Acute coronary syndrome (ACS)

ACS Introduction
 Patient presents with chest pain → history (ask about risk factors, onset of chest
pain, medications), clinical examination (BP, pulse, Spo2, auscultated murmur) and
ECG.
 Exclude other causes of chest pain (aortic dissection, Pneumothorax, PE) or non-
cardiac pain.
 If ACS → stratify you patient:
o STEMI or very high risk NSTE-ACS → then he is for ICA (to transfer to the
nearest facility with PPCI but STEMI can receive thrombolytic therapy).
o NSTE-ACS with no very high risk features → admit for medical treatment.
o Low risk patients → discharge home for follow up at outpatient clinic.
Very high risk features of NSTE-ACS patient (transfer for PPCI):
1. HD instability or cardiogenic shock or acute heart failure.
2. Recurrent or ongoing chest pain refractory to medical treatment.
3. Life-threatening arrhythmias or cardiac arrest.
4. Mechanical complications of MI.
5. Recurrent dynamic ST-T wave changes particularly with intermittent ST- elevation.

ACS treatment
Patient diagnosed with ACS (STEMI or NSTE-ACS):
 For all patients give loading doses of medications at ER without delay:
 300 mg aspirin PO (4 tab Aspocid) +
 300 mg clopidogrel PO (4 tab Plavix) +
 60 IU UFH IV (maximum 4000 IU) then 12 IU/kg/hr IVI (maximum : 1000 IU /hr)
or Clexane (30 mg IV then 1 mg/kg/12 hr SC starting 15 min after bolus dose
(amp/12 hr), don’t give bolus dose for patients ≥ 75 years old patient and give
only 0.75 mg/kg/12 hr, and use half dose of enoxaparin (1 mg/kg every 24hr not
every 12 hr) or use UFH If CrCl < 30 ml/min +
 80 mg atorvastatin or 40 mg rosuvastatin ±
 5 mg isosorbide dinitrate (Dinitra) SL every 5 min ±
 2-4 L/min O2 if SpO2 < 90% or patient showed respiratory distress to be > 95%.

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 4-8 mg morphine IV can be repeated every 15 min ±

 2.5-5 mg midazolam (Dormicum, midathetic) IV if patient is very anxious.

After ER stage, transfer patient to CCU

 If the patient is shocked or hemodynamically unstable:
o Stabilize your patient; ABC (maintain airway, breathing and maintain
circulation by IV fluids (if indicated), ± inotropes, ± vasopressors,
termination of arrhythmia if present (by DC shocks) then arrange for
transfer to an equipped hospital (PPCI-capable hospital, Minia University
hospital).
 If patient has STEMI:
o Give streptokinase as soon as possible (within 10 min of diagnosis) (1
amp, 1,500,000 IU diluted in 100 ml NS over 30-60 min) if chest pain
onset < 12 hr and after exclusion of contraindications.
o Obtain another ECG 60-90 min after fibrinolytic infusion and assess
successfulness (by chest pain relief, STE resolution > 50% {or >70%} and
accelerated idioventricular rhythm). If thrombolytic failed arrange for
transfer to PCI-capable hospital.
Absolute CI Relative CI
 Previous ICH or stroke of unknown origin at any  Ischemic stroke of > 3 mo (ACC).
time.  TIA (< 6 mo).
 Recent (6 mo) ischemic stroke.  Use of OAC.
 Recent (1 mo) major trauma/surgery/head  Pregnancy or within 1 week
injury. postpartum.
 Recent (2 mo) intracranial or intraspinal surgery.  Refractory HTN (SBP > 180
 Recent (1 mo) GI bleeding mmHg).
 Active bleeding or bleeding diathesis.  Prolonged CPR (> 10 min).
 CNS damage or neoplasm or A-V malformation.  Active peptic ulcer.
 Recent (24 hr) non-compressible punctures  Infective endocarditis.
(lumber puncture, liver biopsy).  Non-compressible vascular
 Suspected aortic dissection. puncture.
 For streptokinase, prior recent (6 mo) use  Advanced liver disease.

 If patient has NSTE-ACS without very high risk features, admit to CCU and
conduct anti-ischemic therapies.

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Anti-ischemics in CCU:
 Aspirin: 75 mg PO od.
 Clopidogrel (Plavix): 75 mg PO od.
 Enoxaparin (Clexane): 1 mg/kg SC/12 hr till hospital discharge.
 Atorvastatin: 40 or 80 mg po od.
 Bisoprolol (concor): 2.5-10 mg po od.
 Ramipril (tritace): 1.25-10 mg.
 Spironolactone (specton): 25 mg od PO if has LV dysfunction.
 Empagliflozin (Jardiance): 10 mg od po if has LV dysfunction or DM.
 Nitroglycerin (Nitromak): 2.5 mg PO tid or qid if has residual chest pain.
 Treatment of comorbidities.

Duration of admission:
 48-72 hr for all patients or prolonged as clinically indicated.
 ECG monitoring for at least 24 hr for all patients during admission (monitoring for
arrhythmias)

Upon discharge:
 Medications:
o DAPT: aspirin 75 mg od + Plavix 75 mg od.
o Statin: atorvastatin 40 or 80 mg od or rosuvastatin 20-40 mg od.
o BB: bisoprolol: 2.5-10 mg od.
o ACEI: ramipril: 2.5-10 mg od.
o Spironolactone: 25 mg od if has LV dysfunction
o Empagliflozin: 10 mg od if has LV dysfunction or DM.
o Torsemide: 10-20 mg od if there is evidence of volume overload.
o PPI: pantoprazole 40 mg od (if has high risk of GI bleeding).
o No anticoagulant after hospital discharge.
 Advices:
o Echocardiography before discharge to be repeated after 6 weeks if has
LV dysfunction.
o Arrange for coronary angiography ± revascularization.
o Recommend annual influenza vaccine.

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

Tachyarrhythmias

Introduction:
 History (e.g, onset of palpitation, recurrence?, Hx of cardiac disease), clinical
examination (BP, SPo2), ECG.
 Identify and treat causes (hypoxia, electrolytes, anemia and acute illness)
 Narrow complex, regular → mostly SVT.
 Narrow complex, irregular → mostly AF.
 Wide complex, regular → mostly VT (till prove otherwise).
 Wide complex, irregular → mostly pre-exited AF.

Tachyarrhythmias treatment:

 HD unstable patient → give DC shock (first give 1 amp /5000 IU UFH IV or 1 mg/kg
Clexane SC and give 2-5 mg IV midazolam and ensure that the patient is sedated
unless is deteriorating rapidly, then use 100 J for regular rhythm (SVT, MVT) and
200 J for irregular rhythm (AF, PVT) if biphasic device, or use 360 J for monophasic
device (or use the maximum dose if unknown). Give synchronized shock if there is
pulse and a synchronized shock if there is no pulse.

HD unstable patient: means presences of hypotension, altered mental status, signs

of shock, ischemic discomfort or AHF.

 HD stable patient:
o If the patient has NCT start with vagal maneuvers (carotid massage
(unilateral application of pressure on carotid sinus for 5 sec) or blowing in a
syringe), if failed →
 Give verapamil (Isoptin: 5-10 mg IV over 2 min, repeat 10 mg twice 30
min apart) if has no history or signs of HF( LVEF > 40%) or
propranolol (Inderal: 1 mg IV over 1 min repeat after 3-5 min up to 3
mg) or Lanoxin (0. 5 mg repeat up to 1.5 mg/24 hr or amiodarone
(300 mg {2 amp} over 1 hr then 10-50 mg/hr {900-1200 mg over 24
hr} for 24 hr) or if failed → give DC shock.

Dilute 2 amp Cordarone in 250 ml 5% dextrose and 6 amp in 500 ml 5% dextrose.

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o If the patient has WCT start with vagal maneuvers or amiodarone and if
failed give DC shock (You can give DC shock from the start if regular or
irregular WCT).
 If the patient has AF and HD unstable (give DC shock), or you want to control the
rate then act as mentioned above with NCT, but if the patient is HD stable and you
decide to restore normal sinus rhythm (in young patients, 1st episode, with normal
LAVI/LA diameter and no comorbidities and evidence of absence of LA thrombi or
patient anticoagulated) then consider the following:
o Give 5000 IU IV UFH before DC shocks or pharmacological cardioversion
o Consider electrical cardioversion (CV) by DC shocks or.
o Consider pharmacological CV by amiodarone (5-7 mg/kg IV infusion over 1 hr
then 50 mg/hr IV for 24 hr OR 150 mg IV over 10 min then 1 mg/min for 6 hr
then 0.5 mg/min foe 18 hr) or by propafenone (Rytmonorm: 450 mg (3 tab)
PO if < 70 kg or 600 mg (4 tab) PO if > 70 kg if patient has no SHD or IHD.
o You can consider (wait and watch) for 24 hr as many patient will revert to
NSR spontaneously.
 If the patient has pre-excited AF (irregular WCT) deliver DC shock after AC.
 If the patient has atrial flutter: manage as AF.

After ER stage: rate or rhythm control in CCU:

 Search and treat any identifiable cause.
 For rate control:
o Give bisoprolol (concor): 2.5-10 mg od po or Lanoxin: 0.25 mg od for
patient with LVEF < or > 40%, or Isoptin 80-240 mg od or bid for patient
with LVEF > 40%.
 For rhythm control:
o Give Cordarone: 400 mg (2 tab) po bid for 2-4 weeks then 200 mg po od
or Rytmonorm: 150 mg po tid up to 300 mg tid if has no SHD or IHD.
 For AF patient give an anticoagulant:
Rivaroxaban: 20 mg od po or apixaban 5 mg po bid or
Marevan: 5-10 mg od po then adjust according to INR for valvular AF
patient or if NOACs are contraindicated/not tolerated.
 Treatment for any comorbidities (HF, IHD, DM).
 Ask for baseline labs (e.g, CBC, serum creatinine, Na, K, TSH).

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Upon discharge:

 For rate control: give Isoptin SR: 120-480 mg od po or concor: 5-10 mg od po or

Lanoxin 0.25 mg po od.
 For rhythm control: give Cordarone: 400 mg bid for 2 weeks then 200 mg od po
or Rytmonorm: 150 mg tid po up to 300 mg tid if patient has no IHD or SHD.
 Anticoagulation: for at least 4 weeks after cardioversion, then assess the need
for anticoagulation according to CHA2DS2VASc score.
 Medications of comorbidities.
 Advice patient to revise a cardiologist/EP specialist for possibility of catheter
ablation or device therapy.

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

Hypertensive crisis

Hypertensive crisis include two categories:

1. Hypertensive urgency: elevated BP with no target organ damage.
 If BP ≥ 180/110 mmHg give oral captopril (25-50 capoten po can be repeated up
to 450 mg daily) and once controlled to < 180/100 mmHg discharge home to be
reviewed at the outpatient clinic (need no admission).
2. Hypertensive emergency: elevated BP with target organ damage (ACS, LVH,
proteinuria, pulmonary edema, encephalopathy/stroke, and aortic dissection).
 For most cases, generally, start IV antihypertensive drug and admit to CCU to
reduce SBP by no > 25% in the 1st hr then to < 160/100 mmHg over the next 6
hr then normalize over the next 24 hr.

In case of specific TOD is diagnosed, consider control according to the TOD:

1. ACS/pulmonary edema: immediate (over 6 hr) reduction of SBP to < 140 mmHg
by nitroglycerin (10 mcg/min increased every 10 min by 10 mcg/min up to 200
mcg/min).
2. HTN encephalopathy: immediate reduction of MAP by 20-25%.

For the following scenarios start the first step and refer to an equipped hospital.
 Aortic dissection: immediate (within 20 min) reduction of SBP to < 120 mmHg
(+HR < 60 bpm) by esmolol or nitroglycerin.
 Ischemic stroke: reduce BP if > 180/110 and eligible to thrombolytic to maintain
BP < 180/105 mmHg for the first 24 hr or if > 220/120 mmHg and not eligible to
thrombolytic by 15% over 24 hr (if < 220/120 and not eligible to thrombolytic don’t
give antihypertensive drugs).
 Hemorrhagic stroke: reduce BP to 140-160 mmHg ideally within 1 hr.
 Eclampsia/preeclampsia: immediate reduction of SBP to < 160 mmHg & DBP <
105 mmHg.

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

Acute decompensated heart failure or pulmonary edema

 History, clinical examination, ECG (ACS, tachyarrhythmias) ± labs ± ECHO.

 Identify and treat precipitating factors (ACS, pulmonary embolism, cardiac
tamponade, infection, tachyarrhythmias, and hypertensive crisis).
 If hemodynamically unstable → refer to an equipped hospital but start supportive
therapy (O2 therapy if SpO2 < 90% or PaO2 < 60 mmHg, if failed, arrange for
transfer to start non-invasive ventilation (NIV) if RR > 25 and Sp02< 90% with
respiratory distress, if failed, proceed to invasive mechanical ventilation and start
inotropes/vasopressors or vasodilators as needed).
 If hemodynamically stable: assess volume status and perfusion:
o If congested (wet) and perfused (warm) patients (as pulmonary edema) →
start IV furosemide (Lasix: 20-40 mg IV or double the daily oral dose and
reassess after 2 hr) and nitroglycerin (10 mcg/min increased every 10 min by
10 mcg/min up to 200).
o If wet or cold patient with SBP > 110 mmHg start IV nitroglycerin ± Lasix.
o If congested (wet) and hypoperfused (cold) patient with hypotension
(cardiogenic shock) → refer.

Then monitor response to diuretic (urine output > 150 ml after 2 hr, if not, increase
furosemide dose).

After ER stage, in CCU start anti-failure drugs:

 Bisoprolol (Concor): 1.25-10 mg od po (or the same dose as pre-admission).

 Ramipril (tritace): 1.25-10 mg od po (if BP tolerate).
 Spironolactone (spectone): 25-50 mg od po (if CrCl > 30 ml/min).
 Empagliflozin (Jardiance): 10 mg od po (if CrCl > 25 ml/min).
 Furosemide (Lasix): 20-40 mg bid IV.
 Plus medications of comorbidities (e.g, IHD, DM).

Upon discharge:
Medications:
 Give medications as prescribed in CCU plus medications of comorbidities.

Advices:

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 Follow up in outpatient clinic after 1-2 weeks to adjust medications doses and to
recheck labs (serum creatinine, potassium level).
 Reduce salt intake.
 Screen for iron deficicncy.

Cardiac arrest

In hospitals with limited resources, and without ICU, advanced airways or mechanical
ventilators, start resuscitation and conduct first aids till ROSC and arrival of ambulance
to be transferred to an equipped hospital.

 Start high-quality compression (CPR), compression for 2 min or for 5 cycles (5 x 30

compressions/2 breaths).
 High quality compression = compression at rate of 100-120/min, with depth
5 cm (not > 6 cm) and allow complete chest recoil after each compression.
 The compressor must perform compression for 2 min or for 5 cycles (5 x {30
compressions/2 breaths}) before change with another compressor but must
change with another compressor earlier if fatigued to ensure HQ
compression.
 If you are unsure about the presence of pulse, start compression
(unnecessary compression less harmful than delayed compression when
needed).
 If no breathing and there is a pulse, start rescue breathing at 1 breath/5-6
seconds and check pulse about every 2 min.
 If no pulse, start HQ compression and check for shockable rhythm.
 Any interruption for defibrillation shock or pulse check must not to exceed 10
sec and for switching the compressors should not to exceed 5 sec.

 History (from relatives), clinical examination, ECG + Lab (all conducted during CPR).
 Establish IV access → identify and treat causes (5 Hs & 5 Ts)) → supportive therapy
(O2 therapy, IV fluids, vasopressor/inotrope/adrenaline).

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ER & CCU Protocol Ahmed Abdelmageed Alfarra

 Check rhythm → if shockable (VT/VF) rhythm → DC shock as early as possible and

start CPR immediately for 2 min & give amiodarone (300 mg IV after the third shock
then 150 mg after 5 min).
 If unshockable rhythm→ continue CPR and reassess/2 min → establish advanced
airway (e.g; laryngeal mask airway or endotracheal tube if possible otherwise
continue o2 therapy though mask).
 Start adrenaline: 1 mg /3 min → ROSC→ give supportive therapy and treat the
cause & consider post-cardiac arrest care (arrange for transfer).

5 Hs = Hypovolemia (IV fluids), Hypoxia (O2), Hydrogen ion/acidosis (NaHco3),

Hypo/hyperkalemia (KCl or Calcium gluconate + insulin-glucose), Hypothermia
(warming), 5 Ts = Tension pneumothorax (needle decompression+ chest tube),
Tamponade (IV fluids + pericardiothentesis), Toxins or drugs (antidote or reversal
agents, activated charcoal), pulmonary Thrombosis (AC± thrombolytic) or
coronary Thrombosis; (Cath lab consultation ± thrombolytic)

References:

 ESC guidelines (each topic from its related guidelines).

 ACC/AHA guidelines (each topic from its related guidelines).
 [Link].
 ACLS provider manual/[Link].

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