JNC 8

9 RECOMMENDATIONs

Thrombolysis in STEMI

• Patients with STEMI and onset of symptoms within 12 hours if PCI delay > 120 minutes (class I)
• Patients with STEMI and onset of symptoms between 12-24 hours if continued symptoms or ECG changes and PCI unavailable (class IIa) 

 Door to needle time <30 minutes
 Not indicated for patients with ST depression

Absolute contraindications for fibrinolytic use in STEMI include the following:^[16]

• Prior intracranial hemorrhage (ICH)
• Known structural cerebral vascular lesion
• Known malignant intracranial neoplasm
• Ischemic stroke within 3 months
• Suspected aortic dissection
• Active bleeding or bleeding diathesis (excluding menses)
• Significant closed head trauma or facial trauma within 3 months
• Intracranial or intraspinal surgery within 2 months
• Severe uncontrolled hypertension (unresponsive to emergency therapy)
• For streptokinase, prior treatment within the previous 6 months

Relative contraindications for fibrinolytic use in STEMI include the following:^[16]

• History of chronic, severe, poorly controlled hypertension
• Significant hypertension on presentation (systolic blood pressure > 180 mm Hg or diastolic blood pressure > 110 mm Hg
• Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation (CPR) or major surgery less than 3 weeks previously
• History of prior ischemic stroke not within the last 3 months
• Dementia
• Recent (within 2-4 weeks) internal bleeding
• Noncompressible vascular punctures
• Pregnancy
• Active peptic ulcer
• Current use of an anticoagulant (eg, warfarin sodium) that has produced an elevated international normalized ratio (INR) higher than 1.7 or a prothrombin time (PT) longer than 15 seconds

Well Score for DVT and Pulmonary Embolism

TIMI (Thrombolysis in Myocardial Infarction)

Modified Early Warning Score (MEWS)

Score	3	2	1	0	1	2	3
Systolic BP	<45%	30%	15% down	Normal for patient	15% up	30%	>45%
Heart rate (BPM)	—	<40	41-50	51-100	101-110	111-129	>130
Respiratory rate (RPM)	—	<9	—	9-14	15-20	21-29	>30
Temperature (°C)	—	<35	—	35.0-38.4	—	>38.5	—
AVPU	—	—	—	A	V	P	U

A score >= 5 is statistically linked to increased likelihood of death or admission to an ICU

Early Goal-Directed Therapy in Sepsis

In hypotension persists despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl), goals in the first 6 hours of resuscitation include:

• CVP of 8-12 mmHg. Mechanical ventilation, increased abdominal pressure, and preexisting impaired ventricular compliance may require higher CVP targets of 12-15 mmHg^[5]

• Superior vena oxygen saturation (ScvO2) of > 70% OR mixed venous oxygen saturation (SvO2) of > 65%. If initial fluid resuscitation fails to achieve adequate oxygen saturation additional options include dobutamine infusion (maximum 20 µg/kg/min) or transfusion of packed red blood cells to a hematocrit ≥ 30%. If a ScvO2 is unavailable, lactate normalization may be used as a surrogate marker. A reduction in lactate by ≥ 10% is noninferior to achieving a ScvO2 of ≥ 70% ^[6]

• Achieve MAP ≥ 65mmHg^[5] The presence of atherosclerosis or pre-existing uncontrolled hypertension may necessitate a higher MAP target.
• Achieve Urine output ≥ 0.5 mL/kg/h^[5]

Successful targeting the above goals in the first 6-hour period results in a 15.9% absolute reduction in 28-day mortality rate.