CCU SURVIVAL GUIDE

INDEX
1. Basic tips about CCU/ management in CCU
a. Telemetry
b. STEMI patients
c. Patient with swan
d. Hypertensive emergency
e. Code chill
f. LVAD patients
g. Heart Transplant
h. Afib/ RVR
i. Vtach
j. Bradycardia/ Heart block
2. Tips based on primary attending on the case
a. UCG
b. Heart Failure
c. Privates
d. Nights
3. Admissions/ Screens
4. Transfer of Care (downgrade from CCU)
5. Common abbreviations

1. To start, here are some basic tips for you…

Look at telemetry
-Note events and what time they occurred (helps with presentation)
-If you think something is VT, note the rate
-If someone is in afib, note if they are rate controlled
-if unsure if VT vs. A.fib w/ abberancy, ask the fellow!
Check old EKGs for help (bundle blocks)
- remember AIVR (post MI/cath) vs. VT (active ischemia)
-Don’t be fooled by a paced rhythm (which can look wide)
-If there are pauses, note how long the pause is
-always check meds (AV nodal blocking agents – CCB, BB, dig)

For STEMI patients

-Know the lesion that was stented (if there is not a cath report in the computer, it may be
in the chart or the fellow may know)
-What other lesions exist (and what is planned for them)
-Get daily EKGs (and understand how they have evolved over time, i.e. where there
were prior STE there are now Q waves, how does presenting EKG correlate w/culprit
vessel)
-additional meds:? (intergrillin, abxicimab, etc) ask the fellow:
Patients with Swan Ganz Catheter
-Usually this means that Heart Failure is the primary. The Heart Failure attending will
round separately on these patients with you (they also round on patients admitted to
their service on the floors, so it may be later)
-All of these patients should have a daily portable CXR (to keep an eye on swan
position)
-The nurses/fellow should level the patient to get “swan numbers” (see below)
-Calculate a Cardiac Output and Cardiac Index (see below) for all patients with a swan
-usually need VBGs regularly

Hypertensive Emergency
-Nicardipine can usually control BP better than Nitro drip (which is what the ER starts on
most patients)
-Patients should have an A-line if they are on a drip
-If occurs with flash pulmonary edema: Try BIPAP (10/6 starting) and Lasix 40mgIVpush
-Once controlled on drip, start adding back home meds and titrate down drip

Code chill
-Patients are chilled if they have had a VT or VF arrest with ROSC AND are NOT
neurologically intact
-Will often already have appropriate lines from ER, but if not, get them in ASAP as it is
important to start cooling (and more likely to bleed if cold w/o appropriate catheters)
-if patient has IVC filter, may not be able to place cooling catheter!
-There are 2 ways to cool: via a catheter or external pads
-There are very specific instructions that nurses follow for code chill, and most of
them know it well- there is a binder with the info that you can ask the charge nurse
about if you have questions
-Electrolyte repletion is important during chilling process- Q4H labs are done
-Electrolytes are not repleted during rewarming as lytes tend to increase during this time

LVAD Patients
-If patient with an LVAD warrants ICU level care (even if not for a seemingly cardiac
issue), they will be admitted to the CCU
-Heart Failure will be primary
-Treatment will revolve around active issue (sometimes infection, sometimes bleed, etc)
-All LVAD patients will be on a Heparin drip/ Coumadin - necessary with the LVAD
-All blood pressures are taken by nurse with a manual cuff and a Doppler
-Since LVAD is a continuous circulation of blood, there is no true systolic or diastolic
pressure. The MAP is what should be taken as representing the systolic pressure
-A-lines are not helpful in LVAD patients
Heart Transplant
-If patient with a heart transplant warrants ICU level care (even if not for a seemingly
cardiac issue), they will be admitted to the CCU
-Oftentimes this may be for infection since they are on immunosuppressive meds
-Heart Failure will be primary
-Check daily levels of immunosuppressant @ 7AM (just like our renal transplant patients
on floors)- don’t worry about changing these doses- HF attending will do this

Atrial Fibrillation with RVR

-If low BP, may need cardioversion (call fellow ASAP)
-Digoxin can help with rate control without affecting BP (dig can be toxic above 1.2 FYI!)
-If BP can tolerate, consider an Esmolol drip (easy to titrate)
-In general, 5mg IVP Metoprolol can be given to help control rate and is not too high of a
dose to really affect BP (though will only act for short period of time, so need a plan after
this)
-Rule out infection as cause of RVR, if recurrent
-if new onset, think thyroid disease vs. PE

Ischemia
If giving adenosine, start with 6mg IV push (3 if through central line).
-increase to 12mg if doesn’t work.
-Before giving adenosine, hook up to running EKG machine (helpful to see underlying
tachyarrythmia)
Ventricular Tachycardia
-Important to distinguish if sustained vs nonsustained
-Follow ACLS: synchronized cardioversion vs Amiodarone
-If Amiodarone has not helped, can consider Lidocaine (talk with fellow about this)
– Dr. Coromilus will say if ischemia, lidocaine is first line

Heart Block/ Bradycardia

-If heart block is 2nd degree type II or higher, patient will need pacing- start with
transcutaneous pacing using the ACLS machine.
-If Bradycardic, follow ACLS: Atropine then pacing (see pic below)

How to do transcutaneous pacing:

1. Apply pads to front and back of patient (as in a code situation)
2. Consider sedation
3. Set HR to 60-80bpm
4. Set current to 0 mA (can start at 200mA and work down if patient sedated)
5. Turn pacemaker on
6. Increase current by 10mA at a time until capture is achieved
-You will know you have capture when you see the wide QRS complexes from
the pacer and this corresponds to a palpable carotid pulse
7. After you find current that captures, increase to 10mA above it
(See below for a pic of the monitor)
2. General tips organized by who is primary:

UCG
Presentations - UCG usually rounds first, so pre-round on these patients first.
-Make sure you look at telemetry!
-Be prepared to get interrupted and get off track!
-“Subjective” (not really subjective because it includes more):
1. Start with the plan/intervention from the day before and summarize events since.
(e.g. yesterday we uptitrated the meds and patient did well overnight; yesterday 2
stents were placed…)
2. Include telemetry events
3. Quickly go through relevant cardiac meds and current drips
-Objective: vitals, relevant physical exam, new lab abnormalities, troponins (include
peak), EKG
-Assessment and Plan: Be concise and provide specifics on location of STEMI/ what
arrhythmia they have and what was done for it. (e.g. Patient is admitted for anterior
STEMI c/b acute decompensated heart failure with an EF 20%, now s/p DES to proximal
LAD and ICD placement for primary prevention)

HEART FAILURE
Presentations similar to UCG but also include (after vitals):
-Cardiac Output, Cardiac Index (see below to calculate)
-Leveled swan numbers
-I/Os and weight

How to calculate CO and CI

-A VBG must be drawn from the swan (this is because you are actually getting the blood
that is from the pulmonary artery).
-On occasion if a HF patient does not have a swan, they may choose to draw this
number off of the PICC or another central line, but take this with a grain of salt, because
it will not truly represent PA blood.
-VBG O2% from swan- use to calculate CI (this is called the Fick Method):
______________125_____________ x 10
(pulse ox% - VBG O2%) x Hgb x 1.34

-(Divide 125 by [(pulse ox% - VBG O2%) x Hgb x 1.34] THEN multiply by 10 in the end
-Multiply CI by body surface area (BSA) to get the CO- can find BSA at top R corner on
SCM
-Consider using fickcalc.com
-CI above 2.2 is good. If patient is less than 2.2, your attending may want to increase
inotrope support (i.e. Milrinone dose, LVAD, etc)
-Don’t ever change Milrinone dose or LVAD settings without attending/ fellow input
-Check cardiac index 6 hours after an adjustment is made to see the effects
There will be many other equations that the HF attendings talk about, and you will learn about.
-The important thing is to know the basic Fick equation above to start.

Often times HF admissions will be straight from right heart cath (RHC)
-It is helpful to know the swan numbers from this original RHC as you are titrating meds
in the CCU
-If patients are on transplant list, they may be admitted straight from RHC with a swan in
in order to “accrue 1A time”- The gist of this is that they are more likely to get a heart
transplant on 1A time

PRIVATES
Rounds are often informal and may vary depending on who the attending is
- It is IMPORTANT to touch base with them each morning. Ask the bedside nurse to call
you when attending is bedside. On first encounter, get their cell phone #, and ask who
will be rounding the next day and whom to call at night if patient decompensates. You
should NOT have to call the answering service
-Nurses can be your liason. Ask them nicely to call you if attending is bedside, so you
don’t miss the chance to interact with them
-if NO contact with attending, please fill SBAR

Always know who the primary attending is for each patient

-This is key to know before patients are unstable so you know whom to contact
-Always feel free to ask fellows about private patients if there is an emergent situation

If transferring a patient out of CCU, be sure to know what attending the private wants to take
over care on floors

Privates should be contacting you to round in the morning

-If they are not, please submit an SBAR (form in call room and on SAKAI) to the chiefs

NIGHTS
INTEGRAL to morning rounds. Preparing patients for rounds is more manageable when the
night person shares the burden!
-Mostly relevant for UCG rounds. If a UCG patient is admitted overnight, the night
person should be prepared to present all aspects about the patient, as a new admission
-It is an unwritten rule that you should write the daily progress note for patients you
admitted overnight in order to help your day team
-Try to touch base with privates that you are writing notes for before rounds so that you
can sign out a plan to the day residents
-Chip in on the discussion of overnight events during rounds
3. Admissions/Screens
Be sure that a CARDIOLOGIST has accepted the patient to the CCU
-Sometimes you will be called by floor nurses, ER, etc., so be sure that an attending is
aware that you are screening the patient

Call Bed Management (8602) to reserve a bed

-Also call charge nurse for CCU to let them know of patient

Residents do the screens (not the fellows), though fellow will co-sign your note if it is a UCG/
Heart Failure patient

Always let the fellow know if you are worried about a patient (even if it is a private)

Many of the admissions are Code MI

-Always go to the ER when you get a page about a Code MI
- Autopilot: Trend troponins to peak, get post-PCI EKG, AM EKG, ECHO, lipid panel,
A1c, TSH, daily EKG

For all admissions, try to get rhythm strips from EMS if available

If a patient comes from an OSH and you were not made aware that the patient is coming, be
sure to write an SBAR to document this

4. Transferring Care/ Downgrading

If you are the early person, be sure to WRITE AND VERBALIZE a sign out for the call resident
so they can convey what you want done to the night person.

Be sure to let unit clerk AND the patient’s nurse know when a patient is up for transfer
-Don’t forget to put the transfer order in the computer, too

Know who the patient should be transferred to

-UCG: usually transferring to a floor team. Rarely, will assume primary care on floors if
patient is not complicated and likely to be discharged the next day
To MTS on-call: Requires a Transfer note, verbal sign out
To NTS: Requires verbal signout, call bed management to change attending of
record (ask receiving APN for attending name)
-If a private group is accepting the patient, be sure to ask if the Cardiologist is giving sign
out to the private (they really should be the one doing this, but you may need to be the
one to call if not).
 -If a Heart failure patient is downgraded, they stay the attending for the patient. They
usually want their patients on 5T or 6T, so be sure to ask

5. Common Abbreviations/ Terms

● ATP – Anti-Tachycardic Pacing (what a pacemaker does before it delivers a shock)

● IABP – Intra-Aortic Balloon Pump
● LVAD – Left Ventricular Assist Device (best to google this and see pic of how it works)
● PA – Pulmonary Artery
● PCWP – Pulmonary Capillary Wedge Pressure (represents left atrial pressure)
● RA – Right atrium
● PVR – pulmonary vascular resistance
● SVR – systemic vascular resistance
● TPG- transpulmonary gradient
● PAPI – pulmonary artery pressure index
● TVP – transvenous pacemaker
● BTT – bridge to transplant
● DT – destination therapy
● PICC – peripherally inserted central catheter