Emergency Department Note Template

BIBA after witnessed cardiac arrest at home. Wife initiated CPR immediately. EMS arrived at 6 min, found patient pulseless with VFib rhythm on monitor. Defibrillated x3, ROSC achieved at 12 min post-arrest. Given aspirin 325 mg PO, heparin 4000 U IV en route. Transport time 14 min.

Airway: intubated with 7.5 ETT (EMS, 22 cm at teeth), bilateral breath sounds confirmed.

Breathing: ventilator-assisted, SpO2 96% on FiO2 40%.

Circulation: BP 98/62 (on norepinephrine 0.05 mcg/kg/min), HR 102 irregular.

Disability: GCS 3T (sedated), pupils 3mm equal and reactive.

Exposure: exposed for exam, temperature 97.8 F (post-ROSC cooling).

Sinus tachycardia ~100 bpm. STEMI pattern: ST elevation 3mm in II, III, aVF with reciprocal depression in I, aVL. Suggests inferior wall MI, likely RCA occlusion.

Troponin I: 2.84 ng/mL (elevated, consistent with acute MI)

BNP: 485 pg/mL

CBC: WBC 14.2, Hgb 13.8, Plt 212

BMP: K 4.0, Cr 1.3 (baseline 1.1), lactate 4.2

Coag: INR 1.0, PTT 28

ABG (on vent): pH 7.32, pCO2 38, pO2 88, HCO3 19

Cardiac: reduced EF visually estimated 35-40%, inferior wall hypokinesis. No pericardial effusion. IVC dilated, non-collapsable.

Witnessed VFib cardiac arrest → ROSC at 12 min. Inferior STEMI on EKG. Post-cardiogenic shock on single pressor. High-risk patient — needs emergent revascularization.

1. Dual antiplatelet: aspirin + ticagrelor 180 mg load

2. Anticoagulation: heparin infusion started (goal PTT 50-70)

3. Pressor support: norepinephrine titrated to MAP >65

4. Targeted temperature management initiated (33 C target)

5. Cardiology paged STAT — cath lab activated

6. Foley placed, UO monitoring started

Emergent cardiac catheterization lab activation for primary PCI. Patient accompanied by ED physician + RN to cath lab. Handoff completed using I-PASS format. Estimated door-to-balloon time: 42 minutes.