Acute Coronary Syndromes




  • Age >18
  • Past medical history
  • MI
  • Angina
  • Diabetes
  • Post-menopausal
  • Medications
  • Erectile dysfunction medications
  • Recent physical exertion
  • Palliation/Provocation
  • Quality (crampy, constant, sharp, dull, etc.)
  • Region/Radiation/Referred
  • Severity (1-10)


Significant Findings:


  • Chest pain/pressure/aching/ tightness
  • Location
  • Substernal
  • Epigastric
  • Arm
  • Jaw
  • Neck
  • Shoulder
  • Radiation of pain
  • Pale/diaphoretic
  • Shortness of breath
  • Nausea/vomiting
  • Dizziness




  • Trauma/medical
  • Angina/MI
  • Pericarditis
  • Pulmonary embolism
  •  Asthma/COPD
  • Pneumothorax
  • Aortic dissection/aneurysm
  • GI reflux/hiatal hernia
  • Esophageal spasm
  • Chest wall injury/pain
  • Pleural pain
  • OD (cocaine/methamphetamine)





  • Oxygen to maintain an O2 sat of ≥ 94%



  • 12 Lead EKG (within 5 min or arrival) transmit questionable 12-Lead's  for physician interpretation.





  • Initiate IV










Positive acute MI


  • STEMI = 1 mm ST segment elevation?


    • Yes




  • Transport with early notification scene time < 15 minutes




  • Consider Normal Saline up to 1,000 mL for inferior MI's/hypotension
  • Consider 2nd IV enroute





  • Notify receiving facility or contact Medical Control and give full oral report including updates since 12-Lead transmission




  • Avoid Nitroglycerin in any patient who has used erectile dysfunction medication (i.e., Viagra or Levitra within 24 hrs. or Cialis within 36 hrs.) due to potential severe hypotension.
  • ACS in the presence of other etiology such as CVA or trauma:
    • DO NOT administers Aspirin or Heparin. Contact Medical Control
  • Nitroglycerin may be repeated at 5-min intervals until pain is relieved (no maximum as long as systolic blood pressure stays above 90).
  • Systolic blood pressure must be greater than 90 for Nitroglycerin administration.
  • Nitroglycerin may be administered without an IV as long as systolic blood pressure is greater than 100 and there is no evidence of an inferior wall MI.
  • Perform a right sided 12-Lead if the patient has an identified inferior MI, or if a right ventricular MI is suspected.
  • If the patient has a suspected right ventricular infarct, Nitroglycerin may be administered in stable patients (blood pressure greater than 120) and after an IV of Normal Saline is established; INT is not acceptable (understanding that a significant blood pressure drop may occur with nitrate administration).
  • Consider Nitroglycerin Paste, 1 gram/1 inch, after 3 SL Nitroglycerin have been administered. Check blood pressure every 5 min.
  • Zofran (Ondansetron) can cause QRS widening.
  • STEMI protocol is for patients older than 18 years old; if under 18 years old,  Contact Medical Control.
  • A STEMI cannot be called in the presence of a paced rhythm or a LBBB unless the LBBB is new.
  • STEMI's typically don't go fast. Consider alternative causes if the heart rate is greater than or equal to 120 beats per minute.
  • Patients with STEMI's should be transported to a PCI capable hospital. Place defib pads on patient and place in a gown if time permits.
  • Diabetics and geriatric patients often have atypical pain (i.e., back pain) or only generalized complaints when having a STEMI.
  • Oxygen may be withheld on the uncomplicated ACS without signs of dyspnea, hypoxemia,dysrhythmias, or heart failure.