Acute Coronary Syndromes

 

History:

 

  • 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
  • Time of onset

 

Differential:

 

  • 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)

 

Treatment:

 

  • 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
  • if SBP ≥ 90 consider Morphine 2 mg IV increments for pain relief Max 10 mg OR Fentanyl 2 mcg;kg slow IV, repeat once in 5 minutes. Max single dose 100 mcg.

 

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
  • if responsive and alert give Heparin 5,000 units IV
  • If unresponsive contact Medical Control prior to Heparin 5,000 units IV administration
  • Notify receiving facility or contact Medical Control and give full oral report including updates since 12-Lead transmission

 

PEARLS:

 

  • 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 100 for Nitroglycerin administration if 12 Lead EKG and peripheral IV are not available. Blood Pressure must be obtained again prior to additional administration of Nitroglycerin.
  • Heparin MUST be withheld if any physical or possible signs or trauma are found. Contact Medical Control.
  • Perform a right sided 12-Lead if the patient has an identified inferior MI, or if a right ventricular MI is suspected.
  • 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.
  • Patients short of breath should be administered high flow Oxygen regardless of O2 saturation.