ACLS Cases – Acute Coronary Syndrome

• Recognize myocardial infarction
  • Chest pain or discomfort
  • Possibly radiating to the arm, shoulder or jaw
  • Nausea
  • Vomiting
  • Sweating
  • Shortness of breath
• EMS management
  • Support airway, breathing, and circulation
  • Be prepared to provide CPR and defibrillation
  • Administer chewable aspirin if patient not seriously allergic
  • Administer oxygen to maintain the oxygen saturation at or above 94%. O₂ not needed if pulse ox ≥94%
  • Obtain a 12-lead ECG in the field and transmit to the receiving hospital if possible
  • Administer nitroglycerin for ongoing pain
  • Take to hospital that performs percutaneous coronary intervention (PCI), if feasible
• ED management
  • Support airway, breathing, and circulation (establish IV access)
  • Place on cardiac and oxygen monitors
  • Be prepared to provide CPR and defibrillation
  • Administer chewable aspirin if patient not seriously allergic and not already given
  • Administer oxygen to maintain the oxygen saturation at or above 94%. O₂ not needed if pulse ox ≥94%
  • Obtain a 12-lead ECG
  • Administer nitroglycerin for ongoing pain
  • Administer morphine for pain not controlled by nitroglycerin
  • Do a quick assessment and history
  • Obtain lab work (includes cardiac enzymes)
  • Obtain chest x-ray
  • Complete the fibrinolytic checklist if PCI is not available
• Goals of Care
  • Reduce myocardial cell death
  • Preserve left heart systolic function
  • Prevent heart failure
  • Limit cardiac complications
  • Treat/avoid life-threatening complications,e.g., VFib and VTach

Low/Medium Risk ACS

• Observation in chest pain unit
• Serial cardiac markers and serial ECGs
• Consider noninvasive test: stress testing
• If ECG changes or cardiac markers elevate, reevaluate for PCI
• Discharge after observation with appropriate cardiac follow-up

Unstable Angina or NSTEMI

• ST depression or T wave inversion
• Troponin elevation
• Add heparin, statin, and ACEinhibitor
• Consider beta blocker, clopidogrel, glycoprotein IIb/IIIa inhibitor
• Admission to cardiac telemetry
• Consult cardiology for further risk stratification (e.g., non-emergent PCI)

STEMI

• Emergent/urgent percutaneous coronary intervention (PCI) is preferred
  • Angiogram
  • Balloon angioplasty
  • Stent placement
  • Admit to ICU/cardiac telemetry
• Fibrinolytic reperfusion therapy is recommended if PCI is unavailable
  • Complete fibrinolytic checklist
  • Administer tissue plasminogen activator (tPA) and admit to ICU