ACLS - Acute coronary syndrome Flashcards
Plaques, also called Atheromas, characteristically occur in regions of
____
branching and/or marked curvature (velocity and direction change)
_____ is the main event that
causes acute presentation of coronary syndromes.
Plaque rupture
Patients with coronary atherosclerosis may develop a spectrum of clinical
presentations, representing various degrees of coronary occlusion. This is called ____
Acute Coronary Syndrome (ACS)
Acute Coronary Syndrome includes the following:
○ ST Elevation ACS (STEMI)
○ Non-ST Elevation ACS (NSTE-ACS)
■ Non-ST Elevation MI (NSTEMI)
■ Unstable Angina
T/F Half of the patients who die of ACS do so before reaching the hospital.
T
Key components and goals of the ACS Algorithm:
○ Rapid identification, assessment, and triage of acute chest pain
○ Initial treatment of possible ACS
○ Emphasis on early reperfusion of the patient with ACS/STEMI
Signs and Symptoms of ACS
● The most common symptom of myocardial
ischemia and infarction is retrosternal chest
discomfort (usually lasts more than for just a few minutes)
Clinical presentation that is also suggestive of ACS:
○ Chest discomfort that is spreading to the shoulders, neck, jaw, or the arms (can
be one or both).
○ Chest discomfort spreading into the back or between the scapula.
○ Chest discomfort with lightheadedness, dizziness, fainting, sweating, nausea, or
vomiting.
○ Unexplained, sudden shortness of breath, which may occur with or without
chest discomfort.
○ Less commonly, some may have epigastric discomfort described as indigestion.
● Diaphoresis with some dyspnea is common.
● An unusual fatigue
It’s also very important to realize that other potentially fatal conditions can
present in the same way (mimicking ACS)
○ Aortic dissection
○ Acute pulmonary embolism (PE)
○ Acute pericardial effusion with Tamponade
○ Tension pneumothorax
EMS Assessment and Care for ACS
○ Monitor and support airway, breathing, and circulation (ABCs).
○ Administer Aspirin and consider oxygen (if O2 saturation is under 90%), nitroglycerin, and morphine (if chest pain is unresponsive to nitro).
○ Obtain a 12-lead EKG and interpret or transmit for interpretation.
■ If there is ST elevation, EMS notifies receiving hospital
○ Especially if ST elevation is present, EMS should complete a prehospital fibrinolytic checklist (more to come) and hospital prepares
Aspirin dosing during EMS assessment and care for ACS
○ A dose of 162-325 mg of non-enteric-coated Aspirin causes near-total and immediate inhibition of platelet thromboxane production
○ This rapidly reduces platelet activation, stopping active thrombus formation and helps prevent coronary reocclusion.
○ Best absorbed if chewed rather than swallowed.
T/F Other than Aspirin, NSAIDs are contraindicated in ACS
T
Oxygen dosing for EMS care with ACS
○ Start oxygen at 4 L/min and titrate oxygen amount to maintain O2 saturation to at least 90%.
Nitroglycerin usage with EMS Assessment and Care for ACS
○ Is known to reduce ischemic chest discomfort and has some beneficial
hemodynamic effects (reduce preload due to vasodilation).
○ Avoid use if hypotensive, bradycardic, or tachycardic
○ Avoid use if recent Phosphodiesterase Inhibitor use
○ Avoid use if Inferior Wall MI and RV infarction
Morphine usage with EMS Assessment and Care for ACS
○ Morphine can be given for chest discomfort that is not responsive to Nitro
■ It produces CNS analgesia, which in turn reduces catecholamine release and
reduces heightened myocardial oxygen demand.
■ It produces vasodilation, decreasing LV preload
■ It decreases peripheral vascular resistance, decreasing LV afterload.
■ Helps redistribute blood in those with pulmonary edema, easing dyspnea
What should be done in the first 10 minutes when a potential ACS patient enters the ER?
● Within the first 10 minutes after arrival, obtain a 12-Lead EKG.
○ The EMS recording can be used if available, or repeating it is common.
○ Assess ABCs, check vital signs, give oxygen if needed
○ Establish IV access
○ Perform a brief, targeted history and physical exam
○ Review/complete a fibrinolytic checklist
○ Obtain initial cardiac marker levels (esp. Troponin)
○ Obtain initial CBC and coagulation studies
○ Obtain a portable Chest X-ray
The results of cardiac markers, CXR, and other labs should not delay reperfusion therapy for a _____ unless clinically necessary
STEMI
What is the relationship between LBBB and Acute MI?
■ ST depression and T wave inversion are commonly seen with a LBBB
○ Because the EKG picture of an evolving MI also includes ST and T wave changes, and because LBBBs are a common consequence of MIs, the
presence of a new or presumably new LBBB must be considered evidence of an acute MI (possibly a STEMI) until proven otherwise
High-risk NSTE-ACS Group
These are the NSTEMIs and Unstable Anginas
○ Evidence of ischemia in the form of ST-segment depression or dynamic T-wave inversion with pain or discomfort.
Low/Intermediate-risk NSTE-ACS Group-
○ Normal or nondiagnostic changes of ST-segment and T-wave.
○ These patients require further risk stratification: Serial cardiac studies
and functional tests are appropriate.
The Four D’s of Delay- These are four major points where delay can occur
■ Door to data (obtaining the EKG)
■ Data to decision (reading the EKG)
■ Decision to drug or PCI
■ Drug or PCI administration
____ is considered the preferred reperfusion therapy for STEMI or new LBBB if available
PCI
The goal for FMC-to-balloon inflation time is ___ minutes
90
What is the backup to PCI reperfusion if it is not available?
fibrinolytics should be considered treatment of
choice in STEMI patients presenting within 12 hours of symptom onset.
○ Examples include Alteplase, Reteplase, and Tenecteplase.
○ The goal for ED door-to-needle time is 30 minutes
Adjunct Therapies to ACLS may be useful when indicated:
○ Unfractionated Heparin or LMWH - Routinely used as adjunct for PCI
and fibrinolytic therapy (read more on page 42 of the book).
○ IV Nitroglycerin - Not routinely used in STEMI, but may be indicated in
some situations
Adjunct therapies that are generally started/recommended for a STEMI or LBBB
by a consulting cardiologist if indicated:
○ Bivalirudin (Angiomax)
○ P2Y12 Inhibitors
○ Beta Blockers
○ Glycoprotein 2b/3a Inhibitors
The presence of ____ differentiates NSTEMI from UA
elevated Troponins
If tPA is going to be administered, the goal is that
it is given within _____
30 minutes of arrival.
● Do not administer anticoagulants or antiplatelet treatment within 24 hours after tPA has been administered.
