ACLS - Acute coronary syndrome Flashcards

1
Q

Plaques, also called Atheromas, characteristically occur in regions of
____

A

branching and/or marked curvature (velocity and direction change)

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2
Q

_____ is the main event that
causes acute presentation of coronary syndromes.

A

Plaque rupture

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3
Q

Patients with coronary atherosclerosis may develop a spectrum of clinical
presentations, representing various degrees of coronary occlusion. This is called ____

A

Acute Coronary Syndrome (ACS)

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4
Q

Acute Coronary Syndrome includes the following:

A

○ ST Elevation ACS (STEMI)
○ Non-ST Elevation ACS (NSTE-ACS)
■ Non-ST Elevation MI (NSTEMI)
■ Unstable Angina

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5
Q

T/F Half of the patients who die of ACS do so before reaching the hospital.

A

T

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6
Q

Key components and goals of the ACS Algorithm:

A

○ Rapid identification, assessment, and triage of acute chest pain
○ Initial treatment of possible ACS
○ Emphasis on early reperfusion of the patient with ACS/STEMI

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7
Q

Signs and Symptoms of ACS

A

● The most common symptom of myocardial
ischemia and infarction is retrosternal chest
discomfort (usually lasts more than for just a few minutes)

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8
Q

Clinical presentation that is also suggestive of ACS:

A

○ 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

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9
Q

It’s also very important to realize that other potentially fatal conditions can
present in the same way (mimicking ACS)

A

○ Aortic dissection
○ Acute pulmonary embolism (PE)
○ Acute pericardial effusion with Tamponade
○ Tension pneumothorax

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10
Q

EMS Assessment and Care for ACS

A

○ 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

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11
Q

Aspirin dosing during EMS assessment and care for ACS

A

○ 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.

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12
Q

T/F Other than Aspirin, NSAIDs are contraindicated in ACS

A

T

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13
Q

Oxygen dosing for EMS care with ACS

A

○ Start oxygen at 4 L/min and titrate oxygen amount to maintain O2 saturation to at least 90%.

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14
Q

Nitroglycerin usage with EMS Assessment and Care for ACS

A

○ 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

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15
Q

Morphine usage with EMS Assessment and Care for ACS

A

○ 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

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16
Q

What should be done in the first 10 minutes when a potential ACS patient enters the ER?

A

● 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

17
Q

The results of cardiac markers, CXR, and other labs should not delay reperfusion therapy for a _____ unless clinically necessary

A

STEMI

18
Q

What is the relationship between LBBB and Acute MI?

A

■ 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

19
Q

High-risk NSTE-ACS Group

A

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.

20
Q

Low/Intermediate-risk NSTE-ACS Group-

A

○ Normal or nondiagnostic changes of ST-segment and T-wave.
○ These patients require further risk stratification: Serial cardiac studies
and functional tests are appropriate.

21
Q

The Four D’s of Delay- These are four major points where delay can occur

A

■ Door to data (obtaining the EKG)
■ Data to decision (reading the EKG)
■ Decision to drug or PCI
■ Drug or PCI administration

22
Q

____ is considered the preferred reperfusion therapy for STEMI or new LBBB if available

A

PCI

23
Q

The goal for FMC-to-balloon inflation time is ___ minutes

A

90

24
Q

What is the backup to PCI reperfusion if it is not available?

A

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

25
Q

Adjunct Therapies to ACLS may be useful when indicated:

A

○ 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

26
Q

Adjunct therapies that are generally started/recommended for a STEMI or LBBB
by a consulting cardiologist if indicated:

A

○ Bivalirudin (Angiomax)
○ P2Y12 Inhibitors
○ Beta Blockers
○ Glycoprotein 2b/3a Inhibitors

27
Q

The presence of ____ differentiates NSTEMI from UA

A

elevated Troponins

28
Q

If tPA is going to be administered, the goal is that
it is given within _____

A

30 minutes of arrival.
● Do not administer anticoagulants or antiplatelet treatment within 24 hours after tPA has been administered.