Acute Coronary Syndrome

Question 1

ACS Treatment

Answer 1

ASA 324mg PO

Immediate 12-lead. (if inferior MI or ST Dep in contiguous leads, perform Right Sided and Posterior (15-lead). Repeat if pt condition changes.

If suspected STEMI, notify ER and transmit EKG.

Immediately initiate transport to STEMI ER

Consider 50mcg Fentanyl IV/IM for pain. Repeat every 5 min as needed.

If SBP < 90: 500mL fluid bolus. Repeat to titrate SBP >90.

Question 2

Obtain Right Sided and Posterior (15-lead) if:

Answer 2

Inferior MI or ST Depression in contiguous leads.

Question 3

Acute Coronary Syndrome Pain Treatment

Answer 3

Fentanyl 50mcg IV/IM. Repeat every 5 minutes if needed.

Question 4

Hypotension in ACS (SBP < 90) treatment

Answer 4

500mL fluid bolus IV/IO. May repeat to titrate SBP >90.

Question 5

(ACS PEARLS) Attention should be directed at:

Answer 5

1. Early recognition of STEMI
2. Early notification of receiving hospital
3. Early initiation of transport

Question 6

(ACS PEARLS) Should we keep patient connected to our 12-lead at ED bedside?

Answer 6

If possible, yes.

Question 7

(ACS PEARLS) STEMI is characterized by:

Answer 7

Greater than 1mm elevation in 2 contiguous leads.

Question 8

(ACS PEARLS) No additional ASA dosing is indicated for patients that self-medicated with ASA at 324mg within the prior ____ hrs.

Answer 8

12 hours

Question 9

(ACS PEARLS) Consult OLMCP prior to administration of Fentanyl if SBP is…

Answer 9

SBP less than 90.

Question 10

ACS Indications for 15-lead

Answer 10

A. Initial 12-lead shows inferior MI
B. Initial 12-lead shows ST elevation in V1
C. ST depression in V1-V3
D. Patients complaining of significant cardiac type chest pain or other symptoms but normal 12-lead.
E. Any patient where the medic suspects the presence of MI with RV or posterior involvement.

Question 11

ACS 15-lead Procedure

Answer 11

A. Unsnap V4-V6.
B. Place V4 at 5th intercostal space, mid clavicular line, right side. This becomes V4R.
C. Place electrodes on V5,V6.
D. V5 becomes V8 and is placed on 5th intercostal space, mid scapular line.
E. V6 becomes V9 and is placed on 5th intercostal space, between V8 and the spine.
F. Once leads are applied, perform another 12-lead.
G. Assess for ST elevation in V4R, V8, V9 and treat appropriately.
H. Label the print out to show it is Right sided and posterior.

Question 12

ACS. Up to 50% of patients with an inferior MI may also have _____ ___________ infarction or ischemia and the use of ____________ should be _______.

Answer 12

Right Ventricular, vasodilators, avoided

Question 13

ACS. Approximate 15-20% of all MI’s involve posterior wall of the left ventricle and when found in conjunction with an inferior or lateral wall MI, mortality is significantly _________.

Answer 13

Increased.

Question 14

ACS. Up to 11% of all MI’s are thought to be isolated ________ wall MI’s.

Answer 14

posterior

Question 15

12-leads should be performed early in patients experiencing arrhythmias. These include:

Answer 15

Bradycardia, tachycardia, or irregular rhythms.

Question 16

True/False. A patient experiencing an arrhythmia should remain on the monitor throughout the course of care.

Answer 16

True.

Question 17

Clinical instability is a combination of…

Answer 17

Vital signs, patient symptoms, and clinical impression.

Question 18

EMS should consider a patient unstable if SBP in the adult is <____ or in pedi’s the SBP <____ and any of the following: (4)

Answer 18

<90, <70+(2 x age in years)

Altered mental status
Chest pain
Dyspnea
Syncope

Question 19

Transplanted hearts are not responsive to _______.
_ _ _ is the treatment of choice.

Answer 19

Atropine.
TCP (Pacing)

Question 20

Bradycardia in the 40-60bpm range may be seen in patients with cerebral injuries or CVA. In these patients the bradycardia will usually be accompanied by hypertension and should not be treated with _______ or ______ as the hypertension and ICP will worsen.

Answer 20

Atropine, pacing

Question 21

Bradycardia in the presence of MI is first treated with…

Answer 21

a fluid bolus of 500mL.

Question 22

Consult the _____ for a _____ patient in profound Bradycardia (HR<40) about the use of Atropine or TCP to prevent decompensating into Bradycardic PEA or Asystole.

Answer 22

OLMCP, STEMI

Question 23

In the absence of hypovolemia, the priority of care in tachydysrhythmias is ____ _______.

Answer 23

rate control.

Question 24

Non-sustained V-Tach is VT less than ___ seconds duration.

Answer 24

30 seconds

Question 25

Sustained VT is over ___ seconds.

Answer 25

30 seconds.

Question 26

Valsalva Maneuver steps:

Answer 26

1. Position patient sitting up at 45deg angle.
2. Ask patient to blow into tip of 10mL syringe for 15 seconds.
3. Immediately lower the head of the stretcher flat AND elevate patient’s legs at 45deg angle at the hips for 15 seconds.
4. Return the patient to a sitting position for 30 seconds.

Question 27

If Postural Valsalva Maneuver is unsuccessful, do what?

Answer 27

Encourage the patient to tighten their abdominal muscles or to “bear down.” Carotid massage is not advised.

Question 28

Specific arrhythmias should be treated according to their presentation. If unable to identify a wide complex arrhythmia, do what?

Answer 28

Transmit ECG to OLMCP for physician interpretation.