Acute Coronary Syndrome Algorithm

Question 1

What does the initial care include for a patient with suspected ACS?

Answer 1

Assess:

1. ABC’s, CPR if indicated (CAB’s), Monitor, Defibrillation if indicated
2. Consider MONA protocol (administer ASA if ACS suspected)
3. Obtain 12 Lead, note ST elevation and time of contact

Question 2

What are the 3 possible rhythm interpretations in the ACS algorithm?

Answer 2

1. ST elevation or new BBB
2. ST depression or dynamic T wave inversion
3. Normal or non diagnostic changes in ST segment or T wave

Question 3

Steps to take if rhythm interpretation is ST elevation or new BBB

Answer 3

High index of suspicion for STEMI, transport to cathlab

Question 4

Steps to take if rhythm interpretation is ST depression or T wave inversion

Answer 4

Strongly suspicious for ischemia, high-risk unstable angina, possible non STEMI, transport to cath lab

Question 5

Steps to take for normal or non diagnostic EKG changes

Answer 5

Low/intermediate risk ACS, transport to ED

Question 6

EKG interpretation that represents high risk of a patient with ACS secondary to CAD

Answer 6

1. New or transient ST segment deviation >= 1 mm

2. T wave inversion in multiple precordial leads

Question 7

EKG interpretation that represents moderate risk of a patient with ACS secondary to CAD

Answer 7

1. Fixed Q waves
2. ST depression .5-1mm
3. T wave inversion >1mm

Question 8

EKG interpretation that represents low risk of a patient with ACS secondary to CAD

Answer 8

1. T wave flattening or inversion < 1mm in leads with a dominant R wave
2. Normal EKG

Question 9

A patient that presents with the following history would be considered a high risk of ACS secondary to CAD

Answer 9

C.C. of CPx or left arm Px, known Hx of MI or CAD

Question 10

A patient that presents with the following history would be considered a moderate risk of ACS secondary to CAD

Answer 10

CPx or left arm Px as C.C., >70 yo, Male, Diabetes

Question 11

A patient that presents with the following history would be considered a low risk of ACS secondary to CAD

Answer 11

Probable ischemia even in absence of CPx, left arm pain, <70 yo, non diabetic

Question 12

Immediate general treatment protocol for patients with suspected ACS

Answer 12

MONA

Question 13

Morphine usage in suspected ACS patients

Answer 13

1. Indicated if CPx not relieved by nitro
2. Contraindicated if BP<100
3. Caution in patients with suspected hypovolemia

Question 14

Morphine dosage for STEMI and NSTEMI

Answer 14

STEMI = 2-4mg IV; may give additional 2-8mg up to 10 mg at 5-15 min intervals
NSTEMI = 1-5mg IV only if Px not relieved by nitrates

Question 15

Oxygen usage in suspected ACS patients

Answer 15

Maintain >= 94% O2 sat

Question 16

Nitroglycerin usage in patients with suspected ACS

Answer 16

1. Indicated for suspected ischemic CPx
2. Contraindicated if BP < 100, HR 100, or use of ED drugs in last 48 hrs
3. Caution if drop of 30mm SBP from baseline
4. Obtain right sided EKG in patients with suspected inferior MI or RV infarct due to need for adequate preload

Question 17

Nitro dosage for suspected ACS

Answer 17

SL: .3-.4mg, repeat x 2 at 3-5 min intervals

Question 18

Aspirin usage in suspected ACS patients

Answer 18

1. Indicated for all pts with suspected ACS unless true allergy exists
2. Caution with active peptic ulcer disease, bleeding disorders, severe hepatic disease or Hx of asthma

Question 19

Aspirin dosage

Answer 19

162-324mg oral