Acute Coronary Syndrome, Angioplasty & T-LoC

Question 1

Acute Coronary Syndrome (ACS)

Answer 1

Sudden ischaemic (restriction blood supply to tissue) disorders of the heart include: Unstable Angina & Acute Myocardial Infarction
Represent a continuum of a similar disease process.

Question 2

Unstable Angina

Answer 2

Angina of effort increasing frequency & provoked by less excitation.
Angina occurring recurrently & unpredictably (not specific to exercise).
Unprovoked & prolonged episode of chest pain - no ECG or laboratory evidence of MI.

Question 3

Acute Myocardial Infarction

Answer 3

A process of death or damage to an area of the myocardium.
Occurs when a coronary artery becomes blocked or significantly narrowed.
This is due to spasm, atheroma (arterial wall damage) or thrombus (blood clot).

Question 4

ACS Signs and symptoms

Answer 4

Central pain in the chest and constricting in nature.
It may present in the shoulders and/or the upper abdomen.
May be referred to the neck, jaws and arms.
Pain will be persistent.
Indigestion type pain: typical in some parts of London.
Female presentation often differs: fatigue, heavy arm, neck pain, indigestion.

Question 5

ACS aims

Answer 5

Reduction of myocardial necrosis in patients with ongoing infarction.
Prevention of major adverse cardiac events.
Rapid defibrillation when VF occurs.

Question 6

ACS

Answer 6

All have sudden ischaemia.
Can not be differentiated in the first few hours.
All have the same initiating events.

Question 7

ACS initiating events

Answer 7

Plaque rupture.
Thrombus formation.
Vasoconstriction (blood vessel walls contracting).

Question 8

Diagnosis

Answer 8

Clinical Presentation.
ECG changes.
Cardiac Markers.
Angiographic evidence.

Question 9

Time is life

Answer 9

for every 30 minutes of occlusion. 1 year of life is lost.

1 minute = 11 days.

Question 10

Treatment for ACS

Answer 10

Primary survey assessment and correction.
Monitor closely, O2 if the patient is hypoxic.
Entonox as required.
Paramedic GTN & Aspirin 300mg.
Where appropriate remove to the ambulance at this stage, avoid patient exertion.
12 lead ECG monitor cardiac rhythm and base obs.
N.B. pain assessment before and after analgesia.
Hospital pre-alert (blue call).
Continue further treatment en route.

Question 11

target time on scene with ACS patient

Answer 11

no more then 10 minutes.

Question 12

TLoc

Answer 12

A brief loss of conciousness that is caused by a temporary reduction of oxygenated blood flow to the brain.

Also termed as Vaso-Vagal attack, Syncope or Faint.

Question 13

TLoC three main causes

Answer 13

Postural Syncope
Emotional Stress
Cardiac Arrhythmias (abnormal hear rhythms)

Question 14

Postural Syncope - causes

Answer 14

often occurs when a patient sits or stands quickly from a recumbent position.
Prolonged periods of standing, particularly in hot weather.
Athletes are vulnerable when standing still suddenly after vigorous activity.

Question 15

Emotional Stress - causes

Answer 15

Usually precipitated by stress or fright which causes a reflex dilation of blood vessels and results in pooling of blood in the limbs.

Question 16

Cardiac Arrhythmias - causes

Answer 16

Due to a transient decrease in cardiac output as a result of severe bradycardia (BPM ) which diminishes cardiac output.
Usually resolves itself when the arrhythmia settles.

Question 17

TLoC Red Flags: these patients should go to hospital

Answer 17

ECG abnormality.
Signs or history consistent with heart failure (breathlessness, bi-basal crackles on auscultation of the lungs, relevant medications, oedema, SOB on exertion, orthopnoea (Dyspnoea [SOB] while lying flat) etc.)
TLoC on exertion
Family History of sudden cardiac death in people aged who did not experience prodromal (show signs indicating an attack about to happen) symptoms.

Question 18

TLoC - signs and symptoms

Answer 18

Pulse feeble and slow, changing to feeble and fast.
Skin pale, cold and clammy.
Pupils equal and dilated.
Breathing shallow to normal.
LoC
Usually of sudden onset.
Often preceded by feeling giddy, cold sweat, abdominal discomfort and blurred vision.

Question 19

TLoC - General management

Answer 19

Primary survey.
Ensure open airway.
AVPU.
Appropriate oxygen therapy.
Loosen any tight clothing but maintain patients modesty.
Treat any injuries.
12 lead ECG.
Monitor for any change in condition.
Reassurance.

Question 20

TLoC - management of concious patient

Answer 20

Keep patient recumbent to facilitate cerebral perfusion.
Elevate lower limbs where possible.
Encourage patient to remain in recumbent position.
Transport as a stretcher case.

Question 21

TLoC - management of unconscious patient

Answer 21

Place patient in stable-side position.

Ensure open airway.

Question 22

TLoC recovery

Answer 22

TLoC is normally of a brief duration.
Delayed recovery could mean a more serious condition.
All unexplained and prolonged recovery TLoC should go to hospital.
May, on a rare occasion, be a precursor to sudden death.