Acute Coronary Syndromes and Stroke

Question 1

3 categories of ACS

Answer 1

STEMI
NSTE-ACS
Low/Intermediate-risk ACS

Question 2

Most common symptoms of MI

Answer 2

Retrosternal chest discomfort

• pressure, fullness, squeezing
• Chest discomfort spreading to shoulders, neck, one or both arms, jaw
• Spreading to back or between shoulder blades
• Chest discomfort with light-headedness, dizziness, fainting, sweating, nausea, or vomiting
• Unexplained, sudden shortness of breath

Question 3

ACS mimics

Answer 3

aortic dissection
acute pulmonary embolism (PE)
pericardial effusion with tamponade
tension pneumothorax

Question 4

ACS: step after recognition of symptoms
Step 2
EMS assessment and hospital prep

Answer 4

• ABCs, be prepared to provide CPR and defibrillation
• Admin aspirin
• Consider O2, if sat is less than 90%
• Nitroglycerin
• Morphine (if discomfort unresponsive to nitrates)
• ECG: if STEMI: Notify hospital of STEMI
• Note time of onset and first medical contact
• If considering prehospital fibrinolytic, complete fibrinolytic checklist

Question 5

Dosing of sublingual nitroglycerin

Answer 5

1 sublingual nitroglycerin tablet or spray every 3-5 minutes

• Total of 3 doses allowed
• Administer only if hemodynamically stable (SBP >90, or no lower than 30 below baseline, HR 50-100)

Question 6

CI of nitroglycerin

Answer 6

It is a venodilator and used cautiously or not at all with inadequate ventricular preload.

• Caution with RV or interior MI
• Avoid with Hypotension SBP

Question 7

Step 3: Concurrent ED assessment and initial workup

Answer 7

Check vitals, eval O2 sat
Establish IV access
Brief history and physical
Fibrinolytic checklist
Cardiac markers, electrolyte and coag studies
Portable chest x-ray

Question 8

Step 4: After ED assessment and ED general treatment

Answer 8

ECG interpretation
If STEMI is identified = fibrinolytic checklist

If ST depression or T wave inversion:

• strongly suspicious for ischemia
• NSTE-ACS
• High risk patient or elevated troponin: consider invasive strategy
• Start adjunctive therapies: nitro, heparin

Normal of nondiagnostic ST and T changes
- Consider admission and monitor

Question 9

Goal for patient with STEMI (times to rtPA or PCI)

Answer 9

Reperfusion

• Fibrinolytics within 30 minutes of arrival
• PCI within 90 minutes of arrival

Question 10

CI of aspirin

Answer 10

True aspirin allergy

Active or recent GI bleeding

Question 11

When to transfer ACS to PCI center

Answer 11

Transfer high risk patients who receive fibrinolysis in non-PCI center within 12 hours of symptom onset
- or within 6 hours of fibrinolytic admin

Question 12

ECG characteristic pointing toward administer fibrinolytic agent?

Answer 12

J-point ST-segment elevation greater than 2mm in leads V2 and V3.

• or 1 mm or more in all other leads
• or presumed new LBBB

Question 13

Use of fibrinolytic time frame

Answer 13

Patient with STEMI and onset of symptoms within 12 hours of presentation of ECG finds
- and PCI not available within 90 min of first medical contact.

Question 14

Patients who do not qualify for fibrinolytic treatment: time and ECG characteristics:

Answer 14

To patients who present more than 24 hours after onset of symptoms
- or patients with ST-segment depression unless a true posterior MI is suspected.

Question 15

NSTEM-ACS high risk patients

Answer 15

Refractory ischemic chest discomfort
Recurrent/persistent ST deviation
Ventricular tachycardia
Hemodynamic instability
Signs of heart failure

Question 16

Immediate ED general treatment

Answer 16

• If O2 sat less than 90 start O2 4L/min, titrate
• Aspirin 160-325 mg, if not given by EMS
• Nitroglycerin sublingual or spray
• Morphine IV if discomfort not relieved by nitro