Cardiac Ischemia Medical Directive

Question 1

Cardiac Ischemia Medical Directive

Answer 1

A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if authorized.

Question 2

Indications

Answer 2

Suspected cardiac ischemia.

Question 3

Conditions - ASA

Answer 3

Age: 18 years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: Able to chew and swallow.

Question 4

Conditions - Nitroglycerin

Answer 4

Age: ≥18 years
LOA: Unaltered
HR: 60-159 bpm
RR: N/A
SBP: Normotension
Other: Prior history of nitroglycerin use OR IV access obtained

Question 5

Contraindications - ASA

Answer 5

Allergy or sensitivity to NSAIDS
If asthmatic, no prior use of ASA
Current active bleeding
CVA or TBI in the previous 24 hours

Question 6

Contraindications - Nitroglycerin

Answer 6

Allergy or sensitivity to nitrates
Phosphodiesterase inhibitor use within the previous 48 hours
SBP drops by one-third or more of its initial value after nitroglycerin is administered.
12-lead ECG compatible with Right Ventricular MI

Question 7

Treatment

Answer 7

Consider ASA
Consider 12-lead ECG acquisition and interpretation for STEMI
Consider nitroglycerin

Question 8

Consider ASA

Answer 8

Route: PO
Dose: 160-162 mg
Max. single dose: 162 mg
Dosing interval: N/A
Max. # of doses: 1

Question 9

Consider nitroglycerin

Answer 9

STEMI - No:
SBP ≥100 mmHg
Route: SL
Dose: 0.3 mg OR 0.4 mg
Max. single dose: 0.4 mg
Dosing interval: 5 min
Max. # of doses: 6

STEMI - Yes:
SBP ≥100 mmHg
Route: SL
Dose: 0.3 mg OR 0.4 mg
Max. single dose: 0.4 mg
Dosing interval: 5 min
Max. # of doses: 3

Question 10

Clinical Considerations

Answer 10

Suspect a Right Ventricular MI in all inferior STEMIs and perform at minimum V4R to confirm (ST-elevation ≥1mm in V4R).
Do not administer nitroglycerin to a patient with Right Ventricular STEMI.
IV condition applies only to PCPs authorized for PCP Autonomous IV.
Apply defibrillation pads when a STEMI is identified.
The goal for time to 12-lead ECG from first medical contact is <10 minutes where possible.