Cardiac Ischemia Medical Directive

Question 1

What are the indications for the cardiac ischemia MD?

Answer 1

Suspected cardiac ischemia.

Question 2

Ischemia

What are the conditions for ASA?

Answer 2

Age ≥18 years
LOA - Unaltered
Other - Able to chew and
swallow

Question 3

Ischemia

What are the conditions for nitroglycerin?

Answer 3

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

Question 4

Ischemia

What are the contraindications for ASA?

Answer 4

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

Question 5

Ischemia

What are the contraindications for nitroglycerin?

Answer 5

• 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 6

Ischemia

What is the order of treatment for the cardiac ischemia MD?

Answer 6

1. Consider ASA
2. Consider 12-lead ECG acquisition and interpretation for STEMI
3. Consider nitroglycerin

Question 7

Ischemia

What is the dose for ASA?

Answer 7

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

Question 8

Ischemia

What is the non-STEMI nitro dosing info?

Answer 8

SBP must be ≥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

Question 9

Ischemia

What is the STEMI positive nitro dosing info?

Answer 9

SBP must be ≥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

Ischemia

What are the 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.