Chest Pain/STEMI Administrative Guideline

Question 1

History

Answer 1

• Age
• Medications (Viagra / sildenafil,
• Levitra / vardenafil, Cialis / tadalafil)
• Past medical history (MI, Angina,
• Diabetes, post menopausal)
• Recent physical exertion

Question 2

Signs and Symptoms

Answer 2

• CP (pain, pressure, aching, vice-like
• tightness)
• Location (substernal, epigastric, arm,
• jaw, neck, shoulder)
• Radiation of pain
• Pale, diaphoresis
• Shortness of breath
• Nausea, vomiting, dizziness
• Time of onset

Question 3

Differential

Answer 3

• Angina vs. Myocardial infarction
• Pericarditis
• Pulmonary embolism
• Asthma / COPD
• Pneumothorax
• Aortic dissection or aneurysm
• GE reflux
• Chest wall injury or pain
• Pleural pain

Question 4

Nontraumatic chest pain or

anginal equivalent <18

Answer 4

Obtain 12 Lead ECG and consider transport per SAEMS Critical Pediatric Triage Protocol

Question 5

Nontraumatic chest pain or
anginal equivalent >18
BLS steps

Answer 5

If dyspnea or hypoxemic administer oxygen
and titrate to maintain SaO2 of 94%
Administer aspirin 324 mg PO (chewed)
Consider assisting patient with administration of own
nitroglycerin 0.4 mg SL tablets or one full spay
if SBP > 110 mm Hg
Repeat every 5 minutes until pain relieved or to a max of 3 doses

Question 6

Nontraumatic chest pain or
anginal equivalent >18
ALS steps

Answer 6

Consider administration of nitroglycerin 0.4 mg SL tablets if SBP > 110 mm Hg
Repeat every 5 minutes until pain relieved or to a max of 3 doses
Consider morphine 0.1 mg/kg IV/IO
2-5 mg increments every 5 minutes, to a max total dose 20 mg.
Hold for hypotension
Administer 250 mL NS/LR fluid bolus for SBP < 110
May repeat as needed
If nauseated administer ondansetron 4 mg IV

Question 7

What constitutes a STEMI alert?

Answer 7

(STEMI = 1 mm ST segment

elevation in 2 or more contiguous limb leads or 2 mm elevation in precordial leads

Question 8

IF STEMI then?

Answer 8

Obtain second IV

Transport patient to Cardiac Receiving Center

Question 9

CHF exacerbation/

pulmonary edema on exam

Answer 9

Consider CHF/Fluid Overload AG if indicated

Question 10

STEMI diagnostic criteria for limb leads

Answer 10

Anginal symptoms plus one of the following:
- 1 mm ST elevation in 2 or more contiguous limb leads (I, II, III, avF, aVR, aVL) and reciprocal ST
depressions

Question 11

STEMI diagnostic criteria for precordial leads

Answer 11

Anginal symptoms plus one of the following:

- 2 mm ST elevation in 2 or more precordial leads (V1-V6) and reciprocal ST depressions

Question 12

STEMI treatment and timing goals

Answer 12

• Obtain and transmit ECG within 5 minutes
• Provide STEMI alert within 10 minutes
• Time at scene less than 15 minutes

Question 13

What about morphine?

Answer 13

Morphine provides analgesia but offers no survival benefit. Morphine should be used with caution in unstable angina/non-STEMI due to an association with increased mortality.

• Monitor for hypotension after administration.
• Opioids may be repeated per dosing guidelines.