Algorithm for emergency care for Acute Coronary Syndrome

Algorithm for Acute Coronary Syndrome

Client discomfort suggestive of Ischemia

↓

1.      EMS assessment and care and hospital preparation:

·         Monitor, support (ABC) Airway, Breathing, Circulation .  Be prepared to provide CPR and defibrillation

·         Administer Oxygen, Aspirin, Nitroglycerine, and Morphine if needed

·         If available, obtain 12-lead ECG, If S-T elevation:

          Notify receiving hospital with transmission or interpretation

          Begin fibrinolytic checklist

·         Notified hospital should mobilize hospital resources to respond to ST Elevation MI

2.1 

Immediate Emergency assessment

 (done inless than 10 min)

·         Check Vital signs; evaluate oxygen saturation

·         Establish IV access

·         Obtain/review 12 lead ECG

·         Perform brief, targeted history; Physical exam

·         Review/complete fibrinolytic checklist, check contraindications

·         Obtain initial cardiac mark levels, initial electrolyte and coagulation studies

·         Obtain Portable Chest X-ray (<30 min)

2.2 

Immediate Emergency General Treatment:

·         Start Oxygen at 4L /min, maintain O2 sat>90%

·         Aspirin 160-325 mg (if  not given by EMS)

·         Nitroglycerine sublingual, spray, or IV

·         Morphine IV if pain not relieved by nitroglycerine

3. Review 12 Lead  ECG

4.1

ST ELEVATION MI

(means complete blockage of the artery)  or new/presumably new Left Bundle Branch Block; strongly suspicious for injury ST-elevation MI

4.2   

ST DEPRESSION

Or dynamicall T wave inversion;

Strongly suspicious of Ischemia

High-risk Unstable Angina

Non ST-Elevation MI

4.3

Normal or non diagnostic changes in ST segment or T-wave

Intermediate/ Low risk UA

5.1

Start Adjunctive treatments as indicated:

·         Do not delay mechanical reperfusion

·         Pharmacologic Therapy:

Thromblytic Therapy

B-adrenergic receptor blockers

Clopidogrel

Heparin /Aspirin

Nitroglycerine

ACE Inhibitors

5.2

Start Adjunctive treatments as indicated:

·         Do not delay reperfusion

·         Nitroglycerin

·         B-Adrenergic Receptor Blockers

·         Clopidogrel

·         Heparin

·         Glycoprotein IIb/IIIa inhibitor

5.3

Develops high or intermediate risk criteria:

If Troponin (+)

← follow directions in 5.2

If Troponin (-)

 go to 6.3

↓

6.1

 If less than 12 hours of onset

MECHANICAL  REPERFUSION

Therapy defined by the patient center criteria:

BE AWARE OF REPERFUSION GOALS:

·         (PCI) Door- to-ballon inflation (Angioplasty) goal=90 min

·         Door-to needle (Fibrinolysis) = goal=30 min

Continue adjunctive therapies and:

ACE Inhibitors/angiotensin receptor blocker (ARB) within 24 hours of symptom onset

HMG CoA reductase inhibitor

(statin therapy

6.2

Admit to monitored bed

Assess risk status

High risk Patient:

·         Refractory ischemic chest pain

·         Recurrent/persistent ST deviation

·         Ventricular Tachycardia

·         Hemodynamic Instability

·         Signs of pump failure

·         Early invasive strategy including catheterization and revascularization for shock within 49 hours of an Acute MI.  Continue ASA, Heparin, and other therapies as indicated

·         ACE Inhibitors /ARB

·         HMG CoA reductase INhiitor (statin therapy)

·          

Not at high risk: Cardiology to risk t stratify

6.3

Consider admission to ED chest pain unit or to monitored bed in ED

Follow:

Serial Cardiac markers (including Troponin)

Repeat ECG/continous ST segment monitoring

Consider Stress test

6 .1.2

 If more than 12 hours of onset:

Follow 6.2         →

7

Develops high or intermediate risk criteria

Or

If Troponin (+)

←  follow directions in 6.2

If Troponin (-)

    If there is no evidence of ischemia or infarction, patient can be discharge with follow up