Acute Coronary Syndrome

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Acute coronary syndrome (ACS) is a collection of clinical presentations including unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI). ACS is classically recognized by one or more of the following symptoms: crushing chest pain, shortness of breath, pain that radiates to the jaw, arm or shoulder, sweating, and/or nausea or vomiting. It is important to note that not all individuals with ACS will present with these classic findings, particularly women and individuals with diabetes mellitus. It is impossible to determine a specific cardiac event from the ACS symptoms; therefore, ACS symptoms are managed in the same way.

Every individual with these symptoms should be evaluated immediately. If an individual appears to be unconscious, begin with the BLS Survey and follow the appropriate pathway for advanced care. If the individual is conscious, proceed with the pathway below.

EMS
Oxygen

• Use four liters per minute nasal cannula; titrate as needed

Aspirin

• If no allergy, give 160 to 325 mg ASA to chew. Avoid coated ASA

Nitroglycerin

• Give 0.3 to 0.4 mg SL/spray x two doses at 3 to 5 minute intervals
• Do not use if SBP < 90 mmHg
• Do not use if phosphodiesterase inhibitor, like Viagra, taken within 24 hours

Morphine

• Give 1 to 5 mg IV only if symptoms not relieved by nitrates or if symptoms recur. Monitor blood pressure closely

12-Lead ECG

• Evaluate for MI: ST elevation or depression, and poor R wave progression

IV Access

• Large gauge IV in antecubital fossa

Notify Hospital

• Take to PCI center if probable STEMI
• Activate ACS protocol at hospital

Figure 41

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