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Advanced Cardiac Life Support (ACLS) Certification Course

Acute Coronary Syndrome

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.


• Use four liters per minute nasal cannula; titrate as needed to keep oxygen saturation to 94-99 percent.


• If no allergy, give 160 to 325 mg ASA to chew. Avoid coated ASA. Ideally, baby aspirin is the aspirin of choice.


• 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


• 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

• At least two large gauge IVs in each antecubital fossa.

Notify Hospital

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

Figure 41