Acute Coronary Syndromes

  1. Acute coronary syndrome
    1. Epidemiology
    2. Precipitating causes
      1. Atherosclerosis
      2. Vasospastic (Prinzmetal's)
    3. Morbidity/ mortality
      1. Not a self-limiting disease
      2. Chest pain may dissipate, but myocardial ischemia and injury can continue
      3. A single anginal episode may be a precursor to myocardial infarction
      4. May not be cardiac in origin
      5. Must be diagnosed by a physician
      6. Related terminology
        1. Defined as a brief discomfort, has predictable characteristics and is relieved promptly - no change in this pattern
        2. Stable
          1. occurs at a relative fixed frequency
          2. usually relieved by rest and/ or medication
        3. Unstable
          1. occurs without fixed frequency
          2. may or may not be relieved by rest and/ or medication
        4. Initial - first episode
        5. Progressive - accelerating in frequency and duration
        6. Preinfarction angina
          1. pain at rest
          2. sitting or lying down
      7. Differential diagnoses
        1. Cholecystitis
        2. Acute viral pericarditis or any other inflammatory cardiac disease
        3. Aneurysm
        4. Hiatal hernia
        5. Esophageal disease
        6. Gastric reflux
        7. Pulmonary embolism
        8. Peptic ulcer disease
        9. Pancreatitis
        10. Chest wall syndrome
        11. Costochondritis
        12. Acromioclavicular disease
        13. Pleural irritation
        14. Respiratory infections
        15. Aortic dissection
        16. Pneumothorax
        17. Dyspepsia
        18. Herpes zoster
        19. Chest wall tumors
        20. Chest wall trauma
    4. Primary survey findings
      1. Airway/ breathing
        1. Labored breathing may or may not be present
      2. Circulation
        1. Peripheral pulses
          1. quality
          2. rhythm
        2. Peripheral perfusion
          1. changes in skin (color, temperature and moisture)
    5. History of the present illness/SAMPLE history
      1. Chief complaint
        1. Typical - sudden onset of discomfort, usually of brief duration, lasting three to five minutes, maybe 5 to 15 minutes; never 30 minutes to 2 hours
        2. Typical - usually relieved by rest and/or medication
        3. Epigastric pain or discomfort
        4. Atypical
      2. Denial
      3. Contributing history
        1. Initial recognized event
        2. Recurrent event
        3. Increasing frequency and/or duration of event
    6. Secondary survey findings
      1. Airway
      2. Breathing
        1. May or may not be labored
        2. Breath sounds
          1. may be clear to auscultation
          2. may be congested in the bases
      3. Circulation
        1. Alterations in heart rate and rhythm may occur
        2. Peripheral pulses are usually not affected
        3. Blood pressure may be elevated during the episode and normalize afterwards
        4. ECG Devices
          1. monitor
          2. transmission
          3. documentation
          4. computerized pattern identification
          5. pitfalls
          6. common errors
        5. Findings
          1. ST segment changes are often not specific
          2. arrhythmias and ectopy may not be present
    7. Management
      1. Position of comfort
      2. Refer to ILCOR Consensus for treatment
      3. ECG
        1. Whenever possible, and scene time is not delayed, record and transmit 3-lead and/ or 12-lead ECG during pain, since ECG may be normal during the pain-free period
        2. Measure, record and communicate ST segment changes
      4. Indications for Rapid Transport
        1. Sense of urgency for reperfusion
        2. No relief with medications
        3. Hypotension/hypoperfusion with CNS involvement
        4. Significant changes in ECG
      5. No transport
        1. Patient refusal
        2. Referral
    8. Support and communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
  2. Acute myocardial infarction/Angina
    1. Epidemiology
    2. Precipitating causes (as with angina)
      1. Atherosclerosis
      2. Persistent angina
      3. Occlusion
      4. Non-traumatic
        1. Recreational drugs
      5. Trauma
    3. Morbidity/ mortality
      1. Sudden death
      2. Extensive myocardial damage
      3. May result in ventricular fibrillation
    4. Primary survey findings
      1. Airway/ breathing
      2. Circulation
        1. Peripheral pulses
          1. quality
          2. rhythm
        2. Peripheral perfusion
          1. changes in skin
            1. color
            2. temperature
            3. moisture
    5. History of the present illness/SAMPLE history
      1. Chief complaint
        1. Typical onset of discomfort, usually of long duration, over 30 minutes
        2. Typically unrelieved by rest and/ or nitroglycerin preparation
        3. Epigastric pain or discomfort
        4. Atypical
      2. Contributing history
        1. First time
        2. Recurrent
        3. Increasing frequency and/ or duration
      3. Denial
    6. Secondary survey findings
      1. Airway
      2. Breath sounds
        1. May be clear to auscultation
        2. Congestion in bases may be present
      3. Circulation
        1. Skin
          1. pallor during the episode
          2. temperature may vary
          3. diaphoresis is usually present
        2. Alterations in heart rate and rhythm may occur
        3. Peripheral pulses are usually not affected
        4. Blood pressure may be elevated or lowered
        5. ECG findings
          1. ST segment elevation
            1. height, depth and contour
            2. ST changes
            3. ST segment depression in reciprocal leads
          2. Q waves
            1. depth, duration and significance
            2. greater than 5 mm, greater than .04 seconds
            3. may indicate necrosis
            4. may indicate extensive transient ischemia
          3. ECG Rhythm analysis
            1. criteria for patient selection for rapid transport and reperfusion
            2. value
            3. signs of acute ischemia, injury, and necrosis
            4. criteria for patient selection for rapid transport and reperfusion
              1. time of onset of pain
              2. location of ischemia and infarction
              3. ST segment elevation
            5. cardiac arrhythmias
              1. sinus tachycardia with or without ectopy
              2. narrow or wide QRS complex tachycardia
              3. sinus bradycardia
              4. heart blocks
              5. ventricular fibrillation
              6. pulseless electrical activity (PEA)
              7. asystole (confirmed in a second lead)
    7. Management
      1. Position of comfort
      2. Refer to ILCOR Consensus for treatment
      3. Transport
        1. Criteria for rapid transport
          1. no relief with medications
          2. hypotension/ hypoperfusion
          3. significant changes in ECG
            1. ectopy
            2. arrhythmias
        2. ECG criteria for rapid transport and reperfusion
          1. time of onset of pain
          2. ECG rhythm abnormalities
      4. Indications for “no transport”
        1. Refusal
        2. No other indications for no-transport
      5. Support and communications strategies
        1. Explanation for patient, family, significant others
        2. Communications and transfer of data to the physician

Content Creator: Joyce Lockwood

CAPCE Course Number: 19-EMTP-F3-7212

Total CE Hours: 1

Level: Advanced

EMT-CE uses the NEMSES guidelines as the foundation for every course outline.