Acute Coronary Syndromes
- Acute coronary syndrome
- Epidemiology
- Precipitating causes
- Atherosclerosis
- Vasospastic (Prinzmetal's)
- Morbidity/ mortality
- Not a self-limiting disease
- Chest pain may dissipate, but myocardial ischemia and injury can continue
- A single anginal episode may be a precursor to myocardial infarction
- May not be cardiac in origin
- Must be diagnosed by a physician
- Related terminology
- Defined as a brief discomfort, has predictable characteristics and is relieved promptly - no change in this pattern
- Stable
- occurs at a relative fixed frequency
- usually relieved by rest and/ or medication
- Unstable
- occurs without fixed frequency
- may or may not be relieved by rest and/ or medication
- Initial - first episode
- Progressive - accelerating in frequency and duration
- Preinfarction angina
- pain at rest
- sitting or lying down
- Differential diagnoses
- Cholecystitis
- Acute viral pericarditis or any other inflammatory cardiac disease
- Aneurysm
- Hiatal hernia
- Esophageal disease
- Gastric reflux
- Pulmonary embolism
- Peptic ulcer disease
- Pancreatitis
- Chest wall syndrome
- Costochondritis
- Acromioclavicular disease
- Pleural irritation
- Respiratory infections
- Aortic dissection
- Pneumothorax
- Dyspepsia
- Herpes zoster
- Chest wall tumors
- Chest wall trauma
- Primary survey findings
- Airway/ breathing
- Labored breathing may or may not be present
- Circulation
- Peripheral pulses
- quality
- rhythm
- Peripheral perfusion
- changes in skin (color, temperature and moisture)
- Peripheral pulses
- Airway/ breathing
- History of the present illness/SAMPLE history
- Chief complaint
- 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
- Typical - usually relieved by rest and/or medication
- Epigastric pain or discomfort
- Atypical
- Denial
- Contributing history
- Initial recognized event
- Recurrent event
- Increasing frequency and/or duration of event
- Chief complaint
- Secondary survey findings
- Airway
- Breathing
- May or may not be labored
- Breath sounds
- may be clear to auscultation
- may be congested in the bases
- Circulation
- Alterations in heart rate and rhythm may occur
- Peripheral pulses are usually not affected
- Blood pressure may be elevated during the episode and normalize afterwards
- ECG Devices
- monitor
- transmission
- documentation
- computerized pattern identification
- pitfalls
- common errors
- Findings
- ST segment changes are often not specific
- arrhythmias and ectopy may not be present
- Management
- Position of comfort
- Refer to ILCOR Consensus for treatment
- ECG
- 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
- Measure, record and communicate ST segment changes
- Indications for Rapid Transport
- Sense of urgency for reperfusion
- No relief with medications
- Hypotension/hypoperfusion with CNS involvement
- Significant changes in ECG
- No transport
- Patient refusal
- Referral
- Support and communications strategies
- Explanation for patient, family, significant others
- Communications and transfer of data to the physician
- Acute myocardial infarction/Angina
- Epidemiology
- Precipitating causes (as with angina)
- Atherosclerosis
- Persistent angina
- Occlusion
- Non-traumatic
- Recreational drugs
- Trauma
- Morbidity/ mortality
- Sudden death
- Extensive myocardial damage
- May result in ventricular fibrillation
- Primary survey findings
- Airway/ breathing
- Circulation
- Peripheral pulses
- quality
- rhythm
- Peripheral perfusion
- changes in skin
- color
- temperature
- moisture
- changes in skin
- Peripheral pulses
- History of the present illness/SAMPLE history
- Chief complaint
- Typical onset of discomfort, usually of long duration, over 30 minutes
- Typically unrelieved by rest and/ or nitroglycerin preparation
- Epigastric pain or discomfort
- Atypical
- Contributing history
- First time
- Recurrent
- Increasing frequency and/ or duration
- Denial
- Chief complaint
- Secondary survey findings
- Airway
- Breath sounds
- May be clear to auscultation
- Congestion in bases may be present
- Circulation
- Skin
- pallor during the episode
- temperature may vary
- diaphoresis is usually present
- Alterations in heart rate and rhythm may occur
- Peripheral pulses are usually not affected
- Blood pressure may be elevated or lowered
- ECG findings
- ST segment elevation
- height, depth and contour
- ST changes
- ST segment depression in reciprocal leads
- Q waves
- depth, duration and significance
- greater than 5 mm, greater than .04 seconds
- may indicate necrosis
- may indicate extensive transient ischemia
- ECG Rhythm analysis
- criteria for patient selection for rapid transport and reperfusion
- value
- signs of acute ischemia, injury, and necrosis
- criteria for patient selection for rapid transport and reperfusion
- time of onset of pain
- location of ischemia and infarction
- ST segment elevation
- cardiac arrhythmias
- sinus tachycardia with or without ectopy
- narrow or wide QRS complex tachycardia
- sinus bradycardia
- heart blocks
- ventricular fibrillation
- pulseless electrical activity (PEA)
- asystole (confirmed in a second lead)
- ST segment elevation
- Skin
- Management
- Position of comfort
- Refer to ILCOR Consensus for treatment
- Transport
- Criteria for rapid transport
- no relief with medications
- hypotension/ hypoperfusion
- significant changes in ECG
- ectopy
- arrhythmias
- ECG criteria for rapid transport and reperfusion
- time of onset of pain
- ECG rhythm abnormalities
- Criteria for rapid transport
- Indications for “no transport”
- Refusal
- No other indications for no-transport
- Support and communications strategies
- Explanation for patient, family, significant others
- 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
NJ Course Number: 1826433604392
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.