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www.lhsc.on.ca/bhp
Acute Coronary Syndrome
(ACS)
Tony Jaroszewicz, AEMCA, ACP Dr. Adam Dukelow, LMD
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Objectives
Given this webinar presentation, the paramedic should be able to: • Define Acute Coronary Syndrome • Locate and identify the coronary arteries and the section of the
myocardium that they feed • Describe and identify the common signs and symptoms of left sided
and right sided myocardium infarct, injury and ischemia • Summarize the pharmacokinetics and pharmacodynamics of
Nitroglycerin, ASA and Morphine • Relate the proper application of the Suspected Cardiac Ischemia
Chest Pain Protocol As evaluated by the learner.
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Acute Coronary Syndrome (ACS)
Definition:
• Sudden ischemic disorders of the heart
• Include unstable angina and acute myocardial infarction
• Represent a continuum of a similar disease process
• All have sudden ischemia
• Cannot be differentiated in the first hours
• All have the same initiating events
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Acute Coronary Syndrome (ACS)
Initiating Events
• Plaque rupture
• Thrombus formation
• Vasoconstriction
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Initiating Events - Plaque Rupture
Lumen
Lipid Core
Fibrous Cap
Stable Vulnerable
Lumen Lipid Core
Fibrous Cap
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Initiating Events
Plaque Rupture
Lipid Core
Fibrous Cap
Lumen
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Initiating Events
Thrombus Formation
Lipid Core
Fibrous Cap
Platelets Adhere
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Initiating Events
Thrombus Formation
Platelet Aggregation
Lipid Core
Fibrin
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Acute Coronary Syndrome (ACS)
Will Infarct Occur?
Tissue
Death?
Plaque
Rupture
Thrombus
Formation
Coronary
Vasoconstriction
Collateral
Circulation
Myocardial
Oxygen Demand
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Acute Coronary Syndrome (ACS)
• The Three I’s
• Ischemia • lack of oxygenation
• Injury • prolonged ischemia
• Infarct • death of tissue
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Acute Coronary Syndrome (ACS)
Well Perfused Myocardium
Epicardial Coronary Artery
Lateral Wall of LV Septum
Left
Ventricular
Cavity
Interior Wall of LV
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Acute Coronary Syndrome (ACS)
Ischemia
Epicardial Coronary Artery
Lateral Wall of LV Septum
Left
Ventricular
Cavity
Interior Wall of LV
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Acute Coronary Syndrome (ACS)
Thrombus
Ischemia
Injury
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Acute Coronary Syndrome (ACS)
Infarction
Infarcted Area
Thrombus
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Coronary Artery Anatomy
• Varies from patient to patient
• General patterns of distribution exist
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Left Coronary Artery
Left Main
Left Circumflex
Lateral Wall
Anterior Wall
Septal Wall
Right Ventricle
Right Coronary Artery
Anterior Descending Artery
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Left Coronary Artery Occlusion
Signs and Symptoms
• ACS Spectrum
• Shortness of breath
• Diaphoresis
• Pulmonary Edema
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Right Coronary Artery
Right Coronary Artery
Posterior Descending Artery
Inferior Wall
Posterior Wall
Lateral Wall
Left Ventricle
Left Coronary Artery
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Right Coronary Artery Occlusion
Signs and Symptoms
• Dyspnea with clear lungs
• Jugular vein distension
• Hypotension
• Relative or absolute
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Acute Coronary Syndrome (ACS)
** Now we to know how to rapidly recognize and treat ACS **
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Immediate Evaluation
• Story
• Risk factors
• ECG
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Clinical Presentations of ACS
• Classic anginal chest pain
• Atypical chest pain
• Anginal equivalents
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Classic Anginal Chest Pain
• Central anterior chest
• Dull, fullness, pressure, tightness, crushing
• Radiates to arms, neck, back
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Classic Anginal Chest Pain
•Consider the following case study
• 48 year old male
• Dull central CP 2/10, began at rest
• Pale and wet
• Overweight, smoker
• Vital signs: RR 18, P 80, BP 180/110, Sa02 94% on room air
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Atypical Pain
• Musculoskeletal, positional or pleuritic features
• Often unilateral
• May be described as sharp or stabbing
• Includes epigastric discomfort
• Females often express atypical pain
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Atypical Pain
•Consider the following case study
• A 54-year-old female with a history of type 2 diabetes, hypertension, complaining of chest pain, weakness, and fatigue. Her chest pain was pleuritic in nature, worsening with movement and deep breathing. When she was motionless, the pain completely resolved.
• Pale and overweight
• Vital signs: RR 18, P 80, BP 180/110, Sa02 94% on room air
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Anginal Equivalents
• Dyspnea
• Palpitations
• Syncope or pre-syncope
• General weakness
• DKA
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Anginal Equivalents
•Consider the following case study
•68 year old female • Sudden onset of anxiety and restlessness,
• States she “can’t catch her breath”
• Denies chest pain or other discomfort
•History of IDDM and hypertension
•RR 22, P 110, BP 190/90, Sa02 88% on NC at 4 lpm.
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Important Notation
• Note EXACT time symptoms began
• Duration of symptoms may effect therapeutic options and destination decisions
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Consider Risk Factors
• Evaluated with a high index of suspicion for ACS
• Decision pathways with potential ACS patients
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Risk Factors of ACS
•Diabetes
• Smoking
•Hypertension
•Age
• Family history of CAD
•Obesity
• Stress
• Sedentary
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General Therapy for ACS
• Assessment
• Expose the chest
• Story and risks
• Monitor & 12-lead
• Vital signs & Sa02
• Lab draw/cardiac markers
Treatment
• Oxygen
• IV access
• Aspirin
• NTG
• Morphine
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Treatment for ACS
• Oxygen
• ASA
• IV Therapy
• NTG
• Morphine
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Cardiac Ischemia Directive
• Ischemic Chest Pain
• Angina
• Typical angina/MI Pain
• Nitroglycerin 0.4 mg (6 doses)
• ASA 160 mg (one dose)
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Conditions for Nitro
• Be ≥ 40 kg
• Alert and responsive
• Prescribed and taken Nitroglycerin in the past , or paramedic has started an IV
• No ED medication in past 48 hours
• SBP ≥ 100 mmHg
• Heart rate ≥ 60 and < 160
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Conditions for ASA
• Be ≥ 40 kg
• Alert
• Responsive
• No allergy to ASA or other NSAID
• No current active bleeding
• No evidence of CVA or head injury – 24 hours
• Previous use of ASA with no adverse reaction if a known asthmatic
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Procedure
• Oxygen
• Monitor, vital signs,
• Do not delay treatment to start IV
• If no IV, administer Nitroglycerin only in patients with a history of previous Nitroglycerin use.
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Procedure
• Systolic BP is ≥ 100 mmHg
• Heart rate is ≥ 60 bpm and < 160 bpm.
• Nitroglycerin 0.4 mg spray SL, q 5 minutes
• Maximum of six (6) doses.
• Administer ASA 160-162 mg
• 12-Lead if certified
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Procedure
• Vital signs before/after each dose
• Stop NTG administration if SBP drops by more than 1/3
• Discontinue NTG if vital signs fall outside of parameters
• If required and certified, follow the Intravenous Access & Fluid Administration Protocol
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Notes
• Chest pain fully resolves and then recurs, it is treated as a new episode
• Nitroglycerin protocol is repeated, but not the ASA.
• Administer ASA if the patient has already taken their normal dose
• Administer ASA even if the chest pain has resolved
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Morphine Sulphate Procedure (ACP Only) • After three (3) doses of NTG, patient is still c/o chest
pain
• No allergies to Morphine Sulfate
• SBP ≥ 100 mmHg
• Administer 2 mg Morphine Sulfate IV q 5 minutes if SBP is ≥ 100 mmHg and the pain has not been relieved
• Maximum of five (5) doses (10 mg total) of MSO4
• NTG maximum of six doses.
• Contact the BHP if further orders are required
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Summary
• ACS is a sudden ischemic disorder of the heart including unstable angina and AMI
• Can involve ischemia, injury, or infarct
• Rapid recognition and treatment is vital for best possible outcome
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Questions ?
• Contact SWORBHP
• 519-667-6718
• ParamedicEducation@lhsc.on.ca
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References
• ACS Consultants, Inc. • Little RA, Frayn KN, Randall PE, et al. (1986). "Plasma catecholamines in the
acute phase of the response to myocardial infarction". 3 (1): 20–7. PMID 3524599.
• Mallinson, T (2010). "Myocardial Infarction". Focus on First Aid (15): 15. http://www.focusonfirstaid.co.uk/Magazine/issue15/index.aspx. Retrieved 2010-06-08
• Collins-Abrams, A., & Goldsmith., TC. (1991). Clinical Drug Therapy 3rd Edition Rationale for Nursing Practice, Philadelphia, PA. J.B. Lippincott Company
• • Mycek, MJ., Harvey, RA., & Champe, PC. (1997). Lippincott’s Pharmacology 2nd Edition, Philadelphia, PA. J.B. Lippincott Company
• • Sanders, MJ., McKenna, K., Lewis, LM., & Quick G. (2007). Mosby’s Paramedic Textbook Revised 3rd Edition, St. Louis, Missouri: Elsevier
• • Statistics (2010). Retrieved June 8, 2010, from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b. 3483991/k.34A8/Statistics.htm
• London Health Sciences Base Hospital Medical Directives, BLS & ALS, 2009 • ACLS, AHA, 1997
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