ACUTE CORONARY SYNDROMES ALGORITHM

Patient has signs suggestive of ischemia or infarction

1 MONITOR & SUPPORT ABC’S 4 STEMI RESPONSE

EMS Prepare to provide CPR or defibrillate if needed Notified hospital should mobilize
hospital resources
ASSESSMENT, 2 ADMINISTER ASPIRIN
Consider oxygen, nitroglycerin, and 5 COMPLETE FIBRINOLYTIC CHECKLIST
CARE, AND
morphine If considering prehospital fibrinolysis,
HOSPITAL 3 OBTAIN 12-LEAD ECG: INTERPRET/TRANSMIT use fibrinolytic checklist
PREPARATION If ST elevation, note time of onset and first
medical contact and notify receiving hospital.

CHECK VITAL SIGNS & OXYGEN SAT START OXYGEN

ESTABLISH IV ACCESS At 4 L/min, titrate if O2 sat <90%

BRIEF HISTORY & PHYSICAL ADMINISTER ASPIRIN

CONCURRENT IMMEDIATE ED
160 to 325 mg (if not given by EMS)
ED ASSESSMENT COMPLETE FIBRINOLYTIC CHECKLIST
ADMINISTER NITROGLYCERIN GENERAL
(<10 MINUTES) OBTAIN INITIAL CARDIAC MARKERS Sublingual or spray TREATMENT
And initial electrolyte and coagulation studies ADMINISTER MORPHINE IV
PORTABLE CHEST X-RAY (<30 MIN) If nitroglycerin doesn’t relieve discomfort

ECG Interpretation

ST-Elevation MI (STEMI) Low/Intermediate-Risk ACS

ST elevation or new or presumably new Normal or nondiagnostic changes in ST
LBBB; strongly suspicious for injury High-Risk Non-ST-Elevation ACS segment or T wave
ST depression or dynamic T-wave inversion;
strongly suspicious for ischemia

Start adjunctive therapies as indicated Admission OR Monitoring

Consider admission to ED chest pain unit or to
Don’t delay reperfusion Troponin Elevated OR appropriate bed for further monitoring and
High-Risk Patient possible intervention

Consider Early invasive strategy if:

Refractory ischemic chest discomfort
> 12
Time from onset of symptoms is: Recurrent / persistent ST deviation
Hours
Ventricular tachycardia
≤ 12 Hours Hemodynamic instability
Signs of heart failure
Start Adjunctive Therapies
Reperfusion Goals: eg. Nitroglycerin, heparin as indicated
Therapy defined by patient & center criteria
See AHA/ACC NSTE-ACS guidelines
Door-to-balloon inflation (PCI)
Goal: 90 Minutes
Door-to-needle fibrinolysis)
Goal: 30 Minutes

This Algorithm is based on the latest (2015) American Heart Association standards and guidelines.

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