Acute Coronary Syndrome
ACLS
certification institute
1 Patient presentation suggests
[Link]
Ischemia or acute MI
2 Appropriate EMS care and hospital notification
Provide cardiac monitor
Assess/support ABCs
Prep for CPR and rapid defibrillation if needed
If no contrary indications, administer aspirin, nitroglycerin and
morphine (if needed)
Administer appropriate oxygen therapy
Perform 12-Lead ECG: if ST elevation observed, notify receiving hospital,
relay 12-Lead findings or transmit if possible; provide medical report
on patient
Hospital should activate STEMI team
Use fibrinolytic checklist if fibrinolytic therapy is considered
ED Assessment (within 10 min
of patient arrival)
10 min
Assess vital signs and oxygenation status
Establish vascular access
Perform rapid focused history/physical exam
Perform/review fibrinolytic exclusion checklist
Perform appropriate lab tests including:
cardiac markers and coagulation studies
Order portable chest x-rays
(within 30 min of patient arrival)
Immediate ED Treatment
_
Administer O2 at 4L/min, titrate to SPO2 >94%
Administer Aspirin 16--325 mg
(if not administered by EMS)
Administer sublingual or spray Nitroglycerin
Consider IV Morphine if pain not relieved
by Nitroglycerin
(Assess for contraindications for all
drug administrations)
30 min
5 ST Elevation or assumed new LBBB,
9 ST Depression or T-Wave Inversion,
strong suspicion for injury
13 Normal or nondiagnostic
ST or T wave changes
strong suspicion for Ischemia
ST-Elevation MI (STEMI)
12-Lead ECG
Interpretation
Low/intermediate-risk ACS
High-risk unstable angina/non-ST elevation MI
(UA/NSTEMI)
14
Start adjunctive therapies as needed
Do not delay reperfusion
10
7 Onset of symptoms
Monitor serial cardiac markers
(including troponin)
Continue with ECG monitoring
for ST-segment changes
Consider non-invasive diagnostic test
High-risk patient or
elevated Troponin level
Consider invasive therapies if:
No
_
<12
hrs?
Refractory ischemic chest pain
Persistent/recurrent ST deviation
Unstable blood pressure
Ventricular tachycardia
Signs/symptoms of heart failure
15 Patient develops 1 or more
of the following?
Yes
ECG changes consistent with Ischemia?
Elevated Troponin levels?
Clinical assessment revealing
high-risk findings?
Yes
11
8 Initiate appropriate reperfusion
Initiate adjunctive treatments
as needed
No
Nitroglycerin
Heparin (UFH or LMWH)
Consider:
therapy
Balloon inflation PCI: within 90 min
Consider admission to ER
or appropriate unit
PO -Blockers
Clopidogrel
Glycoprotein IIb/IIIa inhibitor
90 min
Fibrinolytic therapy: within 30 min
16
Abnormal findings on
diagnostic non-invasive imaging
or physicologic testing?
30 min
12
Admit to appropriate monitor unit
Reassess risk status
Continue heparin, ASA, and appropriate
therapies as needed
ACE inhibitor/ARB
HMG CoA reductase inhibitor
(statin therapy)
(Not at high risk: cardiology to risk stratify)
Yes
No
17
If patient has no evidence of Ischemia
or infarction by testing, discharge patient
with instructions to follow up or return/call 911
should symptoms reoccur
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