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Rapid Algorithm Review Acute Coronary Syndrome

Hi. I'm Mark for ACLS Certification Institute, and welcome back to another Rapid Algorithm Review. Today, we're going to cover ACS, acute coronary syndrome. Now, it all starts with the patient, the patient's presentation. When we think about heart attacks and acute coronary syndrome, we tend to think of the typical symptoms, the chest pain, shortness of breath, pain radiating up into the shoulder, maybe up into the jaw. Remember that in women ... An unusual fatigue by itself can be a symptom of a heart attack. It should be suspect for acute coronary syndrome, so in women an unusual fatigue. Now in men, remember that if the patient wanted to they could fake any symptom. They could fake the chest pain, they go, "Oh, my chest hurts, maybe trouble breathing, my butt itches." They can fake every symptom they want except sweating. The patient cannot fake diaphoreses. So you show up at the scene, or you have the patient come into your emergency room. They have shortness of breath, complaining of chest tightness and they're sweaty, they're in trouble. Everybody's in trouble and it's time to go to work. So, remember it starts with the patient presentation.

So you've determined your patient is having an acute coronary event, time to go to work. Now looking at the algorithm, there's all these different things we need to do, and in reality, these are going to happen in concert. Somebody's calling the shots, we tend to do all these at the same time. Support the ABC's if needed and be prepared for things to go south. We have an ischemic heart that can become irritated very easily, so have your defibrillator and resuscitative gear ready. We're going to oxygenate to achieve an SPO2 of 94 to 95%. Need to get this patient on a monitor, get an IV in him, get a 12-lead EKG, start administering our medications.

If there's no contraindications, aspirin administration, and nitroglycerin, again, if there is no contraindications. You can ask the guy, "Sir, have you taken Viagra or Cialis within the last 24 to 48 hours?" He may look at you and say, "No, pliff." I'm like a Turkish soldier once served in a circus freak show. Then you say, "Okay, sir. That's fine, but if you're taking that drug and I give you this drug, it may potentiated cause a precipitous fatal drop in your blood pressure, we may not even make it to the parking lot," and then he goes, "Oh, Viagra. I thought you asked if you had a Snicker's bar. Yes, I have had Viagra in the last 24 hours." Do not administer the nitro. Again, it can cause a precipitous fatal drop in their blood pressure. Get that 12-lead EKG. Remember, we're looking for ST-segment elevation. If your patient's having ST-segment elevation, notify the receiving facility immediately, so that they can prepare to receive this patient and get things moving so we can open up that coronary vessel when they hit the door.

Now, if you're in the emergency department and your receiving a patient in the field, a Code STEMI within the first 10 minutes of their arrival, we want to do a few things. First, reassess the patient, get an updated set of vital signs, review their history. Assure adequate oxygenation. Assure adequate vascular access. We want to try to get a chest x-ray within the first 30 minutes, but if that's part of your Code STEMI response, x-ray should already be at the door when they hit the door. Administer your medications if they haven't already been administered, your aspirin, your nitro if there's no contraindications. Retake a 12-lead EKG. Again, we're looking for ST-segment elevations. Now if that 12-lead is showing ST-segment elevation or a new or presumed left bundle branch block, games on, time to open up that coronary vessel. The patient's either going right to the cath lab or because we've already started our fibrinolytic checklist, they may receive t-PA right there in the ER.

Now, looking at the algorithm, there's a couple of suggested time frames for opening up this vessel. If we're using fibrinolytic therapy, should be within 30 minutes; that's our goal. We should have done our exclusion checklist within the first 10 minutes of the patient hitting the ER, or if they're going to the cath lab, door the balloon up within 90 minutes; that's our goal. That's why its so important in the field to call early. Give the hospital time to prepare to receive this patient, get everything in line so we can reduce the time it takes us to open up that vessel and reperfuse the heart.

Now, if your 12-lead doesn't show ST-segment elevation but instead some depression or T-wave inversion, which could mean ischemia, and your patient's still having complaint consistent with an MI, you still may want to follow your protocol, still consider your nitro, your aspirin therapy, and get an expert involved in this patient right away. Other medications to consider, heparin, IIb/IIIa inhibitors, and beta blockers. Remember beta blocker are going to help slow the heart rate down and reduce the force of contractility, thus, reducing the heart's oxygen requirements. It's like an engine with a gumped up fuel line, the beta blockers are taking your foot off the gas.

So, your 12-lead shows no ST-segment elevation, no T-wave inversion, you have a normal 12-lead, but your patient still has complaints. We're not going to let him just walk out of the ER just yet, maybe run some labs, check the cardiac markers, and then watch for changes in that patient's condition. So, 12-lead was normal, labs came back normal, we're getting ready to discharge this patient, but discharge him with the instructions that should any of these symptoms reoccur, immediately call 911.