Acute Coronary Syndrome

ACLS
certification institute
1 Patient presentation suggests www.aclscertification.com
Ischemia or acute MI

2 Appropriate EMS care and hospital notification

Provide cardiac monitor
Assess/support ABC’s
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

3 ED Assessment (within 10 min

Immediate ED Treatment
of patient arrival) 10 min

Assess vital signs and oxygenation status Administer O2 at 4L/min, titrate to SPO2 >94%
_
Establish vascular access Administer Aspirin 16--325 mg
Perform rapid focused history/physical exam (if not administered by EMS)
Perform/review fibrinolytic exclusion checklist Administer sublingual or spray Nitroglycerin
Perform appropriate lab tests including: Consider IV Morphine if pain not relieved
cardiac markers and coagulation studies by Nitroglycerin
Order portable chest x-rays (Assess for contraindications for all
(within 30 min of patient arrival) drug administrations)
30 min

4 12-Lead ECG
Interpretation

5 ST Elevation or assumed new LBBB, 9 ST Depression or T-Wave Inversion, 13 Normal or nondiagnostic

strong suspicion for injury strong suspicion for Ischemia ST or T wave changes
ST-Elevation MI (STEMI) High-risk unstable angina/non-ST elevation MI Low/intermediate-risk ACS
(UA/NSTEMI)

14 Consider admission to ER
6 Start adjunctive therapies as needed or appropriate unit
Do not delay reperfusion Monitor serial cardiac markers
(including troponin)
Continue with ECG monitoring
for ST-segment changes
Consider non-invasive diagnostic test
10 High-risk patient or
elevated Troponin level
7 Onset of symptoms Consider invasive therapies if:
No Refractory ischemic chest pain
<12
_ hrs? Persistent/recurrent ST deviation 15 Patient develops 1 or more
Unstable blood pressure
Ventricular tachycardia of the following?
Signs/symptoms of heart failure Yes ECG changes consistent with Ischemia?
Elevated Troponin levels?
Yes Clinical assessment revealing
high-risk findings?

11 Initiate adjunctive treatments

as needed
No
8 Initiate appropriate reperfusion Nitroglycerin
therapy Heparin (UFH or LMWH)
Consider:
Balloon inflation PCI: within 90 min PO -Blockers
90 min Clopidogrel
Glycoprotein IIb/IIIa inhibitor 16
Fibrinolytic therapy: within 30 min Abnormal findings on
30 min diagnostic non-invasive imaging
or physicologic testing?

12
Admit to appropriate monitor unit
Reassess risk status
Continue heparin, ASA, and appropriate
therapies as needed Yes No
ACE inhibitor/ARB
HMG CoA reductase inhibitor
(statin therapy)
(Not at high risk: cardiology to risk stratify)
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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