ACLS - Acute coronary syndrome

Question 1

Plaques, also called Atheromas, characteristically occur in regions of
____

Answer 1

branching and/or marked curvature (velocity and direction change)

Question 2

_____ is the main event that
causes acute presentation of coronary syndromes.

Answer 2

Plaque rupture

Question 3

Patients with coronary atherosclerosis may develop a spectrum of clinical
presentations, representing various degrees of coronary occlusion. This is called ____

Answer 3

Acute Coronary Syndrome (ACS)

Question 4

Acute Coronary Syndrome includes the following:

Answer 4

○ ST Elevation ACS (STEMI)
○ Non-ST Elevation ACS (NSTE-ACS)
■ Non-ST Elevation MI (NSTEMI)
■ Unstable Angina

Question 5

T/F Half of the patients who die of ACS do so before reaching the hospital.

Answer 5

T

Question 6

Key components and goals of the ACS Algorithm:

Answer 6

○ Rapid identification, assessment, and triage of acute chest pain
○ Initial treatment of possible ACS
○ Emphasis on early reperfusion of the patient with ACS/STEMI

Question 7

Signs and Symptoms of ACS

Answer 7

● The most common symptom of myocardial
ischemia and infarction is retrosternal chest
discomfort (usually lasts more than for just a few minutes)

Question 8

Clinical presentation that is also suggestive of ACS:

Answer 8

○ Chest discomfort that is spreading to the shoulders, neck, jaw, or the arms (can
be one or both).
○ Chest discomfort spreading into the back or between the scapula.
○ Chest discomfort with lightheadedness, dizziness, fainting, sweating, nausea, or
vomiting.
○ Unexplained, sudden shortness of breath, which may occur with or without
chest discomfort.
○ Less commonly, some may have epigastric discomfort described as indigestion.
● Diaphoresis with some dyspnea is common.
● An unusual fatigue

Question 9

It’s also very important to realize that other potentially fatal conditions can
present in the same way (mimicking ACS)

Answer 9

○ Aortic dissection
○ Acute pulmonary embolism (PE)
○ Acute pericardial effusion with Tamponade
○ Tension pneumothorax

Question 10

EMS Assessment and Care for ACS

Answer 10

○ Monitor and support airway, breathing, and circulation (ABCs).
○ Administer Aspirin and consider oxygen (if O2 saturation is under 90%), nitroglycerin, and morphine (if chest pain is unresponsive to nitro).
○ Obtain a 12-lead EKG and interpret or transmit for interpretation.
■ If there is ST elevation, EMS notifies receiving hospital
○ Especially if ST elevation is present, EMS should complete a prehospital fibrinolytic checklist (more to come) and hospital prepares

Question 11

Aspirin dosing during EMS assessment and care for ACS

Answer 11

○ A dose of 162-325 mg of non-enteric-coated Aspirin causes near-total and immediate inhibition of platelet thromboxane production
○ This rapidly reduces platelet activation, stopping active thrombus formation and helps prevent coronary reocclusion.
○ Best absorbed if chewed rather than swallowed.

Question 12

T/F Other than Aspirin, NSAIDs are contraindicated in ACS

Answer 12

T

Question 13

Oxygen dosing for EMS care with ACS

Answer 13

○ Start oxygen at 4 L/min and titrate oxygen amount to maintain O2 saturation to at least 90%.

Question 14

Nitroglycerin usage with EMS Assessment and Care for ACS

Answer 14

○ Is known to reduce ischemic chest discomfort and has some beneficial
hemodynamic effects (reduce preload due to vasodilation).
○ Avoid use if hypotensive, bradycardic, or tachycardic
○ Avoid use if recent Phosphodiesterase Inhibitor use
○ Avoid use if Inferior Wall MI and RV infarction

Question 15

Morphine usage with EMS Assessment and Care for ACS

Answer 15

○ Morphine can be given for chest discomfort that is not responsive to Nitro
■ It produces CNS analgesia, which in turn reduces catecholamine release and
reduces heightened myocardial oxygen demand.
■ It produces vasodilation, decreasing LV preload
■ It decreases peripheral vascular resistance, decreasing LV afterload.
■ Helps redistribute blood in those with pulmonary edema, easing dyspnea

Question 16

What should be done in the first 10 minutes when a potential ACS patient enters the ER?

Answer 16

● Within the first 10 minutes after arrival, obtain a 12-Lead EKG.
○ The EMS recording can be used if available, or repeating it is common.
○ Assess ABCs, check vital signs, give oxygen if needed
○ Establish IV access
○ Perform a brief, targeted history and physical exam
○ Review/complete a fibrinolytic checklist
○ Obtain initial cardiac marker levels (esp. Troponin)
○ Obtain initial CBC and coagulation studies
○ Obtain a portable Chest X-ray

Question 17

The results of cardiac markers, CXR, and other labs should not delay reperfusion therapy for a _____ unless clinically necessary

Answer 17

STEMI

Question 18

What is the relationship between LBBB and Acute MI?

Answer 18

■ ST depression and T wave inversion are commonly seen with a LBBB
○ Because the EKG picture of an evolving MI also includes ST and T wave changes, and because LBBBs are a common consequence of MIs, the
presence of a new or presumably new LBBB must be considered evidence of an acute MI (possibly a STEMI) until proven otherwise

Question 19

High-risk NSTE-ACS Group

Answer 19

These are the NSTEMIs and Unstable Anginas
○ Evidence of ischemia in the form of ST-segment depression or dynamic T-wave inversion with pain or discomfort.

Question 20

Low/Intermediate-risk NSTE-ACS Group-

Answer 20

○ Normal or nondiagnostic changes of ST-segment and T-wave.
○ These patients require further risk stratification: Serial cardiac studies
and functional tests are appropriate.

Question 21

The Four D’s of Delay- These are four major points where delay can occur

Answer 21

■ Door to data (obtaining the EKG)
■ Data to decision (reading the EKG)
■ Decision to drug or PCI
■ Drug or PCI administration

Question 22

____ is considered the preferred reperfusion therapy for STEMI or new LBBB if available

Answer 22

PCI

Question 23

The goal for FMC-to-balloon inflation time is ___ minutes

Answer 23

90

Question 24

What is the backup to PCI reperfusion if it is not available?

Answer 24

fibrinolytics should be considered treatment of
choice in STEMI patients presenting within 12 hours of symptom onset.
○ Examples include Alteplase, Reteplase, and Tenecteplase.
○ The goal for ED door-to-needle time is 30 minutes

Question 25

Adjunct Therapies to ACLS may be useful when indicated:

Answer 25

○ Unfractionated Heparin or LMWH - Routinely used as adjunct for PCI
and fibrinolytic therapy (read more on page 42 of the book).
○ IV Nitroglycerin - Not routinely used in STEMI, but may be indicated in
some situations

Question 26

Adjunct therapies that are generally started/recommended for a STEMI or LBBB
by a consulting cardiologist if indicated:

Answer 26

○ Bivalirudin (Angiomax)
○ P2Y12 Inhibitors
○ Beta Blockers
○ Glycoprotein 2b/3a Inhibitors

Question 27

The presence of ____ differentiates NSTEMI from UA

Answer 27

elevated Troponins

Question 28

If tPA is going to be administered, the goal is that
it is given within _____

Answer 28

30 minutes of arrival.
● Do not administer anticoagulants or antiplatelet treatment within 24 hours after tPA has been administered.