Acute Coronary Syndromes

Course overview

Objectives Describe the concept of acute coronary syndromes Identify different types of ACS List the symptoms related to each type of ACS Content 1 Acute coronary syndrome 1 Epidemiology 2 Precipitating causes 1 Atherosclerosis 2 Vasospastic Prinzmetals 3 Morbidity mortality 1 Not a self limiting disease 2 Chest pain may dissipate but myocardial ischemia and injury can continue 3 A single anginal episode may be a precursor to myocardial infarction 4 May not be cardiac in origin 5 Must be diagnosed by a physician 6 Related terminology 1 Defined as a brief discomfort with predictable characteristics relieved promptly with no change in pattern 2 Stable 1 Occurs at a relatively fixed frequency 2 Usually relieved by rest or medication 3 Unstable 1 Occurs without a fixed frequency 2 May or may not be relieved by rest or medication 4 Initial first episode 5 Progressive accelerating in frequency and duration 6 Preinfarction angina 1 Pain at rest 2 Sitting or lying down 7 Differential diagnoses 1 Cholecystitis 2 Aneurysm 3 Hiatal hernia 4 Acute viral pericarditis or other inflammatory cardiac disease 5 Esophageal disease 6 Gastric reflux 7 Pulmonary embolism 8 Peptic ulcer disease 9 Pancreatitis 10 Chest wall syndrome 11 Costochondritis 12 Acromioclavicular disease 13 Pleural irritation 14 Respiratory infections 15 Aortic dissection 16 Pneumothorax 17 Dyspepsia 18 Herpes zoster 19 Chest wall tumors 20 Chest wall trauma 4 Primary survey findings 1 Airway breathing 1 Labored breathing may or may not be present 2 Circulation 1 Peripheral pulses 1 Quality 2 Rhythm 2 Peripheral perfusion 1 Changes in skin color temperature and moisture 5 History of the present illness SAMPLE history 1 Chief complaint 1 Typical sudden onset of discomfort usually brief lasting three to five minutes possibly five to fifteen minutes never thirty minutes to two hours 2 Typical usually relieved by rest or medication 3 Epigastric pain or discomfort 4 Atypical 2 Denial 3 Contributing history 1 Initial recognized event 2 Recurrent event 3 Increasing frequency or duration of event 6 Secondary survey findings 1 Airway 2 Breathing 1 May or may not be labored 2 Breath sounds 1 May be clear to auscultation 2 May be congested in the bases 3 Circulation 1 Alterations in heart rate and rhythm may occur 2 Peripheral pulses usually not affected 3 Blood pressure may be elevated during the episode and normalize afterward 4 ECG devices 1 Monitor 2 Transmission 3 Documentation 4 Computerized pattern identification 5 Pitfalls 6 Common errors 5 Findings 1 ST segment changes often not specific 2 Arrhythmias and ectopy may not be present 7 Management 1 Position of comfort 2 Refer to ILCOR consensus for treatment 3 ECG 1 When possible and without delaying scene time record and transmit three lead or twelve lead ECG during pain as ECG may be normal during pain free periods 2 Measure record and communicate ST segment changes 4 Indications for rapid transport 1 Sense of urgency for reperfusion 2 No relief with medications 3 Hypotension hypoperfusion with CNS involvement 4 Significant changes in ECG 5 No transport 1 Patient refusal 2 Referral 8 Support and communications strategies 1 Explanation for patient family and significant others 2 Communication and transfer of data to physician 2 Acute myocardial infarction angina 1 Epidemiology 2 Precipitating causes 1 Atherosclerosis 2 Persistent angina 3 Occlusion 4 Non traumatic 1 Recreational drugs 5 Trauma 3 Morbidity mortality 1 Sudden death 2 Extensive myocardial damage 3 May result in ventricular fibrillation 4 Primary survey findings 1 Airway breathing 2 Circulation 1 Peripheral pulses 1 Quality 2 Rhythm 2 Peripheral perfusion 1 Changes in skin 1 Color 2 Temperature 3 Moisture 5 History of the present illness SAMPLE history 1 Chief complaint 1 Typical onset of discomfort lasting over thirty minutes 2 Typically unrelieved by rest or nitroglycerin 3 Epigastric pain or discomfort 4 Atypical