Pt is responsive at this time.
(Remember Door to Drug treatment should be < 30 minutes)
I. Pt is having chest pain.
Signs and Symptoms
A. Uncomfortable pressure, fullness, squeezing, or pain in the center
of the chest lasting greater than 15 minutes.
B. Pain spreading to shoulders, neck, arms, jaw, or pain between the
shoulder blades.
C. Chest discomfort with lightheadedness, fainting, sweating, nausea,
or shortness of air.
II. Immediate Assessment
A. Place on "O2, IV, Monitor"
B. Get vital signs
C. Obtain a 12-lead ECG
D. Draw blood for cardiac marker levels (CPK, CK-MB, Troponin I),
Electrolytes, CBC, & coagulation panel
E. Initial physical exam and history focus on eligibility for
thrombolytic therapy.
F. Portable Chest X-Ray
III. Immediate General Treatment (MONA greats everyone at the door)
M.O.N.A.
(Morphine 2-4mg IV q 5 minutes not relieved by NTG,
Oxygen 2-4 Liters/min. via nasal cannula,
Nitroglycerin (NTG) 0.4mg sublingual q 5 minutes x 3-will lower BP, monitor
Aspirin 160-325mg po chewed)
Remember your ABCDs when deciding what order to give these in.
Oxygen is the first priority.
NTG is next to dilate the arteries and stop the chest pain.
Aspirin is next to strip the platletts to prevent clotting.
Morphine IV is next to stop the pain and decrease oxygen demand.
IV. Assessment of 12 Lead ECG-Center of the Decision Pathway
Place into 1 of the 3 categories: A, B, or C below
A. ST segment elevation or new Bundle Branch Block
1. Strongly suspicious for injury
2. Leads: II, III, AvF-inferior
V2,V3,V4-anterior
I, V5, V6-lateral
V1-septal
3. Treatment: Beta blockers-class I < 12hrs
Nitroglycerin (NTG) IV-class I < 24-48hrs
Heparin IV esp. with TPA if indicated
ACE Inhibitors
B. ST segment depression or dynamic T-wave inversion or high
risk unstable angina or non-Q wave acute MI
1. Strongly suspicious for ischemia
2. Leads: see above
3. Treatment: Heparin IV (unfractionated heparin) or
LMWH (low molecular weight heparin), NTG IV, Aspirin,
Beta-blockers IV, Glycoprotein Receptor Inhibitors
4. If the patient is high risk, then send them for a heart cath.
(PTCA-percutaneous transluminal coronary angioplasty)
and/or open heart surgery (CABG-coronary artery bypass
grafting)
5. If the patient is stable, then monitor ECG and serial cardiac
markers
C. Nondiagnostic ECG
1. Absence of changes in ST segment or T waves
2. New onset angina tx same as IV. B.
3. Otherwise admit to a ECG monitored bed and serial ECGs and
cardiac markers
V. General guidelines for all < 12 hour time frame from onset of
symptoms
Consider a reperfusion strategy:
A. Thrombolytics (or commonly know as clot busters)
1. Within 3 to 6 hrs is best, some studies suggest within 12 hours
2. Contraindicated in: active bleeding, recent intracranial,
intraspinal, or eye surgery, severe hypertension, bleeding
disorders, GI bleeding, > 75 yrs old
NOTE: General Information for drugs does not preclude
your institutions policies and procedures. Read and follow
them.
There are several new thrombolytics on the market now, these are
some of the older ones.
3. TPA short acting within 2-6 hrs, expensive: 15 mg IV bolus,
then 0.75mg/kg over next 30 minutes (not greater than 50mg),
then 0.50mg/kg over next 60 minutes (not greater than 35mg),
start your Heparin protocol with the TPA
4. Streptokinase longer acting, less expensive, watch for pts
with strep throat or received this product in the past may be
contraindicated: 1.5 million IU over 1 hour, start Heparin
protocol after Streptokinase is finished
5. Reteplase: 10 units IV plus a 10 unit IV bolus over 2 minutes,
30 minutes apart.
B. PTCA (heart cath) with CABG (open heart surgery) as back up
VI. General guidelines for all > 12 hours
A. Assess symptoms and treat
B. If high risk (1, 2, or 3), then PTCA, PTI (stent) or CABG
1. symptoms continue despite M.O.N.A. tx and others stated
above
2. depressed left ventricular fx
3. ECG changes
C. If stable, monitor serial ECGs and cardiac markers (CPK,
CK-MB, and Troponin I)
