ACLS review: Acute Coronary Syndromes Part 2

Morphine

·         Morphine is the preferred analgesic for patients with STEMI

·         Use small dosages 2-4mg

·         May repeat q5 minutes as needed

·         Demerol for patients who are intolerant or allergic to MSO4

Note:  Morphine is indicated in STEMI when chest discomfort is unresponsive to nitrates (Class I, LOE C)

Oxygen

·         2-4L/min via mask or nasal cannula

·         Maintain saturations over 94%

Note:  If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to 94% (Class I, LOE C).

ACC/AHA Guidelines have noted that there appeared to be little justification for continuing routine oxygen use beyond 6 hours

Nitroglycerine

·         Causes dilation of the coronary arteries (particularly in the region of plaque disruption), the peripheral arterial bed, and venous capacitance vessels

·         Give up to 3 doses of sublingual or aerosol nitroglycerin at 3- to 5-minute intervals until pain is relieved or low blood pressure limits its use

Note:  For persistent chest pain, begin either IV  or topical nitroglycerine

Nitroglycerine

Avoid the use of nitrates in patients with hypotension (SBP >90 mm Hg or >30 mm Hg below baseline), extreme bradycardia (>50 bpm), or tachycardia in the absence of heart failure (>100 bpm) and in patients with right ventricular infarction

Note:  Caution is advised in patients with known inferior wall STEMI, and a right-sided ECG should be performed to evaluate RV infarction.
Administer nitrates with extreme caution, if at all, to patients with inferior STEMI and suspected right ventricular (RV) involvement because these patients require adequate RV preload.
Nitrates are contraindicated when patients have taken a phosphodiesterase-5 (PDE-5) inhibitor within 24 hours (48 hours for tadalafil).
Circulation. 2010; 122: S787-S817 doi: 10.1161/​CIRCULATIONAHA.110.971028

Aspirin

·         ASA administration is associated with a decrease in mortality rates

·         160-325mg by mouth

·         Aspirin suppositories (300 mg) for patients with severe N&V, or disorders of the upper GI tract

Note:  Aspirin produces a rapid clinical antiplatelet effect with near-total inhibition of thromboxane A2 production. It reduces coronary reocclusion and recurrent ischemic events after fibrinolytic therapy
EMS providers should administer nonenteric aspirin (160 [Class I, LOE B] to 325 mg [Class I, LOE C]). The patient should chew the aspirin tablet to hasten absorption.
NSAIDS should not be administered during hospitalization for STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use (Class III, LOE C).180–182
Circulation. 2010; 122: S787-S817 doi: 10.1161/​CIRCULATIONAHA.110.971028