You are an ACLS team Leader who has been presented with a conscious and alert 55 year old male.
As you interview the patient you ask him how he is feeling?
The primary assessment reveals that he is responsive, has an open airway, but he’s
experiencing shortness of breath.
You learn that the patient was watching TV when the symptoms started which was about
3 hours ago.
The patient is now complaining of chest pain, pressure in the chest, shortness of breath,
and you can tell he’s very diaphoretic.
We know that the patient has a pulse and is breathing, so the next step is to check more
in depth vital signs.
As the team leader, you ask another available team member to attach the blood pressure cuff
and place the patient on an O2 saturation monitor, a more detailed pulse check is taken,
and a respiration rate, and temperature is assessed.
Now even before vitals signs are recorded, a first drug may be given to a patient with
a suspected heart attack.
And that first medication is aspirin.
First, you’ll want to ask the patient if they’re allergic to aspirin or if the patient
has problems with gastrointestinal bleeding.
Keep in mind there’s a difference between aspirin sensitivity and having an anaphylactic
reaction to something like aspirin.
And stomach upset doesn’t really qualify for gastrointestinal bleeding, so just keep
those things in the back of your mind.
And if the patient responds yes to either of those questions then aspirin may be actually
contraindicated.
But in this scenario we’re gonna say that the patient does not have an allergy and there
are no gastrointestinal bleeding problems.
In this case, the correct dose is given somewhere between the range of 160-324 mg of chewable
aspirin.
In our scenario we give the patient 324mg of chewable aspirin.
The team member now has the vital signs and tells you that the patient’s pulse is 124
beats per minute.
It’s regular while respirations are at 22, and the blood pressure is 140 over 90, the
skin is cool and pale, and the O2 sat is 92%.
Now based on this information we decide the patient is stable at the moment.
But one thing to keep in mind is that the goal for oxygen therapy is to titrate the
amount given in order to achieve at least 94% saturation.
It’s not necessary, and is potentially even harmful to use high flow oxygen to bring the
O2 sat higher.
High-flow oxygen therapy can reduce cardiac output and stroke volume.
It can cause vasoconstriction at a time when we especially need vasodilation.
Oxygen is not recommended for an O2 saturation reading that is 94% or greater.
Now since our patient has an O2 sat of 92% it would be appropriate to start a low-flow
amount of oxygen via nasal cannula, and we’re going to do that at between 2 and 4 liters
per minute.
Now that the basic vital signs are known and the oxygen has been established, it’s important
to get a 12 lead ECG on this patient.
Now this is gonna help us in for assessing the need for fibrinolytic therapy.
Within the first 10 minutes of being seen by a healthcare provider, a 12 lead ECG, a
targeted history, and a physical exam all need to be done to assess whether or not fibrinolytic
therapy is appropriate.
Now, when assessing the 12 lead ECG, an ST elevation or depression would create a strong
suspicion for injury or ischemia.
In our scenario, however, it looks like a normal sinus rhythm.
And at this time it’s important to gain IV access and draw blood to send to the lab.
A good choice would be an 18 gauge IV with normal saline at a TKO rate.
Now, since the patient is still having chest pain and the blood pressure is above 90 systolic.
Nitroglycerin should be administered.
Before giving nitroglycerin it is important to ask if the patient has taken any erectile
dysfunction drugs, or any other medications that would behave in a vasodilation way, within
the last 24-48 hours.
If the patient has, nitroglycerin would be contraindicated.
Now if patient can have nitro, it’s given in a .4 mg tablet or spray sublingually, and
it can be repeated every 5 minutes for pain as long as the blood pressure remains above
90 systolic.
You would tell the patient that you’re going to give a tablet of nitroglycerin to dissolve
under the tongue and that it should help with the pain.
It wouldn’t be wrong to tell them that they might even develop a little bit of a headache
with it, or that it tingles under the tongue, as normal side effects.
It’s important to monitor the patient closely to look for changes in status.
The level of the chest pain and the blood pressure need to be assessed at least every
5 minutes, which we call serial vitals, in order to consider additional doses of nitroglycerin.
In our scenario the patient’s pain is still at about an 8 out of 10 and the blood pressure
is 120 over 88.
It would be recommended to administer a second dose of nitro at .4 mg sublingually.
It would also be appropriate to run another 12 lead to see if there are any changes have
occurred.
The most important interventions early on for an acute coronary syndrome patients are
to provide adequate oxygenation, administer pharmacologic interventions to reduce pain
and anxiety, perform a timely assessment using a 12 lead EKG, history and blood labs.
The patient needs to be evaluated early for the possibility of fibrinolytic therapy, Cath
Lab consideration for percutaneous coronary interventions known as PCI, or to be transferred
for continued care at a Cardiac Unit.