Chest Pain / Acute Coronary Syndrome

UNCONTROLLED WHEN PRINTED

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Introduction

Acute coronary syndrome (ACS) represents a continuum of clinical presentations sharing common pathology, ranging from worsening angina through to ST-elevation MI (STEMI).
Most patients present with prolonged (>10mins) or recurrent central chest discomfort described as tightness, heaviness, squeezing or crushing sensation. The absence of these symptoms does not rule out ACS.
Patients suffering from Acute Coronary Syndromes do not always present with chest pain, and are subsequently frequently misdiagnosed

Clinical Presentation

Chest pain or discomfort of presumed cardiac origin
Acute or Sub-acute shortness of breath with no clear reason or cause (up to ⅓ of ACS patients may present without chest pain).

Other signs and symptoms associated with atypical ACS presentation may include:

Officers should have a low threshold for performing an ECG when any of the above symptoms are found.

Exclusion Criteria

Risk Assessment

Suspicion of acute myocardial ischaemia (AMI) is based entirely on field history. A normal-looking ECG does not rule out ACS.
Glyceryl Trinitrate (GTN) administration can precipitate severe hypotension in susceptible patients however it is a rare occurrence.
Limit patients exertion as much as is practically possible.
LBBB with associated chest pain should be treated as acute until proven otherwise.
Patients with a history of diabetes have an increased risk of presenting without chest pain in ACS. Officers should have a low threshold for performing an ECG.

Management

Primary Care

Primary Survey
Reassurance (continuous)
Limit patients exertion as much as is practically possible
Vital Sign Survey (monitor regularly including pre-and-post intervention pain scores)
Consider Oxygen if indicated as per CPG
Consider Secondary Survey

Intermediate Care (EMT / Level 2)

Apply cardiac monitor if trained and authorised.
Administer aspirin
Administer GTN early (if pain is ongoing and provided GTN not contraindicated)
Pain relief: If pain >3/10 post 1x spray of GTN, administer Methoxyflurane
Ondansetron if required
Monitor patient continuously, recording full observations every 10 minutes (or 5 minutes if time critical)
Transport Priority 1 if patient time critical, pre-notifying receiving facility

Advanced Care (AP)

12 lead ECG; transmit telemetry to receiving hospital as indicated
- Multiple 12-lead ECG’s are advocated and may capture evolving changes. If the initial ECG is not diagnostic of a STEMI but the patient remains symptomatic and clinical suspicion for ACS remains high, the ECG should be repeated at least every 15 minutes.
Aspirin
Early Glyceryl Trinitrate (GTN)
Analgesia (where GTN has failed to relieve the chest pain completely)
- Methoxyflurane if unable to administer opioid analgesia
- Intranasal or intravenous Fentanyl
Vascular access; obtain pre-hospital blood sample
Ondansetron if required
Administer heparin if the patient has a STEMI confirmed by the receiving hospital and patient is going direct to Cardiac Catheterisation Lab

STEMI Inclusion Criteria

Indications for Transmission

Critical & Extended Care (CCP, PSO)

Additional Information

References

Key Terms & Links

Colour assist:

Directorate

Clinical Services

Responsible Manager

Head of Clinical Services

Published Date

Review Date