UNCONTROLLED WHEN PRINTED
Quick Chart
 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

Read the complete article; Acute Coronary Syndrome in the Medical Library > Pathophysiology.

 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:

  • Inter-scapula pain
  • Epigastric pain
  • Dizziness, Lightheadedness or Transient Loss of Consciousness
  • Unexplained upper limb / neck discomfort
  • Nausea / Vomiting with no obvious cause
  • Palpitations / dysrhythmias
  • Weakness / Malaise

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

 Exclusion Criteria
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.
  • Officers should have a low threshold for placing defibrillation pads on peri-arrest patients and consider early pad placement on all case of confirmed STEMI.
 Management
Primary Care
Intermediate Care
  • Apply cardiac monitor if trained and authorised. Conduct 12-Lead ECG and transmit to CSPSCC for interpretation.
  • 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
  • 12 lead ECG
    • If STEMI or STEMI Equivalent, consider placement of defibrillation pads 
    • 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)
  • 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
  • Symptom onset < 12 hours
  • Mobile and independent ADLs
  • GCS15
Indications for Transmission
  • Monitor reads "ACUTE MI" or "Meets STEMI criteria" OR
  • ST elevation ≥ 1mm in 2 contiguous limb leads OR
  • ST elevation in ≥ 2mm in 2 contiguous chest leads OR
  • Symptomatic acute left bundle branch block
Critical & Extended Care
 Additional Information
  • Clinical Deterioration
  • Dysrhythmias
  • Cardiac arrest
Key Terms & Links
Settings
Extended Care:
Colour assist:

References
References

Document Control


Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

Version

Published Date

Review Date

Clinical Resources Website

St John Ambulance Western Australia Ltd (ABN 55 028 468 715) (St John WA) operates ambulance and other pre-hospital clinical services. St John WA’s Clinical Resources, including its Clinical Practice Guidelines (Clinical Resources), are intended for use by credentialed St John WA staff and volunteers when providing clinical care to patients for or on behalf of St John WA, within the St John WA Clinical Governance Framework, and only to the extent of the clinician’s authority to practice.

Other users – Terms of Use

The content of the St John WA Clinical Resources is provided for information purposes only and is not intended to serve as health, medical or treatment advice. Any user of this website agrees to be bound by these Terms of Use in their use of the Clinical Resources.

St John WA does not represent or warrant (whether express, implied, statutory, or otherwise) that the content of the Clinical Resources is accurate, reliable, up-to-date, complete or that the information contained is suitable for your needs or for any particular purpose. You are responsible for assessing whether the information is accurate, reliable, up-to-date, authentic, relevant, or complete and where appropriate, seek independent professional advice.

St John WA expressly prohibits use of these Clinical Resources to guide clinical care of patients by organisations external to St John WA, except where these organisations have been directly engaged by St John WA to provide services. Any use of the Clinical Resources, with St John WA approval, must attribute St John WA as the creator of the Clinical Resources and include the copyright notice and (where reasonably practicable) provide a URL/hyperlink to the St John WA Clinical Resources website. 

No permission or licence is granted to reproduce, make commercial use of, adapt, modify or create derivative works from these Clinical Resources. For permissions beyond the scope of these Terms of Use, including a commercial licence, please contact medservices@stjohnambulance.com.au

Where links are provided to resources on external websites, St John WA:

  • Gives no assurances about the quality, accuracy or relevance of material on any linked site;
  • Accepts no legal responsibility regarding the accuracy and reliability of external material; and
  • Does not endorse any material, associated organisation, product or service on other sites.

Your use of any external website is governed by the terms of that website, including any authorisation, requirement or licence for use of the material on that website.

To the maximum extent permitted by law, St John WA excludes liability (including liability in negligence) for any direct, special, indirect, incidental, consequential, punitive, exemplary or other loss, cost, damage or expense arising out of, or in connection with, use or reliance on the Clinical Resources (including without limitation any interference with or damage to a user’s computer, device, software or data occurring in connection with such use).

Cookies

Please read this cookie policy carefully before using Clinical Resources from St John WA.

The cookies used on this site are small and completely anonymous pieces of information and are stored on your computer or mobile device. The data that the cookies contain identify your user preferences (such as your preferred text size, scope / skill level preference and Colour Assist mode, among other user settings) so that they can be recalled the next time that you visit a page within Clinical Resources. These cookies are necessary to offer you the best and most efficient possible experience when accessing and navigating through our website and using its features. These cookies do not collect or send analytical information back to St John WA.

Clinical Resources does integrate with Google Analytics and any cookies associated with this service enable us (and third-party services) to collect aggregated data for statistical purposes on how our visitors use this website. These cookies do not contain personal information such as names and email addresses and are used to help us improve your user experience of the website.

If you want to restrict or block the cookies that are set by our website, you can do so through your browser setting. Alternatively, you can visit www.internetcookies.com, which contains comprehensive information on how to do this on a wide variety of browsers and devices. You will find general information about cookies and details on how to delete cookies from your device. If you have any questions about this policy or our use of cookies, please contact us.

St John Ambulance Western Australia Ltd © Copyright 2020, All Rights Reserved

Terms of Use | Privacy Policy | Copyright Statement & Disclaimer