ACS 2- Initial Mangement in ED

Ischemia

Ischemia

zone of hypoxic myocardial tissue that may recover if circulation and oxygen supply restored

(trying to salvage)

Injury

zone of infarcting tissue where myocardial cell death is occurring due to continued ischemia

(releasing troponin)

Infarction

zone of necrotic nonviable tissue

(no turning back)

Anterior Wall MI

Represents occlusion in left anterior descending artery

Lateral Wall MI

Represents occlusion in left circumflex artery

Inferior Wall MI

Represents occlusion in right coronary artery

Common Cardiac Biomarker

Troponin T and I

What are cardiac markers are needed to:

1)Confirm diagnosis of MI without ST-segment elevation

2)Differentiate between UA and NSTEMI

3)Predict prognosis of STEMI

4)Determine success of reperfusion therapy

cTnI Suspicious for injury cardiac troponin

0.04 ng/mL or more

Negative cTnI

0-0.03 ng/mL

Initial Management of ACS- What do pateints get? (5)

Morphine (IV PRN- AFTER NTG)

Oxygen if POx <90%

Anticoag

NTG IV

ASA 325 mg chewed and swallowed ASAP

MOANA

When to give Oxygen?

Use when POx <90%

When can we use Morphine for ACS? What shoulf we give with Morphine?

Morphine PRN ONLY if inadequate pain relief from NTG

Give with scheduled stool softener

Can you give NSAIDs as analgesics in ACS?

NOOOO!!! (except aspirin )

When to give pts nitrates for ACS?

For pts who still have CP after 3 SL NTG tabs

IV 24-48 hours then switch to oral/ topical if still needed AFTER starting BB

Must keep increasing to avoid tolerance

Contraindications for Nitrates

Avoid in Pts with right ventricular infarcts

PDE inhibitors

What is a common SE of Nitrates

Headache!

When to start BB in ACS?

Initiatie within 24 hours of admission

When should we give a loading dose of BB?

IV load if hypertensive, tachycardic or ahs ongoing ischemia

What beta blocker do we use inpatient ?

Titrate with Tartrate!!

BB Contraindications

Use with caution if HR <60

2nd or 3rd degree AV block

PR interval >0.24 sec

SBP<80 mmHg

Signs of cardiogenic shick

Active asthma or COPD

Reveal pt for BB candidacy once stabilized

When do we use CCBs for ACS and which ones?

Can try diltiazem or verapamil when BB is ineffective, contraindicated or cause side effects or they taking meth or coke

Can we use Nifedipine IR in ACS?

NO! Nifepidipine IR contraindicated