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EMS Professions
Temple College
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The History of Paramedics Begins
with Cardiac Care
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Ischemic Coronary Syndromes
✔Acute Coronary Syndromes
➨Angina Pectoris
➨Unstable Angina
➨Acute Myocardial Injury
➨Acute Myocardial Infarction
✔ Presentation with suspected ischemia
◆ Non-diagnostic ECG
◆ ST segment depression
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Ischemic Coronary Syndromes
✔Angina Pectoris
➨Acute pain, usually in the chest, resulting from
an increased demand for oxygen and a
decreased ability to provide it
➨Usually due to a partially occluded coronary
artery or vasospasm
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Ischemic Coronary Syndromes
✔Angina Pectoris
➨Typical Presentation
◆ Squeezing, Crushing, Heavy, Tight
– Fist to chest = Levine’s sign
◆ Pain/Discomfort may radiate to shoulders,
arms, neck, back, jaw or epigastrium
◆ Usually lasts 3-5 min and rarely exceeds 15 min
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Ischemic Coronary Syndromes
✔Angina Pectoris
➨Typical Presentation
◆ Anxiety
◆ Diaphoresis or clammy skin
◆ Nausea, vomiting
◆ Shortness of breath
◆ Weakness
◆ Palpitations
◆ Syncope
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Ischemic Coronary Syndromes
✔Angina Pectoris
➨Usually Provoked by:
◆ Exercise
◆ Eating
◆ Emotion/Stress
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Ischemic Coronary Syndromes
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Ischemic Coronary Syndromes
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Ischemic Coronary Syndromes
✔Stable Angina Pectoris
➨Treatment
◆ Physical/Psychological rest
◆ Position of comfort, sitting or supine
◆ Oxygen
◆ ECG Monitor
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Ischemic Coronary Syndromes
✔Stable Angina Pectoris
➨Variant Angina (Prinzmetal’s Angina)
◆ Occurs at rest
◆ Episodes at regular times of day
blockers
◆ May result in abnormal 12 lead ECG changes
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Ischemic Coronary Syndromes
✔Unstable Angina
➨Prolonged chest pain/ischemic symptoms or an
atypical presentation of angina without ECG
or laboratory evidence of AMI (Injury)
➨Usually associated with significant or
progressing occlusion of a coronary artery or
severe vasospasm
➨Considered “Pre-infarction Angina”
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Ischemic Coronary Syndromes
✔Unstable Angina
➨May have Typical or Atypical Signs &
Symptoms
◆ Atypical Presentation
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Ischemic Coronary Syndromes
✔Unstable Angina
➨Treatment same as Angina PLUS:
◆ IV, NS (no dextrose), TKO
– Some exceptions to restricting fluid
◆ 12 Lead ECG
– Assess for RVI
◆ Morphine sulfate, 2 - 4 mg q 5-15 min slow IV
titrated to pain relief and BP > 90
◆ Aspirin, 160-325 mg PO
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Ischemic Coronary Syndromes
as Acute MI
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Ischemic Coronary Syndromes
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Ischemic Coronary Syndromes
◆ Microemboli
◆ Severe Hypotension/Shock
◆ Acute Hypoxia
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Ischemic Coronary Syndromes
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Ischemic Coronary Syndromes
involved
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Evolution of AMI
Lipid core
Fibrous cap
Ada pte d from Libby P . Circulat ion. 1995;9 1:2844- 2850, w ith permission.
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Evolution of AMI
Occlusive
thrombosis
Healed plaque
— decreased stenosis
Ada pte d from Davies MJ . In: Schla nt RC, Alexander RW, eds. The Heart, Arteries
and Ve ins. 8th ed. 1994:1 009-102 0, with permission.
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Evolution of AMI
Lipid- Plaque
rich disruptio
plaque n
Reocclusion
Unstable
angina
Thrombus
Partial (labile) occ lusion Recurrent pain
Ada pte d from Fus ter V. N Engl J Med. 199 2;326:2 42-250, with perm iss ion.
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Coronary Artery Without Evidence
of Plaque
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Coronary Artery With Plaque and
Thrombus Formation
A - Coronary
Artery cross-
section
B - Lumen
C - Fissured
Plaque w/o
Cap
D - Acute
thrombus
30Source: Emergency Cardiovascular Care Library (CD-ROM), American Heart Association, Dallas 1997
Plaque and Thrombus Formation
Resulting in Occlusion
The external
anterior
view of the
heart shows
a dark clot
formation in
this artery
30 min 4h 6 - 12 h
Ada pte d from Sa ltissi S , Mushahwar S S. Postgrad Med J. 1995;71 :534-54 1, with permission.
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Ischemic Coronary Syndromes
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Enzyme changes
Therapies
REDUCE MORTALITY
IMPROVE OUTCOME
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Ischemic Coronary Syndromes
– Nitroglycerin IV infusion
– Heparin
◆ Thrombolytics Checklist
– Exclusions for thrombolysis
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Ischemic Coronary Syndromes
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Considerations for Fibrinolytics
Acute Ischemic Syndromes:
Diagnostic Considerations
Thrombolytics are not appropriate in all acute ischemic
syndromes
• Not all acute ischemic syndromes are AMIs
• ST-segment elevation suggests thrombic occlusion
and need for immediate reperfusion
• No proven benefit of thrombolytic therapy in patients
without ST-segment elevation
• Patients with ST-segment depression and/or T-wave
inversion are currently not candidates for thrombolytic
therapy
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Contraindications for
Fibrinolytics
✔ Lack of diagnostic 12 ✔ Surgery or trauma in
Lead ECG changes past 3 weeks
✔ Chest pain < 20 min or ✔ Terminal illness
> 12 hours ✔ Jaundice, hepatitis,
✔ Not oriented, can not kidney failure
cooperate ✔ Use of anticoagulants
✔ History of stroke or TIA ✔ Systolic BP < 180 mm
✔ Known bleeding Hg
disorder ✔ Diastolic BP < 110 mm
✔ Active internal bleeding Hg
in past 2-4 weeks
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Ischemic Coronary Syndromes
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References and Resources