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In this lesson, we're going to let you play the role of team leader during an acute coronary syndrome emergency. From start to finish, you'll be in charge of assessing the patient and providing therapy and treatment recommendations.
In this scenario, you've been presented with a 55-year-old male who is conscious and alert. As you interview the patient and ask him how he's feeling, you learn that he is responsive, has an open airway, and is suffering from shortness of breath.
You also learn that he was watching TV when the symptoms began, which was about 3 hours ago. And he's now complaining of chest pain, pressure in the chest, and is sweating.
Your initial assessment recap:
- 55-year-old male
- Conscious and alert
- Shortness of breath
- Chest pain and pressure
- Sweating
- Symptoms began 3 hours previous
You know the patient has a pulse and is breathing, so the next step is to check for more in-depth vital signs. As the team leader, you ask another available member of your team to attach a blood pressure cuff and place the patient on an O2 saturation monitor.
A more detailed pulse check is taken, and his respiratory rate and temperature check are also assessed. However, even before vital signs are recorded, a first drug may be given to the patient if you suspect a heart attack, and that first drug would be aspirin.
If this is the case, first ask the patient if he's allergic to aspirin or has problems with gastrointestinal bleeding.
Pro Tip #1: Keep in mind, there's a difference between aspirin sensitivity and having an anaphylactic reaction to aspirin. Also, stomach upset doesn't qualify as gastrointestinal bleeding.
If the patient answers yes to either of those two questions above, aspirin may be contraindicated. However, in our fictional scenario, the patient has no aspirin allergy, nor does he have any gastrointestinal bleeding issues.
In this case, the correct dose would be somewhere between 160 and 324 mg of chewable aspirin, and in this particular scenario, you administer 324 mg.
The team member now has the patient's vital signs and tells you the following:
- Pulse: 124 beats per minute and regular
- Respiratory rate: 22
- Blood pressure: 140/90
- Skin: cool and pale
- O2 saturation: 92 percent
Based on this information, you decide that the patient is stable at the moment. One thing to keep in mind, however, is that the goal for oxygen therapy is to titrate the amount given to achieve at least 94 percent saturation.
Pro Tip #2: It's not necessary and even potentially harmful to use high-flow oxygen to bring the O2 saturation higher, as high-flow oxygen therapy can reduce cardiac output and stroke volume, which can cause vasoconstriction at a time when you especially need vasodilation.
Also, remember that oxygen is not recommended for an O2 saturation of 94 percent or greater. But since your patient has an O2 saturation of 92 percent, it would be appropriate to begin a low-flow amount of oxygen via nasal cannula between 2 and 4 liters per minute.
Now that the patient's basic vital signs are known and oxygen has been established, it's important to get a 12-lead ECG on the patient. This will help you in assessing his need for fibrinolytic therapy.
Pro Tip #3: Within the first 10 minutes of contact with a healthcare provider, a 12-lead ECG, a targeted patient history, and a physical exam all need to be done to assess whether or not fibrinolytic therapy is appropriate.
When assessing a 12-lead ECG, an ST elevation or depression would create a strong suspicion of injury or ischemia. In this scenario, however, it looks like a normal sinus rhythm. And at this time, it's important to gain IV access to draw blood to send to the lab.
A good choice for that would be an 18-gauge IV with normal saline at a TKO rate – a rate that flows just enough to keep the vein open. And since the patient is still complaining of chest pain and his blood pressure is above 90 systolic, nitroglycerin should be administered.
Before giving the patient nitroglycerin, it's important to ask him if he's taken any erectile dysfunction drugs or any other medications that would behave in a vasodilatory fashion within the last 24 to 48 hours. If the patient has, nitroglycerin would be contraindicated.
If the patient can have nitroglycerin, it would be given in a 0.4mg tablet or spray sublingually, and this can be repeated every 5 minutes for pain as long as his blood pressure remains above 90 systolic.
Tell your patient that you're going to give him a tablet of nitroglycerin to be dissolved under his tongue, and that this should help with his pain.
Pro Tip #4: Talk to your patient and tell him what to expect. In this situation, you could also mention that the nitroglycerin may cause a little bit of a headache or a tingling sensation under the tongue as normal side effects.
It's important to monitor the patient closely and look for changes in his status, such as his level of chest pain and blood pressure, which should be assessed at least every 5 minutes (or serial vitals) in order to consider additional doses of nitroglycerin.
In this scenario, the patient's level of pain is still at an 8 out of 10 and his blood pressure is 120/88. This would indicate the recommendation for a second dose of nitroglycerin, again at 0.4mg sublingually. It would also be appropriate to run another 12-lead ECG to see if any changes have occurred.
The most important interventions early on for an ACS patient are:
- Provide adequate oxygenation
- Administer pharmacological interventions to reduce pain and anxiety
- Perform timely assessments:
• 12-lead ECG
• History
• Blood labs
The patient should be evaluated early for the possibility of fibrinolytic therapy, catheter lab consideration for percutaneous coronary intervention (PCI), or to be transferred for continued care at a cardiac unit.
