ACS Management by SAAS Paramedics

aCs management by saas ParamediCs

While an aim of the SAAS STEMI Flow Chart is to identify patients eligible for direct transfer to a PCI facility, its primary aim is to examine a number of referral options based on the patient’s presentation, clinical assessment and location. These referral options attempt to strike a balance between patient needs and patient safety.

The flowchart is designed to be used for all patients presenting with chest pain suspicious of ACS involvement. It will guide the paramedic to the appropriate referral decision based on:

• Patient stability • Presence of ongoing pain • Patient specific criteria • 12-Lead ECG criteria • Contraindications

The four possible referral options are shown below and will be discussed in more detail shortly.

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Chest Pain Consistent with ACS

This flowchart should be applied to all patients presenting with chest pain presumed or suspected to be cardiac in origin.

The first section describes preliminary ACS care and should be considered in conjunction with the Paramedic CPG - Chest Pain.

The decision to establish IV access should not be limited to just meeting an obvious need. It should also be established on likely need or anticipated deterioration.

Capturing a 12-Lead ECG at this point has the advantage of establishing an early baseline* and measuring the effectiveness of your treatment.

* 12-Lead ECG criteria for STEMI requires 2 serial ECGs

Is the Patient Stable?

Patient stability not only influences morbidity and mortality in the setting of myocardial infarction, but also influences the referral options in the pre-hospital phase.

If a patient presents as clinically unstable or deteriorates in your care, they must be referred to Clinical Support. If this isn’t possible, consult with the EOC Clinician for advice and referral options.

For the purposes of this flowchart, the term ‘Not Stable’ includes but not limited to:

• Decreasing GCS • Requiring ventilatory support • Inadequate MAP or BP • Inappropriate HR or rhythm • Observations trend suggesting deterioration • Other concerns (Paramedic’s discretion) Before embarking on a long transport, consider the patient’s likelihood of deterioration and where possible mitigate this risk.

If you have determined that the patient is stable, the next question you need to ask is “Has the pain resolved?”

Has Pain Resolved?

Chest pain* that resolves with rest +/- nitrates is suggestive of Stable Angina (where an imbalance between myocardial oxygen demand and supply results in regional myocardial ischaemia).

By contrast, ACS occurs at rest and is usually caused by a coronary plaque rupture and intracoronary thrombosis formation. As a result, the ischaemic pain in ACS is unlikely to resolve without reperfusion therapy.

Even stable patients with ongoing ACS chest pain are at significant risk of developing lifethreatening complications.

For the purposes of this flowchart, a drop in pain score is not the same as pain resolution. If the patient still has residual pain after the completion of treatment, the pain has NOT resolved.

* Chest pain is a term used to describe discomfort in the arm/shoulder/neck/jaw or chest believed to be cardiac in origin.

STEMI Criteria Met?

The Code STEMI activation criteria for SAAS Paramedics is divided into a number of subcriteria. These are:

• Patient Specific Criteria • 12-Lead ECG Criteria • Absence of Contraindications

All sub-criteria must be met before considering Code STEMI activation.

It is important to note that if Code STEMI activation isn’t indicated, this does not mean that the patient isn’t having a myocardial infarction. It simply means that access to a PCI facility isn’t one of your available referral options. Ineligible symptomatic patients should be transported to the nearest appropriate ED, and where possible notification should occur using the ISBAR format. P2 transport should also be considered.

Patient Specific Criteria

• Symptoms consistent with ACS • Ongoing unrelieved chest pain • GCS=15 • Onset of symptoms < 12 hours • Travel time to PCI facility within 60 minutes

12-Lead ECG Criteria

The following features present on 2 serial ECGs: • ST-elevation of at least 1mm in 2 or more contiguous limb leads

AND / OR

• ST-elevation of at least 2mm in 2 or more contiguous chest leads

AND

• Normal QRS* complex duration or RBBB present.

For the purposes of this criterion, normal QRS segment duration is less than 0.12secs.

Contraindications

• Absence of chest pain • Unstable patient (see previous page) • STEMI in the setting of trauma • STEMI in the terminal phase of a terminal illness.

Referral Options

As the title Routine Care implies, this referral option is ‘business as usual’. The suggestions of ongoing observations and transport for further care are there to remind you that while your stable patient’s ACS-like symptoms have resolved, monitoring and follow-up are still required. While Code STEMI activation is NOT warranted in this case, you may still choose to Request Clinical Support or expedite transport to an ED where appropriate This should be the first referral option considered. After assessing the patient during Basic Care, you should be asking the question “Is this patient stable?” If the patient is deemed unstable, Clinical Support must be requested. Where unavailable, consult with the EOC Clinician to discuss management and referral options.

This referral option is only available when all the criteria are met. While Clinical Support is not mandated, you still have the discretion to request it where you feel it would benefit the patient.

This referral option is for stable patients with ongoing / unrelieved chest pain consistent with ACS that fails to meet the Code STEMI activation criteria.

You also have the discretion to request Clinical Support if you believe it is warranted.

While Clinical Support is not mandated, you still have the discretion to request it where you feel it would benefit the patient. This is especially true for cases where significant travel times are involved, and where you believe that the patient is at risk of deteriorating en-route.