CONTINUED PROFESSIONAL DEVELOPMENT
Dr Peter du Toit
Travelling Fleet Supervisor – Medical Services
Cell:: +39 3490875696
Email: peter.dutoit@msccruisesonboard.com
ACUTE CORONARY SYNDROME(ACS) COMPANION DOCUMENT
The ACS companion document is designed to provide essential support to onboard Medical
Teams when addressing patients with chest pain. This document aligns with the monthly
Continuing Professional Development (CPD) program, drawing from the latest insights found on
www.UptoDate.com. It's essential to note that this document does not replace
www.UpToDate.com as your primary medical reference; instead, it complements it.
Medication dosages are not included in this companion document. To ensure accurate dosing, it
is advised to consult www.UpToDate.com or refer to reputable sources such as the British National
Formulary and Medscape.
This companion document serves two purposes. It's a tool both at the patient's bedside for realtime assessment and as a reference during documentation using SeaCare.
Here's how to utilize it at the bedside:
•
Print out the CPD COMPANION SHEET-1 ACS assessment document and secure it on a
clipboard.
CPD COMPANION SHEET-1
ACS ASSESSMENT
Enter relevant patient data directly onto the sheet during the bedside consultation.
Consider following the suggested steps sequentially as outlined in the document.
Upon completing the ACS Assessment document, determine the appropriate next
companion sheet (2-4) based on the patient's history, clinical findings, and 12-lead ECG
results.
• Companion sheets 2,3 and 4 can be printed out in advance and filed in a ACS file.
CPD COMPANION SHEET-2
SUSPECTED ACS MANAGEMENT OPTIONS
•
•
•
CPD COMPANION SHEET-3
NSTEMI/HIGH RISK ACS MANAGEMENT OPTIONS
CPD COMPANION SHEET-4
STEMI MANAGEMENT OPTIONS
• Companion sheets 2,3 and 4 have been developed to provide a methodical approach to
managing these cases.
• The companion document is intended as a support tool and is provided for information
only.
• Clinical decision making remains the responsibility of all medical professionals and you will
need to use your clinical judgement to make appropriate decisions, based on current best
practice.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
CPD COMPANION SHEET-1
ACS ASSESSMENT
Enter text where indicated. Checked boxes indicate completed actions or applicable findings
Always use www.uptodate.com as your main reference resource.
PATIENT INFORMATION
VESSEL:
Click or tap here to enter text.
NAME:
Click or tap here to enter text.
DOCTOR:
Click or tap here to enter text.
CABIN:
Click or tap here to enter text.
DATE:
Click or tap to enter a date.
CREW
ID:
Click or tap here to enter text.
TIME:
Click or tap here to enter text.
STEP 1
HISTORY OF PRESENTING ILLNESS
TIME:
☐
Time chest pain started:
Click or tap here to enter text.
CHEST PAIN: CHARACTERISTICS:
☐
Onset:
Click or tap here to enter text.
☐
Exacerbation or
relieving factors:
Click or tap here to enter text.
☐
Quality:
Click or tap here to enter text.
☐
Radiation:
Click or tap here to enter text.
☐
Site:
Click or tap here to enter text.
☐
Time course:
Click or tap here to enter text.
STEP 2
DETERMINE HIGH AND LOW RISK SYMPTOM
Characteristics typical of Ischaemic pain
Characteristics typical of non-ischaemic chest pain
☐
Shortness of Breath.
☐
Pleuritic pain, sharp or knife-like pain
related to respiratory movements or
cough
☐
Nausea/Belching
☐
Primary or sole location in the mid or
lower abdominal region
☐
Vomiting
☐
Any discomfort localized with one
finger
☐
Indigestion
☐
Any discomfort reproduced by
movement or palpation
☐
Diaphoresis/Clamminess
☐
Constant pain lasting for days
☐
Dizziness/ Light-headedness
☐
Fleeting pains lasting for a few
seconds or less
☐
Fatigue
☐
Pain radiating into the lower
extremities or above the mandible
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 3
DETERMINE HISTORICAL FEATURES INCREASING CHANCE OF ACS
☐
Prior history of ACS - significantly increased risk of recurrent ischaemic events.
☐
Prior history of other vascular disease - increased risk of cardiac ischaemic events
comparable to that seen with a prior history of ACS.
RISK FACTORS
☐
Increased Age
☐
Dyslipidaemia
☐
Male sex
☐ Diabetes
Cigarette
☐ Hypertension
smoking
Recent use of cocaine or other sympathomimetic drugs (e.g., methamphetamine).
STEP 4
☐
☐
☐
CONSIDER ATYPICAL PRESENTATION
Atypical symptoms - more common in women, the elderly, and diabetics
STEP 5
CONSIDER DIFFERENTIAL DIAGNOSIS AND POTENTIALLY LIFETHREATENING CAUSES OF CHEST PAIN
☐
Cardiovascular: ACS, Aortic dissection, Myocarditis, Pericarditis, Cardiac Tamponade,
Pulmonary embolism, Cardiac valve disease, Stress Cardiomyopathies e.g.Takotsubo
☐
Other: Tension pneumothorax, Acute chest syndrome (in sickle cell disease), Boerhaave
syndrome (perforated oesophagus)
STEP 7
☐
INITIAL ASSESSMENT (REVIEW AND CONSIDER THE FOLLOWING
ACTIONS)
ABC’S (Airway, Breathing, Circulation)
Click or tap here to enter text.
☐
Disability: (Awake, Verbal, Pain, Unresponsive)
Click or tap here to enter text.
☐
Blood pressure:
☐
Respiratory rate:
☐
Preliminary history and examination obtained
Click or tap here to
enter text.
Click or tap here to
enter text.
☐
Pulse rate:
☐
Pulse Oximeter
Click or tap here to enter text.
☐
Screening neurologic examination
Click or tap here to enter text.
☐
Resuscitation equipment and 12 Lead ECG brought to the bedside
☐
Cardiac monitor attached to patient
☐
Oxygen given if indicated
☐
Intravenous (IV) access and blood work obtained
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
Click or tap here to
enter text.
Click or tap here to
enter text.
STEP 8
MEDICATIONS TO CONSIDER
☐
Aspirin 162 to 325 mg (not enteric coated)
☐
Nitrates (contraindications to nitrates include severe aortic stenosis, hypertrophic
cardiomyopathy, suspected right ventricular infarct, hypotension, marked bradycardia or
tachycardia, and recent use of phosphodiesterase 5 inhibitor [e.g., Viagra])
STEP 9
ECG ASSESSMENT
Indications for a 12 lead ECG:
☐
Any patient > 21 years old with chest pain
☐
Any patient > 80 years old with abdominal pain, nausea, or vomiting.
☐
Any patient > 50 years old with any of the following: dyspnoea, altered mental status, upper
extremity pain, syncope, or weakness.
1ST ECG
☐
2ND ECG
☐
TIME:
TIME:
Click or tap here to
enter text.
Rate:
Rate:
Click or tap here to
enter text.
Rhythm:
Rhythm:
Click or tap here to
enter text.
Axis:
Axis:
Click or tap here to
enter text.
Intervals (PR, QRS, QT
Intervals (PR, QRS,
Click or tap here to
interval):
QT interval):
enter text.
P wave:
P wave:
Click or tap here to
enter text.
QRS complex:
QRS complex:
Click or tap here to
enter text.
ST segment-T wave:
ST segment-T wave:
Click or tap here to
enter text.
Is there ST elevation or Click or tap here to
Is there ST elevation
depression?
or depression?
enter text.
ECG 1 interpretation: Click or tap here to enter text.
☐
If the initial ECG is non-diagnostic, consider serial ECG’s
☐
ECG 2 interpretation:
Click or tap here to enter text.
☐
Further ECG’s
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
STEP 10
ECG DIRECTED MANAGEMENT OF CHEST PAIN
The 12 lead ECG will now guide you to the suggested treatment options
Use serial ECG's to guide your management options if initial ECG is non-diagnostic
CHOOSE ONE OF THE 4 BELOW OPTIONS:
☐
OBVIOUS NON-ACS CAUSE
•
•
•
ECG reveals a non-ischaemic cause including Pericarditis or
arrhythmias
Clinically not suspicious of ACS
Manage accordingly
NON ACS
GROUP
Click or tap here to enter text.
☐
Suspected ACS due to history and examination
•
•
ECG reveals a Non-ischaemic ECG
ECG reveals a Non-diagnostic ECG
FOLLOW
SUSPECTED
ACS
MANAGEMENT
OPTIONS
Click or tap here to enter text.
☐
ECG reveals Ischaemic ECG changes
• Findings consistent with NSTEMI are:
o New or presumed new horizontal or down-sloping ST
depression ≥0.05 mV (0.5 mm) in two anatomically
contiguous leads
and/or:
o T wave inversion ≥0.1 mV (1 mm) in two anatomically
contiguous leads with prominent R wave or R/S ratio >1
• Other ECG patterns consistent with acute myocardial ischemia
o
aVR ST-segment elevation
o
ST-segment depression
o
Wellen’s syndrome
o
Inverted T-waves
FOLLOW
NSTEMI HIGH
RISK ACS
MANAGEMENT
OPTIONS
Click or tap here to enter text.
☐
ECG: Findings consistent with ST elevation myocardial infarction
(STEMI):
• New ST elevation at the J point in two anatomically contiguous
leads using the following diagnostic thresholds:
o ≥0.1 mV (1 mm) in all leads other than V2 to V3, where
the following diagnostic thresholds apply:
o ≥0.2 mV (2 mm) in men ≥40 years,
o ≥0.25 mV (2.5 mm) in men <40 years,
o or ≥0.15 mV (1.5 mm) in women.
•
•
Patients with typical and persistent symptoms in the presence of
a new or presumably new left bundle branch block or a true
posterior MI are also considered eligible.
For Left bundle branch block or ventricular paced rhythm
consider using the Sgarbossa Criteria or Smith-modified
Sgarbossa Criteria
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
FOLLOW
STEMI
MANAGEMENT
OPTIONS
CPD COMPANION SHEET-2
SUSPECTED ACS MANAGEMENT OPTIONS
Enter the text where indicated. Checked boxes indicate completed actions or applicable findings
Always use www.uptodate.com as your main reference resource.
PATIENT INFORMATION
VESSEL:
Click or tap here to enter text.
NAME:
Click or tap here to enter text.
DOCTOR:
Click or tap here to enter text.
CABIN:
Click or tap here to enter text.
DATE:
Click or tap here to enter date.
CREW ID:
Click or tap here to enter text.
TIME:
Click or tap here to enter text.
STEP 1
INCLUDE THE FOLLOWING PATIENTS INTO THIS GROUP
☐
Patients in this group have suspected ACS, but their 12 lead ECG is either non-diagnostic or even
normal.
It is common to NOT be able to make a definitive diagnosis initially.
☐
ACS still hasn’t been RULED OUT, but you also need to be looking at alternative diagnoses.
☐
STEP 2
ADMISSION TO MEDICAL CENTRE
☐
Consider admission to the medical centre for observations and further investigations
☐
Observations: continuous cardiac monitoring and frequent vitals
☐
Consider supplemental 02 and additional medications if indicated.
STEP 3
☐
CONSIDER DIFFERENTIAL DIAGNOSIS AND POTENTIALLY LIFETHREATENING CAUSES OF CHEST PAIN
Consider investigations for other potentially life-threatening causes of chest pain
•
Aortic dissection
•
Myocarditis
•
Cardiac valve disease
•
Cardiac Tamponade
•
•
Pericarditis
•
Tension pneumothorax
•
Pulmonary
embolism
Stress
Cardiomyopathies
•
Boerhaave syndrome
STEP 4
CONSIDER THE FOLLOWING INVESTIGATIONS:
☐
Serial ECG’s
Click or tap here to enter text.
☐
Serial cardiac enzymes
Click or tap here to enter text.
☐
Chest X-ray
Click or tap here to enter text.
☐
Complete blood count
Click or tap here to enter text.
☐
Click or tap here to enter text.
☐
Basic electrolytes and kidney
function
BNP
☐
D-Dimer (when indicated)
Click or tap here to enter text.
☐
Other:
Click or tap here to enter text.
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 5
☐
RISK ASSESSMENT: COMPLETE HEART SCORE
Complete the Heart Score after the result of the first cardiac enzyme (TropI)
HEART SCORE FOR CHEST PAIN PATIENTS
HISTORY
Highly suspicious = 2 POINTS
Retrosternal pain, pressure, radiation to jaw/left
shoulder/arms, duration 5–15 min, initiated by
exercise/cold/emotion, perspiration, nausea/vomiting,
reaction on nitrates within mins, patient recognizes
symptoms.
ENTER
SCORE
Click or tap
here to enter
text.
Moderately suspicious = 1 POINT
Slightly suspicious = 0 POINTS
Well localized, sharp, non-exertional, no diaphoresis,
no nausea or vomiting, and reproducible with
palpation.
ECG
Significant ST depression = 2 POINTS
Significant ST-segment depression or elevation without
LBBB, LVH, or digoxin.
Nonspecific repolarisation disturbance = 1
POINT
Click or tap
here to enter
text.
LBBB, typical changes suggesting LVH, repolarization
disorders suggesting digoxin, unchanged known
repolarization disorders
Normal = 0 POINTS
AGE
≥65 years = 2 POINTS
Click or tap
here to enter
text.
45-65 years = 1 POINT
<45 years = 0 POINTS
RISK FACTORS
HTN, hypercholesterolemia, DM,
obesity (BMI >30 kg/m²),
smoking (current, or smoking
cessation ≤3 mo), positive
family history (parent or sibling
with CVD before age 65).
TROPONIN
≥3 risk factors or history of atherosclerotic
disease = 2 POINTS
1 or 2 risk factors = 1 POINT
Click or tap
here to enter
text.
No risk factors known = 0 POINTS
>3x normal limit = 2 points
Click or tap
here to enter
text.
1-3x normal limit = 1 point
≤normal limit = 0 point
TOTAL:
Click or tap here to enter
text.
☐
A score of 0 to 3 identifies a patient at low risk of major adverse cardiovascular events
☐
A score of 4 to 6 have intermediate risk of major adverse cardiovascular events.
☐
A score of 7 or greater are high risk of major adverse cardiovascular events
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 6
APPROACH TO THE MANAGEMENT OF PATIENTS AT LOW TO INTERMEDIATE
RISK OF ACS
HEART PATHWAY
Time chest pain
started:
Click or tap here to enter text.
0 HOUR: (ON ADMISSION)
☐
Take 1st cardiac troponin (cTn) preferably use Quidel Triage Meter Pro)
Confirm result and
time:
3 HOURS LATER:
☐
Click or tap here to enter text.
☐
Take 2nd cardiac troponin (cTn) (Preferably use Quidel Triage Meter Pro)
☐
Repeat ECG
☐
If the patient presented to the Medical Centre 3 hours before the chest pain started,
consider taking the second cardiac enzyme at 6 hours from the time the chest pain started.
Confirm result and
Click or tap here to enter text.
time:
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 7
☐
DISPOSITION DEPENDS ON RESULTS AND RISK STRATIFICATION
Check box to indicate which criteria your patient fulfills
FIRST CARDIAC ENZYME TAKEN AT 0 HOURS
1st Cardiac troponin (cTn):
Negative
HEART SCORE:
0
Risk:
LOW
Symptoms best explained by:
Non-cardiac diagnosis
DISPOSITION:
☐
Presumptive Diagnosis:
Click or tap here to enter text.
☐
Regular reviews considered
Click or tap here to enter text.
Click or tap here to enter text.
☐
FIRST CARDIAC ENZYME TAKEN AT 0 HOURS
1st Cardiac troponin (cTn):
Negative
HEART SCORE:
0
Risk:
LOW
Symptoms:
STILL suspicious for an ACS
DISPOSITION:
☐
Continue admission with continuous cardiac monitoring and frequent vitals
☐
Follow HEART Pathway and repeat Cardiac troponin (cTn) in 3 hours
Click or tap here to enter text.
☐
FIRST CARDIAC ENZYME TAKEN AT 0 HOURS
1st Cardiac troponin (cTn):
Negative
HEART SCORE:
≥1
Risk:
Low or intermediate risk of ACS
DISPOSITION:
☐
Continue admission with continuous cardiac monitoring and frequent vitals
☐
Follow HEART Pathway and repeat Cardiac troponin (cTn) in 3 hours
Click or tap here to enter text.
☐
FIRST CARDIAC ENZYME TAKEN AT 0 HOURS
1st Cardiac troponin (cTn):
POSITIVE
Risk:
HIGH risk ACS
DISPOSITION:
☐
Continue admission with continuous cardiac monitoring and frequent vitals
☐
FOLLOW NSTEMI/HIGH RISK ACS MANAGEMENT OPTIONS
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
SECOND CARDIAC ENZYME TAKEN AT 3 HOURS
If the patient presented to the Medical Centre 3 hours before the chest pain started, consider taking the
second cardiac enzyme at 6 hours from the time the chest pain started.
Check box to indicate which criteria your patient fulfills
☐
SECOND CARDIAC ENZYME TAKEN AT 3 HOURS
2nd Cardiac troponin (cTn):
Negative
HEART SCORE:
0-3
Repeat ECG:
NO new ischaemic changes
Risk:
Risk of incident ischaemic events is considered sufficiently
low
DISPOSITION:
☐
Consider Discharge to cabin
☐
Consider regular follow ups
☐
Complete full disposition in SeaCare
☐
Provide patient a copy all ECG's and clinical notes for their shoreside doctor to review.
Click or tap here to enter text.
☐
SECOND CARDIAC ENZYME TAKEN AT 3 HOURS
2nd Cardiac troponin (cTn):
Negative
HEART SCORE:
>3
Repeat ECG:
or New ischaemic changes
Risk:
Intermediate to high risk of major adverse cardiovascular
events.
DISPOSITION:
☐
Continue admission with continuous cardiac monitoring and frequent vitals
☐
FOLLOW NSTEMI/HIGH RISK ACS MANAGEMENT OPTIONS
Click or tap here to enter text.
☐
SECOND CARDIAC ENZYME TAKEN AT 3 HOURS
2nd Cardiac troponin (cTn):
POSITIVE
Risk:
High risk of major adverse cardiovascular events.
DISPOSITION:
☐
Continue admission with continuous cardiac monitoring and frequent vitals
☐
FOLLOW NSTEMI/HIGH RISK ACS MANAGEMENT OPTIONS
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
CPD COMPANION SHEET-3
NSTEMI/HIGH RISK ACS MANAGEMENT OPTIONS
Enter the text where indicated. Checked boxes indicate completed actions or applicable findings
Always use www.uptodate.com as your main reference resource.
PATIENT INFORMATION
VESSEL:
Click or tap here to enter text.
NAME:
Click or tap here to enter text.
DOCTOR:
Click or tap here to enter text.
CABIN:
Click or tap here to enter text.
DATE:
Click or tap to enter a date.
CREW ID:
Click or tap here to enter text.
TIME:
Click or tap here to enter text.
STEP 1
INCLUDE THE FOLLOWING PATIENTS INTO THIS GROUP
Check box to indicate which criteria your patient fulfills
☐
Unstable Angina
☐
Non-ST elevation myocardial infarction (NSTEMI)
☐
Heart Pathway with a score of >3
☐
Patients with ECG findings consistent with acute/subacute myocardial ischemia
☐
☐
aVR ST-segment elevation
☐
ST-segment depression
☐
Wellen’s syndrome. Clinical syndrome characterized by:
☐
Inverted T waves
Patients with ECG findings consistent with STEMI mimics who do not meet the current
criteria for Thrombolysis
☐
De Winter sign
☐
Hyperacute T waves.
☐
STEMI patients who do not meet the criteria for Thrombolysis
☐
STEMI patients who decline Thrombolysis
STEP 2
INITIAL ASSESSMENT (REVIEW AND CONSIDER THE FOLLOWING ACTIONS)
☐
Consider admission to the medical centre ICU for observations and further investigations
☐
Time:
☐
Attach cardiac and oxygen saturation monitors and establish IV access
☐
Observations: continuous cardiac monitoring and frequent vitals
☐
Oxygen: In patients who have an oxygen saturation ≥94 percent and no signs of respiratory
distress, do not routinely treating with supplemental oxygen.
☐
Perform focused history and examination looking for signs of hemodynamic compromise, left heart
failure and determine baseline neurologic function
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 3
CONSIDER THE FOLLOWING INVESTIGATIONS:
☐
Serial ECG’s
Click or tap here to enter text.
☐
Serial cardiac enzymes
Click or tap here to enter text.
☐
Chest X-ray
Click or tap here to enter text.
☐
Complete blood count
Click or tap here to enter text.
☐
Click or tap here to enter text.
☐
Basic electrolytes and kidney
function
BNP
☐
D-Dimer (when indicated)
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
STEP 4
☐
Aspirin
☐
Nitrates
MEDICATIONS TO CONSIDER
•
Before this is done, all patients should be questioned about the use of
phosphodiesterase-5 inhibitors, such as sildenafil (Viagra), vardenafil (Levitra),
or tadalafil (Cialis); nitrates are contraindicated if these drugs have been used in
the last 24 hours (or perhaps as long as 36 hours with tadalafil) because of the
propensity to cause potentially severe hypotension.
•
Extreme care should also be taken before giving nitrates in the setting of an
inferior myocardial infarction with possible involvement of the right ventricle. In
this setting, patients are dependent upon preload to maintain cardiac output,
and nitrates can cause severe hypotension.
☐
Morphine
•
Increments of IV morphine may be given for the relief of severe, persistent chest
pain not relieved by other means but should not be given routinely.
☐
Beta
blockers
•
Oral Betablockers can be considered if no signs of heart failure and not at high
risk for heart failure and no signs of hemodynamic compromise, bradycardia, or
severe reactive airway disease.
If hypertensive, may initiate beta blocker IV instead.
•
☐
Statin
therapy
•
Atorvastatin 80 mg as early as possible and preferably before PCI in patients not
on statin. If patient is taking a low- to moderate-intensity statin, switch to
atorvastatin 80 mg
☐
Antithromboti
c therapy
•
Antiplatelet therapy: Consider clopidogrel, ticagrelor or prasugrel (depending on
what is available)
•
Anticoagulation: Consider Enoxaparin, fondaparinux, bivalirudin or UFH
(depending on what is availabl)
•
•
Give benzodiazepines as needed to alleviate symptoms;
Give standard therapies (e.g., aspirin, nitroglycerin) but do not give beta
blockers.
☐
Cocainerelated
ACS
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 5
RISK STRATIFICATION -Risk scores-
☐
Early risk stratification in patients with acute coronary syndrome (ACS) is essential to identify those
patients at highest risk for further cardiac events who may benefit from a more aggressive
therapeutic approach.
☐
TIMI and Grace risk score are predictive of worsening outcomes and mortality in patients with
unstable angina or an acute NSTEMI
TIMI RISK SCORE: a value of 1 is
assigned when a factor was present
and 0 when it was absent
Age ≥ 65 years? Yes (+1)
SCORE
Click or tap
here to enter
text.
≥ 3 Risk Factors for Coronary Artery
Disease (CAD)? Yes (+1)
Click or tap
here to enter
text.
Known CAD (stenosis ≥
Click or tap
50%)? Yes (+1)
here to enter
text.
ASA Use in Past 7 days? Yes (+1)
Click or tap
here to enter
text.
Severe angina (≥ 2 episodes within
Click or tap
24 hrs)? Yes (+1)
here to enter
text.
ST changes ≥ 0.5mm? Yes (+1)
Click or tap
here to enter
text.
Positive Cardiac Marker? Yes (+1)
Click or tap
here to enter
text.
TOTAL: Click or tap
here to enter
text.
☐
LOW RISK: score of 0 to 2
☐
INTERMEDIATE RISK: score of 3 to 4
☐
HIGH RISK: score of 5 to 7
TIMI risk score for unstable angina or
non-ST elevation MI
Total point
count
2-week risk
of death or
MI
0 to 1
3%
2-week risk
of death, MI,
or urgent
revasculariz
ation
5%
2
3%
8%
3
5%
13%
4
7%
20%
5
12%
26%
Available at: TIMI Risk Score for
UA/NSTEMI (mdcalc.com)
Click or tap here to enter text.
When entering a RISK score into SeaCare, use www.MDCalc.com so you have the ability to copy and paste
the result into your notes, together with the date and time you accessed the site.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
GRACE Score for ACS: The GRACE Score involves 8
variables from history, examination, ECG and laboratory
testing.
Use the On-line risk calculators to calculate score
Age.
Click or tap
Heart Rate (bpm)
Systolic BP (mmHg)
Creatinine Level (mg/dL)
Killip classification of prior or current
congestive heart failure.
Cardiac arrest at admission.
ST segment deviation.
Abnormal cardiac enzymes.
TOTAL:
here to enter
text.
Click or tap
here to enter
text.
Click or tap
here to enter
text.
Click or tap
here to enter
text.
Click or tap
here to enter
text.
Click or tap
here to enter
text.
Click or tap
here to enter
text.
Click or tap
here to enter
text.
Click or tap
here to enter
text.
Risk Category
(tertiles)
GRACE
Risk
Score
Probability
of Death
In-hospital
(%)
☐
Low
1-108
<1
☐
Intermediate
109-140
1 to 3
☐
High
141-372
>3
Available at: Grace Score (outcomesumassmed.org)
Available at: GRACE ACS Risk and Mortality
Calculator (mdcalc.com)
When entering a RISK score into SeaCare,
use www.MDCalc.com as you can copy and
paste the result into your notes, together
with the date and time you accessed the
site.
Click or tap here to enter text.
STEP 6
RISK STRATIFICATION -IDENTIFY ANY HIGH-RISK CHARACTERISTICS-
Patients who have an NSTEMI/UA and one or more of the following characteristics are at extremely high risk
of an adverse cardiovascular event in the short term and should be referred for immediate coronary
arteriography and revascularization.
☐
Hemodynamic instability or cardiogenic shock
☐
Severe left ventricular dysfunction or heart failure
☐
Recurrent or persistent rest angina despite intensive medical therapy
☐
New or worsening mitral regurgitation or new ventricular septal defect
☐
Sustained ventricular arrhythmias
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 7
DISPOSITION
☐
All patients in this group should remain in the medical centre under constant monitoring and be
considered for medical disembarkation.
☐
Serial investigations should include 12 lead ECG's, cardiac enzymes, electrolytes and haematology
☐
Correct any electrolyte abnormalities, especially hypokalemia
☐
Avoid fibrinolysis and stop NSAID therapy if possible.
☐
Patients in the higher risk group should be referred ashore as a matter of urgency and considered
for possible early revascularization.
STEP 8
DISPOSITION
Complete the DOCTOR’S ORDERS in SeaCare including frequency of vitals and laboratory tests,
nursing instructions and parameters for the nursing staff to call the duty doctor.
Consider the following Doctor’s orders
Admit to ICU
☐
Diagnosis: NSTEMI /HIGH RISK ACS
Condition: Critical
Vitals: Monitored and recorded every 15 minutes for the first 2 hours, then ½ hourly for 2 hours, hourly for
4 hours, then 4 hourly if stable
• Parameters for notifying duty doctor if: T >38°C, SBP >190 mm Hg or SBP <90 mm Hg, HR >120
bpm or HR <50 bpm, RR >30 or RR <10
• Supplemental oxygen should be administered if arterial saturation less than 90%, respiratory
distress, or other high-risk features for hypoxemia.
Activity: bed rest
Nursing Instructions:
• SeaCare: Place patient in Inpatient module and completed Assessment module
Diet: Low salt
Allergies (to food & Meds):
Labs and investigations:
• 12 lead ECG: Serial ECGs, initially at 15- to 30-min intervals to detect the potential for development
of ST-segment elevation or depression. Repeat if any changes in ECG morphology, arrythmias, with
chest pain and every 8 hours
• CXR if not already completed
• Cardiac enzymes: At presentation (0 Hour) and then 3 hours later. Repeat enzymes 8 hourly
• Electrolytes, haematology, random blood glucose and LFT's: Initially 8 hourly until further review
• Stat BNP (monitor for heart failure), random cholesterol and possibly D-dimer if indicated.
• Guaiac fecal occult blood test (FOB) with every stool
IV Fluids: As charted
Specialists or consults: Medical disembarkation
Medications
• Analgesia. If ongoing ischemic discomfort, consider nitrates and morphine
• Review: Antiplatelet therapy, Anticoagulation, Statins and B-blockers and PPI's.
• Review patients own medications.
• As needed meds: Review need for: Night sedation, Paracetamol for headaches and constipation
relief
Monitoring: Continuous ECG and O2 sats monitoring. Monitor fluid input and output.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 9
DISEMBARKATION OPTIONS
☐
Determine RISK using HEART score, TIMI/GRACE score and review for the presence of extremely
high-risk symptoms.
Determine local capabilities and possible locations of tertiary cardiac centres
☐
Determine patient preferences
☐
IN PORT:
☐
☐
Arrange urgent medical disembarkation, preferably to a facility with PCI capabilities
☐
If you are in a port without cardiac facilities, discuss the possibility of a medevac to
a cardiac unit in an alternative location with MEDICAL OPERATIONS
Click or tap here to enter text.
☐
At SEA:
☐
Discuss case with MEDICAL OPERATIONS 24/7 MOBILE:
+44 (0) 7770451054
It is important to be prepared BEFORE you make this call
☐
In a NSTEMI/HIGH RISK ACS scenario uploading the ECG’s into SeaCare is essential
☐
Critical information will also include the HEART/TIMI/GRACE risk SCORES
☐
Use attached NSTEMI /HIGH RISK ACS - COMMUNICATION CHECKLIST
☐
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
MEDICAL OPERATIONS (URGENT 24/7 MOBILE: +44 (0) 7770451054)
NSTEMI /HIGH RISK ACS - COMMUNICATION CHECKLIST
☐
•
Ensure you have all the details you need at hand before starting the call.
☐
•
•
•
PREPARE
SEACARE
Time permitting, complete the notes as best you can.
Focus on history, serial vitals and medications administered
Upload ECG’s and laboratory results if possible before contacting Medical Operations
☐
SITUATION:
•
Identify yourself
Click or tap here to enter text.
•
Identify the vessel
Click or tap here to enter text.
•
State current
location
State your concern
Click or tap here to enter text.
•
☐
Click or tap here to enter text.
BACKGROUND:
Patient identifiers and other relevant data:
•
Patient name
Click or tap here to enter text.
•
DOB
Click or tap here to enter text.
•
Nationality
Click or tap here to enter text.
•
Age
Click or tap here to enter text.
•
Gender
Click or tap here to enter text.
•
Weight
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•
Cabin no
Click or tap here to enter text.
•
Traveling
with:
Click or tap here to enter text.
•
Other relevant data
Click or tap here to enter text.
History of presenting illness (add times if relevant):
Click or tap here to enter text.
Relevant medical history
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
☐
ASSESSMENT:
•
Current vitals
(note trends)
Click or tap here to enter text.
•
Current clinical
assessment
Click or tap here to enter text.
•
12 lead ECG
findings (note serial
changes)
Click or tap here to enter text.
•
Laboratory results:
cardiac enzymes,
BNP (note serial
changes)
Click or tap here to enter text.
•
Risk Scores:
HEART SCORE:
•
High-Risk
Characteristics
•
Brief synopsis of
the treatment to
date
Click or tap here to enter text.
•
Course of the
admission
Click or tap here to enter text.
•
Working diagnosis:
Click or tap here to enter text.
•
Concerns:
Click or tap here to enter text.
☐
Click or tap here
to enter text.
Click or tap here to enter text.
TIMI/GRACE
RECOMMENDATION
•
Explain what you
need – be specific
about request and
time frame.
Click or tap here to enter text.
•
Suggestions.
Click or tap here to enter text.
•
Expectations.
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
Click or tap here
to enter text.
CPD COMPANION SHEET-4
STEMI MANAGEMENT OPTIONS
Enter the text where indicated. Checked boxes indicate completed actions or applicable findings
Always use www.uptodate.com as your main reference resource.
PATIENT INFORMATION
VESSEL:
Click or tap here to enter text.
NAME:
Click or tap here to enter text.
DOCTOR:
Click or tap here to enter text.
CABIN:
Click or tap here to enter text.
DATE:
Click or tap to enter a date.
CREW ID:
Click or tap here to enter text.
TIME:
Click or tap here to enter text.
STEP 1
☐
☐
INCLUDE THE FOLLOWING PATIENTS INTO THIS GROUP
The rapid diagnosis of STEMI only requires the presence of symptoms suspicious for an ACS and a
confirmatory ECG; it does not require evidence of elevated cardiac biomarkers such as troponin.
Patients with suspected ACS should undergo a focused history, physical, and ECG within ten
minutes of hospital arrival to identify the key findings of STEMI
• Characteristic symptoms and signs
o Chest pain or chest discomfort
o Dyspnea
o Ventricular arrhythmias, cardiac arrest, or syncope
o Atypical symptoms such as malaise, weakness, and back pain
• ECG findings – ECGs should be reviewed for signs of severe myocardial ischemia, which
include:
o ST-segment elevation with standard lead placement
o Left bundle branch block
o ST elevation with posterior or right-sided lead placement
o STEMI equivalents
STEP 2
INITIAL ASSESSMENT (REVIEW AND CONSIDER THE FOLLOWING ACTIONS)
☐
Admission to the medical centre ICU for further observations, treatment options and further
investigations is recommended
Time of admission:
Click or tap here to enter text.
☐
Ensure resuscitation trolley and manual defibrillator adjacent to patient.
☐
Attach cardiac and pulse oximetry monitors
☐
Observations: Continuous heart rhythm and pulse oximetry monitoring.
Vitals: Blood pressure, Heart rate, Respiratory rate, Temperature and Glasgow Coma Scale (GCS)
on admission and then every 15 minutes for the first hour.
Establish IV access (preferably 2x)
☐
☐
☐
☐
☐
☐
Oxygen: In patients who have an oxygen saturation ≥94 percent and no signs of respiratory
distress, do not routinely treating with supplemental oxygen.
Perform focused history and examination looking for signs of hemodynamic compromise, left
heart failure and determine baseline neurologic function
If there is diagnostic uncertainty:
•
Consider serial ECGs to confirm diagnosis.
•
Consider further investigation including CXR and laboratory testes if uncertainty persists.
•
Compare with reference ECG examples
Aim to complete Thrombolysis within 30 minutes from presentation. (Door to needle time)
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 3
CONSIDER THE FOLLOWING INVESTIGATIONS:
☐
Serial ECG’s
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☐
Serial cardiac enzymes
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☐
Chest X-ray
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☐
Complete blood count
Click or tap here to enter text.
☐
Click or tap here to enter text.
☐
Basic electrolytes and kidney
function
BNP
☐
D-Dimer (when indicated)
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
STEP 4
☐
☐
Aspirin
Nitrates
INITIAL MEDICATIONS TO CONSIDER
•
•
☐
Morphine
☐
Cocainerelated
ACS
•
•
•
•
Before this is done, all patients should be questioned about the use of
phosphodiesterase-5 inhibitors, such as sildenafil (Viagra), vardenafil (Levitra), or
tadalafil (Cialis); nitrates are contraindicated if these drugs have been used in
the last 24 hours (or perhaps as long as 36 hours with tadalafil) because of the
propensity to cause potentially severe hypotension.
Extreme care should also be taken before giving nitrates in the setting of an
inferior myocardial infarction with possible involvement of the right ventricle.
In this setting nitrates can cause severe hypotension
Increments of IV morphine may be given for the relief of severe, persistent chest
pain not relieved by other means but should not be given routinely.
Give benzodiazepines as needed to alleviate symptoms.
Give standard therapies (aspirin, nitroglycerin) but do not give beta blockers.
Click or tap here to enter text.
STEP 5
CONSIDER THE FOLLOWING INVESTIGATIONS:
☐
Before you continue with the STEMI pathway, confirm you have ruled out STEMI mimics
☐
☐
Left Ventricular Hypertrophy
☐
Coronary Vasospasm (Printzmetal’s
Angina)
Pericarditis
☐
Ventricular Aneurysm
☐
Benign Early Repolarization
☐
Brugada Syndrome
☐
Left Bundle Branch Block
☐
Ventricular Paced Rhythm
☐
Raised Intracranial Pressure
☐
Takotsubo Cardiomyopathy
☐
Click or tap here to enter text.
STEP 6
☐
☐
☐
CONFIRM LOCATION OF ISCHEMIA
Confirm location of STEMI and compare with ECG examples.
Indicate location:
Click or tap here to enter text.
Consider Additional leads:
☐ Right-sided leads in Inferior STEMI (V3R-V6R)
☐ Posterior leads V7-9 if changes in V1-3 including horizontal ST depression
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 7
☐
☐
☐
CONFIRM STEMI AND THROMBOLYSIS ELIGIBILITY
Acute ST-elevation myocardial infarction (STEMI): The use of fibrinolytic therapy
(UpToDate 2023)
Patients with chest pain suggestive of acute myocardial ischemia who present up to 12 (and
possibly up to 24) hrs after symptom onset are candidates for fibrinolytic therapy if the following
ECG evidence is present:
• STEMI: New ST elevation at the J point in two anatomically contiguous leads using the
following diagnostic thresholds:
o ≥0.1 mV (1 mm) in all leads other than V2 to V3, where the following diagnostic
thresholds apply:
▪ ≥0.2 mV (2 mm) in men ≥40 years,
▪ ≥0.25 mV (2.5 mm) in men <40 years,
▪ or ≥0.15 mV (1.5 mm) in women.
STEMI equivalents: Patients with typical and persistent symptoms in the presence of a new or
presumably new left bundle branch block or a true posterior MI are also considered eligible.
☐ For Left bundle branch block or ventricular paced rhythm consider using the
Sgarbossa Criteria or Smith-modified Sgarbossa Criteria
STEMI CRITERIA AND THROMBOLYSIS ELIGIBILITY MET:
☐ YES: Go to STEP 8
☐ NO: follow NSTEMI/HIGH RISK ACS management option
Click or tap here to enter text.
STEP 8
☐
STEMI CRITERIA AND THROMBOLYSIS ELIGIBILITY MET:
CHOOSE REPERFUSION STRATEGY (PCI OR THROMBOLYSIS)
PRIMARY PERCUTANEOUS CORONARY INTERVENTION (PCI)
• Preferred option
• If you are in a port with local PCI capabilities, strongly consider this option especially for
patients with cardiogenic shock, heart failure, late presentation, or contraindications to
Thrombolysis.
Click or tap here to enter text.
☐
THROMBOLYSIS
• Fibrinolytic therapy should be used if timely primary PCI is not available
• For patients who will undergo Thrombolysis, the goals of management are to safely
administer fibrinolytics as soon as possible, monitor the response to Thrombolysis, and
prepare for subsequent management (eg, transfer for PCI)
Click or tap here to enter text.
STEP 9
☐
STEMI CONFIRMED, CONSIDER CONCOMITANT THERAPIES
Antithrombotic therapy
•
☐
☐
Antiplatelet therapy
o Consider clopidogrel, ticagrelor or prasugrel (depending on what is available)
• Anticoagulation
o Consider Enoxaparin, fondaparinux, bivalirudin or UFH (depending on what is
available)
Beta blockers
• Consider beta blocker if no signs of heart failure and not at high risk for heart failure and
no signs of hemodynamic compromise, bradycardia, or severe reactive airway disease.
• If hypertensive, may initiate beta blocker IV instead
Statin therapy
• Atorvastatin 80 mg as early as possible and preferably before PCI in patients not on
statin. If patient is taking a low- to moderate-intensity statin, switch to atorvastatin 80 mg
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 10
☐
STEMI CONFIRMED, RULE OUT ABSOLUTE AND RELATIVE
CONTRAINDICATIONS TO THROMBOLYSIS
ABSOLUTE CONTRAINDICATIONS
☐
History of any intracranial hemorrhage
☐
☐
History of ischaemic stroke within the preceding three months, with the important exception of
acute ischaemic stroke seen within three hours, which may be treated with thrombolytic therapy
Presence of a cerebral vascular malformation or a primary or metastatic intracranial malignancy
☐
Symptoms or signs suggestive of an aortic dissection
☐
☐
A bleeding diathesis or active bleeding, with the exception of menses; thrombolytic therapy may
increase the risk of moderate bleeding, which is offset by the benefits of thrombolysis
Significant closed-head or facial trauma within the preceding three months
☐
RELATIVE CONTRAINDICATIONS
☐
☐
History of chronic, severe, poorly controlled hypertension or uncontrolled hypertension at
presentation (eg, blood pressure >180 mmHg systolic and/or >110 mmHg diastolic; severe
hypertension at presentation can be an absolute contraindication in patients at low risk)
History of ischaemic stroke more than three months previously
☐
Dementia
☐
Any known intracranial disease that is not an absolute contraindication
☐
Traumatic or prolonged (>10 min) cardiopulmonary resuscitation
☐
Major surgery within the preceding three weeks
☐
Internal bleeding within the preceding two to four weeks or an active peptic ulcer
☐
Noncompressible vascular punctures
☐
Pregnancy
☐
Current warfarin therapy; the risk of bleeding increases as the INR increases
☐
For streptokinase or anistreplase, a prior exposure ( more 5 days previously) or allergic reaction to
these drugs
Click or tap here to enter text.
STEP 11
CHOOSE FIBRINOLYTIC AGENT AVAILABLE
☐
Alteplase
Click or tap here to enter text.
☐
Tenecteplase
Click or tap here to enter text.
☐
Reteplaze
Click or tap here to enter text.
STEP 12
☐
☐
☐
CONSENT FOR THROMBOLYSIS
Thrombolysis poses a significant risk soensure you have discussed both the benefits and risks with
your patient. Use a translator if needed.
Consider using similar verbiage: Your ECG (heart tracing) shows that you are suffering from a
heart attack, which is caused by a clot blocking blood flow to your heart muscle. The longer the
blockage is left untreated, the more of the heart muscle is damaged. The recommended
treatment includes a clot busting medicine and other medicines that reduce new clot formation.
The medication will be delivered through the vein and is called an intravenous thrombolytic
The patient should sign a consent form agreeing to the treatment. See Annex A
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
STEP 13
ADMINISTRATION OF FIBRINOLYTIC AGENT
☐
Final checks to be completed with rest of the Team present:
☐
Correct location: In ICU with fully equipment resuscitation trolley close by
☐
Correct diagnosis: Confirm STEMI meets criteria and patient eligibility for thrombolysis
☐
☐
Correct monitoring: Continuous heart rhythm and pulse oximetry monitoring.
• Vitals: Blood pressure, Heart rate, Respiratory rate, Temperature and Glasgow Coma Scale
(GCS) on prior to administration and then every 15 minutes for the two hours.
Correct IV access:
• Preferably 2x IV’s are sited and patent
Correct medications and dosage:
• Antiplatelet therapy given
• Anticoagulant given
• Fibrinolytic agent: correct dosage checked.
Consent signed
☐
TIME OF ADMINISTRATION
☐
☐
Click or tap here to enter text.
Click or tap here to enter text.
STEP 14
REMAIN VIGILANT FOR POST THROMBOLYSIS COMPLICATIONS
Patients with STEMI need to remain admitted to the Medical centre and require frequent blood pressure
measurements, continuous heart rhythm monitoring, and continuous pulse oximetry
☐
Bleeding
•
•
☐
Bleeding is the primary complication of fibrinolytic therapy, and hemorrhagic stroke is the greatest
concern.
The most common site for spontaneous bleeding is the gastrointestinal tract
Stroke
•
The risks of stroke and intracranial hemorrhage (ICH) are 1.2 and 0.7 percent.
•
Strokes associated with Thrombolysis are also associated with very high rates of mortality and
morbidity.
Primary failure of Thrombolysis
☐
•
•
☐
•
•
☐
•
Often clinically suspected by persistent or worsening chest pain (particularly if associated with other
symptoms such as dyspnea and diaphoresis), persistent or worsening ST-segment elevation on the
ECG, hemodynamic instability, and/or heart failure.
Repeat Thrombolysis for failed primary Thrombolysis is usually considered when access to PCI is not
available.
Re-occlusion of an infarct-related artery after reperfusion therapy is associated with a significant
increase in mortality
Within the first 18 hours after initial Thrombolysis, a recurrent elevation in cardiac biomarkers
accompanied by recurrent ST-segment elevation on ECG and at least one other supporting criterion
(such as recurrent chest pain or hemodynamic decompensation).
After 18 hours, a biomarker rise of at least 50 percent and at least one additional criterion are
sufficient for the diagnosis.
Heart failure
In addition to appropriate reperfusion, patients with STEMI and HF may require therapy for volume
overload (eg, diuretics) and respiratory distress (eg, supplemental oxygen, positive pressure
ventilation)
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
☐
•
•
☐
•
☐
•
Arrhythmias
In patients with STEMI, the management of arrhythmias is focused on advanced cardiac life support
(ACLS) for unstable patients, rapid reperfusion, and additional therapies that reduce the risk of
arrhythmias.
Prophylactic use of antiarrhythmics. During the early phases of acute MI, ventricular arrhythmias
are common. However, antiarrhythmic agents (other than beta blockers) are not typically used to
prevent ventricular arrhythmias in acute MI.
Right ventricular infarction
Patients with right ventricular infarction may require additional management of complications such
as bradyarrhythmias, hypotension, and shock.
Cardiogenic shock
The management of patients with STEMI and cardiogenic shock depends on the cause of
cardiogenic shock (eg, HF, myocardial wall rupture). In addition to specific therapies for shock,
patients with shock typically benefit from rapid reperfusion.
STEP 15
DISPOSITION
STEMI patients are a HIGH RISK group and should remain in the medical centre under observation
and be considered for urgent/emergent disembarkation for review ashore for possible PCI or
revascularization.
Complete doctor’s orders including frequency of vitals and laboratory tests, nursing instructions
☐
and parameters for the nursing staff to call the duty doctor. Consider adding the following:
Admit to ICU
Diagnosis: STEMI
Condition: Critical
Vitals: Monitored and recorded pre-thrombolytic therapy; then post thrombolytic therapy
• Continuous heart rhythm and pulse oximetry monitoring.
• Vitals: Blood pressure, Heart rate, Respiratory rate, Temperature and Glasgow Coma Scale (GCS) on
prior to administration and then every 15 mins for the first 2 hrs, then ½ hourly for 2 hrs, 1 hourly
for 4 hrs, then 4 hrly if stable.
• Blood pressure: use manual blood pressure cuffs to avoid bruising from over-inflation.
Neuro Vital signs: Monitored and recorded pre-thrombolytic therapy; then post thrombolytic therapy
• Assess GCS, limb assessments and pupil size and reaction to light every 15 mins for the first 2 hrs.,
then ½ hourly for 2 hrs, 1 hourly for 4 hrs, then 4 hrly if stable
Parameters for notifying duty doctor if:
• T >38°C, SBP >190 mmHg or SBP <90 mmHg, HR >120 bpm or HR <50 bpm, RR >30 or RR <10
or drop in GCS, perceived weakness, or pupillary changes.
O2 saturation:
• If oxygen saturation ≥94 percent and no signs of respiratory distress, do not routinely treating with
supplemental oxygen. If required, supplemental oxygen must be administered via a mask as nasal
prongs can cause nasal mucosa damage.
Activity: Strict rest in bed is required for 24 hours. but longer if unstable.
Nursing Instructions:
Bleeding Risk:
Monitor continuously for any signs of bleeding for the first few hours after thrombolysis.
• Should serious bleeding (not controlled by local pressure) occur, stop any concomitant
anticoagulant or antiplatelet agents
• Pressure dressings should be applied to puncture sites to reduce risk of haematoma formation
• During, and for 48 hours after thrombolysis due to the increased risk of bleeding,
unnecessary invasive procedures should be avoided, as should IM injections, wet-shaving,
use of rigid catheters and vigorous brushing of teeth, and nonessential handling of the
patient.
SeaCare: Place in Inpatient module and complete assessments
Diet: Low salt and cholesterol
☐
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
Allergies (to food & Meds): review
Labs and investigations:
• 12 lead ECG: record pre-thrombolysis and then at 60 minutes and 90 minutes post-thrombolysis.
o Repeat if changes in ECG morphology, arrythmias, new onset chest pain and every 8 hrs.
• If ST segments do not show evidence of resolution at 90 minutes, and the patient has on-going
symptoms, the patient should be discussed with MedOps a matter of urgency.
• Cardiac enzymes: at 6 hrs and 12 hrs post thrombolysis.
o Then 8 hrly
• Electrolytes, haematolgy, random blood glucose and LFT's: at 6 hrs and 12 hrs post thrombolysis.
o Then 8 hrly
• Stat BNP (monitor for heart failure), random cholesterol and possibly D-dimer if indicated.
o Repeat as indicated
• Guaiac fecal occult blood test (FOB) with every stool
• Urine dipstick after each time the patient passes urine. If catheterized, check 8 hrly
• CXR if not already completed
IV Fluids: As charted
Specialists or consults: Disembarkation details
Medications
• Analgesia. If ongoing ischemic discomfort, consider nitrates and morphine
• Review: Antiplatelet therapy, Anticoagulation, Statins, B-blockers and PPI's.
• Review patient’s own medications.
• As needed meds: Review need for: Night sedation, Paracetamol for headaches and constipation
relief
Monitoring:
• Continuous ECG and O2 sats monitoring to monitor closely for arrhythmias for a minimum of 48
hours, and defib/pacing pads in-situ for the first 24 hours.
• Monitor fluid input and output.
STEP 15
DISEMBARKATION OPTIONS
☐
STEMI patients are a HIGH-RISK group and should remain in the medical centre under observation
and be considered for urgent/emergent disembarkation for review ashore for possible PCI or
revascularization.
• Even those that underwent successful thrombolysis could still be eligible for PCI
☐
In Port:
•
•
☐
Patients should be disembarked to a local medical facility, preferably with cardiac catheter
laboratory capabilities.
If you are in a port without cardiac facilities, discuss the possibility of a medevac to a
cardiac unit in an alternative location with MEDICAL OPERATIONS
At Sea:
•
•
•
•
•
While at sea, we can only offer thrombolysis as a reperfusion strategy.
Even with successful thrombolysis, these patients remain critical and at risk of serious
complications.
Early communication with MEDICAL OPERATIONS is essential to determine medical
evacuation options.
Timing:
o Thrombolysis is a time critical procedure.
o Do not delay thrombolysis to speak to MedsOps about your patient.
Preparation
o It is important to be prepared BEFORE you make this call
o In a STEMI scenario uploading the ECG’s into SeaCare is essential
o Critical information will also include the use of thrombolytics and post-thrombolytic
course.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
MEDICAL OPERATIONS (URGENT 24/7 MOBILE: +44 (0) 7770451054)
STEMI - COMMUNICATION CHECKLIST
☐
•
Ensure you have all the details you need at hand before starting the call.
☐
•
•
•
PREPARE
SEACARE
Time permitting, complete the notes as best you can.
Focus on history, serial vitals and medications administered
Upload ECG’s and laboratory results if possible before contacting Medical Operations
☐
SITUATION:
•
Identify yourself
Click or tap here to enter text.
•
Identify the vessel
Click or tap here to enter text.
•
State current
location
State your concern
Click or tap here to enter text.
•
☐
Click or tap here to enter text.
BACKGROUND:
Patient identifiers and other relevant data:
•
Patient name
Click or tap here to enter text.
•
DOB
Click or tap here to enter text.
•
Nationality
Click or tap here to enter text.
•
Age
Click or tap here to enter text.
•
Gender
Click or tap here to enter text.
•
Weight
Click or tap here to enter text.
•
Cabin no
Click or tap here to enter text.
•
Traveling
with:
Click or tap here to enter text.
•
Other relevant data
Click or tap here to enter text.
History of presenting illness (add times if relevant):
Click or tap here to enter text.
Relevant medical history
Click or tap here to enter text.
ACS COMPANION DOCUMENTS 2023_08_25 Ver0
☐
ASSESSMENT:
•
Current vitals
(note trends)
Click or tap here to enter text.
•
Current clinical
assessment
Click or tap here to enter text.
•
12 lead ECG
findings (note serial
changes)
Click or tap here to enter text.
•
Laboratory results:
cardiac enzymes,
BNP (note serial
changes)
Click or tap here to enter text.
•
Risk Scores:
TIMI SCORE:
•
High-Risk
Characteristics
•
Brief synopsis of
the treatment to
date
Click or tap here
to enter text.
Click or tap here to enter text.
Thrombolysis
☐
☐
YES
NO
•
Course of the
admission
Click or tap here to enter text.
•
Working diagnosis:
Click or tap here to enter text.
•
Concerns:
Click or tap here to enter text.
☐
•
GRACE
☐
Date and time
administered
☐
Door to needle
time:
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•
•
Expectations.
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to enter text.
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to enter text.
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RECOMMENDATION
Explain what you
need – be specific
about request and
time frame.
Suggestions.
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to enter text.
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ACS COMPANION DOCUMENTS 2023_08_25 Ver0
PATIENT INFORMATION
VESSEL:
Family Name:
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DATE:
First Name:
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TIME:
Gender:
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Cabin
Number:
Country of Residence:
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Crew ID:
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text.
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date.
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text.
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text.
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text.
CONSENT FORM: NAME OF PROPOSED TREATMENT
INTRAVENOUS THROMBOLYSIS FOR ACUTE MYOCARDIAL INFARCTION
Your ECG (heart tracing) shows that you are suffering from a heart attack, which is caused by a clot blocking
blood flow to your heart muscle. The longer the blockage is left untreated, the more of the heart muscle is
damaged. The recommended treatment includes a clot busting medicine and other medicines that reduce
new clot formation. The medication will be delivered through the vein and is called an intravenous
thrombolytic.
STATEMENT OF THE TREATING DOCTOR
I have explained to the patient that they are suffering from a heart attack and that the recommended
treatment includes a clot busting medicine and other medicines that reduce new clot formation
☐ I have explained the procedure to the patient, in particular, I have explained:
the intended benefits:
☐ The sooner you receive these medicines, the lower your risk of dying from this heart attack - which is
why doctors recommend that treatment is started as soon as possible.
☐ The likely benefits of using these medicines are generally much greater than the risks of potential
harm for a person in your circumstance.
☐ Treatment at this stage improves the chances of survival around 20-25%
the significant, unavoidable, or frequently occurring risks:
☐ The biggest risk is potentially life-threatening stroke which affects up to 2 patients in every 100
patients.
☐ Significant bleeding which is not normally life threatening can occur in about 4 in 100 patients.
☐ Some patients also have allergic reactions and other side effects that do not usually cause any major
problems.
PATIENT AGREEMENT TO TREATMENT
☐
The doctor has advised me that I am having a heart attack and has read the information above to
me.
☐ I understand that I will be given an injection of a clot dissolving medication and that this treatment
carries some risks and complications as described in the information above.
☐ I request and consent to the treatment as described above to me.
Signature:
(Patient and or Parent/Guardian)
Name and Designation:
Signature:
(Witness)
Name and Designation:
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TREATING DOCTOR DECLARATION
☐
I have provided the patient and or parent/guardian with the information necessary to inform them of their
condition, the treatment offered, medically acceptable alternatives and the potential risks of receiving
thrombolysis treatment.
Signature:
(Treating Doctor)
Full Name:
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ACS COMPANION DOCUMENTS 2023_08_25 Ver0