February 2009
Goals
Assessments
Labs/Tests
Page 1 of 2
PreHospital
EMS
GBMC Triage
ED MD First Eval
Recognition of
symptoms and
early contact
with EMS
Follows current
MD Medical
Protocols for
EMS Providers
pertinent to the
patients’
presentation.
Rapid
stabilization and
transport to
appropriate acute
care facility.
12 Lead EKG
performed and
interpreted in less
than 10 minutes when
patients meet
screening EKG
criteria.
Rapid identification of
STEMI and activation
of STEMI Alert.
Rapid identification of
patients with
symptoms suggestive
of ACS.
Determine relative
cardiac risk.
Identify patients
requiring
admission/observatio
n/ transfer to PCI
facility/ emergent
transfer to PCI.
Identify reperfusion
strategy for STEMI
Identify receiving
facility and Initiate
rapid transfer for
STEMI.
Quick triage
Screening EKG
criteria.
General triage
assessment.
Vital signs.
Pain assessment
STEMI present (Y/N).
If yes, determine
appropriate
reperfusion strategy
(PCI vs thrombolytics)
Hx&PE
EKG evidence of
ischemia?
Determine relative
cardiac risk and ED
Chest Pain Track (1,
2, or 3)
12 Lead EKG
in field by EMS
STEMI evident in
field (Y/N)
12 Lead EKG
PCXR
CBC
BMP
CK/MB
Troponin T
Draw and Hold PT/
PTT
If patient on
Coumadin—Send PT;
If heparin started—
Send PTT
Troponin T
CK-MB
CBC
Track 1: STEMI
and new onset
LBBB
Primary Strategy:
Transfer to PCI
center
Stabilize and transfer
for reperfusion
Determine receiving
facility
Consider
thrombolytics
Uncomplicated
STEMI assessment
(Does patient meet
criteria for ED
activation of cath
lab?)
Assess for
Dye/contrast allergy
ASA given previously
or true allergy?
12 Lead EKG every 5
– 10 minutes for
unrelieved chest pain
Track 2: Chest
Pain or ACS
Equivalent
(Moderate Risk)
Track 3: Chest
Pain or ACS
Equivalent (Low
Risk)
 Minimize myocardial
injury
 Promote myocardial
perfusion
 Evaluate and
support LV Function
Rule out cardiac
etiology for
symptoms
Identify & Treat
underlying cause of
symptoms
Educate on
modifiable cardiac
risk factors
LVEF
Ongoing cardiac
injury
Hemodynamic
stability
Cardiac arrhythmias
Initial strategy:
Conservative vs
invasive
CK-MB & Troponin T
every 6 hours until
peak
PCXR
CMP
PT/INR daily
PTT every 6 hours
TTE (eval LVEF)
Diagnostic
catheterization, stress
testing, or echo on
day 1 to rule out
cardiac ishemia
CK-MB & Troponin
T x2 sets at least 3
hours apart and 2
hours after onset of
symptoms
PCXR
Chest CT
CT coronary
angiogram
VQ scan
d-dimer
CMP
February 2009
Page 2 of 2
PreHospital
Treatments
Medications
EMS
GBMC Triage
ED MD First Eval
If STEMI present
in field, transport
to nearest PCI
center
2 large bore PIVs
Oxygen 2L & titrate to
keep SaO2 >90%
Continuous cardiac
monitoring
Continuous cardiac
monitoring
ASA, (oxygen,
nitroglycerine,
morphine)
(ASA), oxygen,
nitroglycerine,
morphine
Absolute rest
Uses EMRC
communication
for medical
consultation per
established
protocols
Absolute rest
Diet
Consults
Activity
Teaching,
Discharge
Planning
Community
outreach –
proactive
education and
PSAs that
impact the
patient and
community
before
symptoms
occur.
Continued
support of EMSED integration
with Chest
Pain/ACS
classes for EMS.
Ongoing EDEMS meetings
where PI data is
shared regarding
ACS cases, care,
and treatment.
81mg ASA and
Nitroglycerin SL tabs
at bedside
Oxygen, morphine
NPO
ED MD notified for
patients experiencing
chest pain
Charge nurse notified
for patient placement
in treatment area
Absolute rest
Patient/Family
Teaching:
Anticipated plan of
care for evaluation
and possible transfer
or hospitalization.
** Reinforce the
benefits or early
symptom recognition
and early EMS
contact.
Discharge Planning:
Consider patient
maybe discharged to
home, transferred
emergently to outside
facility or admitted to
telemetry/ICU/CCU
Clopidigrel
Nitroglycerine (SL or
paste)
NPO
Track 1: STEMI
and new onset
LBBB
Track 2: Chest
Pain or ACS
Equivalent
(Moderate Risk)
Track 3: Chest
Pain or ACS
Equivalent (Low
Risk)
Oxygen
Continuous cardiac
monitoring
Continuous cardiac
monitoring
Possible PCI
Continuous cardiac
monitoring
Cardiac Stress
testing
ASA 325mg chewed
Metoprolol 25mg po
(IV if po
contraindicated)
Heparin 60units/kg
bolus
Clopidigrel
Nitroglycerine
Eptifibatide
Consider morphine
NPO
Anticoagulation
therapy
Clopidigrel
Nitroglycerine
Morphine
eptifibatide
ASA
Nitroglycerine
Morphine
Zofran
NPO
NPO
Cardiology for
complicated STEMI,
NSTEMI/UA or
unclear cardiac
presentation
PCI center
Cardiology if
complicated or
unclear etiology
Cardiology for any
positive cardiac
testing result
Cardiology for any
positive cardiac
testing result
Absolute rest
Absolute rest
Bedrest
Bedrest
Communicate with
patient and family:
- Anticipated
disposition:
 Admission and
observation
 Emergent
transfer
 Observation and
discharge home
- Anticipated followup after discharge
Communicate with
patient and family:
- Anticipated
disposition:
 Admission and
observation
 Emergent
transfer
 Observation and
discharge home
- Anticipated followup after discharge
Communicate with
patient and family:
- Anticipated
disposition:
 Admission and
observation
 Emergent
transfer
 Observation and
discharge home
- Anticipated followup after discharge
with patient’s
internist within 2
weeks
Communicate
with patient and
family:
- Anticipated
disposition:
 Admission and
observation
 Emergent
transfer
 Observation
and discharge
home
- Anticipated
follow-up after
discharge: with
patient’s internist
within 2 weeks.