acls protocol for acute coronary syndrome

Narayana Medical Journal Volume-9 | Issue-2 | July - December 2020

ACLS protocol for Acute Coronary Syndrome

Adel Hamed Elbaih MD1*, Mahmoud Riyam Jouid2

1Associate Professor of Emergency Medicine,Faculty of Medicine, Suez Canal University, Ismailia, Egypt.

2Student in College of medicine, Sulaiman Al-Rajhi University, Clinical Medical Science, Saudi Arabia.

ABSTRACT

Background: The American Heart Association (AHA) and European Resuscitation Council (ERC) developed the

most recent ACLS Guidelines in 2010using the comprehensive review of resuscitation literature performed by the International

Liaison Committee on Resuscitation (ILCOR), and these were updated in 2015 and 2018. Acute coronary syndrome (ACS)

refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to

presentations found in non- ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina.

Aim of the study: Impart both cognitive knowledge and psychomotor skills of ACLS to provide a standardized

care in cardiac arrest victims by accordance of the specific guidelines.

Conclusion: Practitioner's expertswould apply the ACLS protocol for cardiac arrest, and once the patient's return

of spontaneous circulation Restore (ROSC). However, we will start post-cardiac arrest care along with the treatment of ACS

algorithm.

Keywords: Chest pain, Acute Coronary Syndrome,ACLS protocol.

26

REVIEW ARTICLE

*Corresponding author

E mail ID: [email protected]

http://dx.doi.org/10.5455/nmj/00000190

Introduction

Advanced cardiac life support (ACLS) guidelines have

evolved over the past several decades based on a

combination of scientific evidence of variable strength and

expert consensus. The AHA and European Resuscitation

Council developed the most recent ACLS Guidelines in 2010

using the comprehensive review of resuscitation literature

performed by the International Liaison Committee on

Resuscitation (ILCOR), and these were updated in 2015 and

2018. Guidelines are reviewed continually but are formally

released every five years and published in the journals

Circulation and Resuscitation (1).Advanced Cardiovascular

Life Support (ACLS) builds on the foundation of Basic Life

Support (BLS), emphasizing the importance of continuous,

high-quality CPR. The hands-on instruction and simulated

cases in this advanced course are designed to help enhance

their skills in the recognition and intervention of


27

cardiopulmonary arrest immediate post-cardiac arrest, acute

arrhythmia, stroke, and acute coronary syndromes (2).

1. Incidences of the problem:

Cardiovascular diseases cause approximately one-third of

all deaths in the world, of which 7.5 million deaths are

estimated to be due to ischemic heart disease (IHD). Acute

coronary syndromes (ACS) and sudden death cause most

IHD-related deaths, which represent 1.8 million deaths per

year. 1.57 Million Hospital Admissions, 1.24 million unstable

angina and Non-ST elevation MI and 0.33 million admitted

with ST-elevation MI (3).

2. Definitions, Indications and contraindi-

cations:

Acute coronary syndrome (ACS) refers to a spectrum of

clinical presentations ranging from those for ST-segment

elevation myocardial infarction (STEMI) to presentations

found in non-ST-segment elevation myocardial infarction

(NSTEMI) or in unstable angina.Itis almost always

associated with rupture of an atherosclerotic plaque and

partial or complete thrombosis of the infarct-related artery

(4). Acute coronary syndromes result from acute obstruction

of a coronary artery. Consequences depend on degree and

location of obstruction and range from unstable angina to

non-ST-segment elevation myocardial infarction (NSTEMI),

ST-segment elevation myocardial infarction (STEMI), and

sudden cardiac death (3).

-Unstable angina is chest pain which is persist for more

than 5-10 min and not relived by rest or using nitroglycerine,

it caused by Non occlusive thrombus and there is

Nonspecific ECG changes with normal cardiac enzymes

-NSTEMI:Non-occlusive thrombus sufficient to cause tissue

damage & mild myocardial necrosis. There is ST depression

+/- T wave inversion on ECG with Elevated cardiac enzymes

-STEMI: More severe symptoms caused by complete

thrombus occlusion of coronary arteries. There is ST

elevations on ECG or new LBBB with elevated cardiac

enzymes.

3. Description of a problem, a lack of knowledge

on a certain topic or a segment on WHY this is a

problem:

Acute coronary syndrome is the most common cause of


28

cardiac arrest, and it is the leading cause of death in USA.

so, it is very common to face such a caseevery day in

emergency department. Thus, it is important for the Health

Care Provider to know every single detail about this topic

from the symptoms that the patients could present with to

management plan since a single intervention can prevent

death to occur and saving time. It is important also to educate

the general people about the symptoms of ACS and how to

deal with it and what actions should they do. Lacking of

knowledge about ACS can lead to the death of the patient

since the intervention will be delayed and wrong diagnosis

will be given to such a patient.Not only lacking of the

knowledge can cause a problem, also applying wrong

technique of ACLS or not following the algorithm of ACLS

when dealing with critical patient who present with ACS

also will put the patient life in danger.

So, the researchquestions are the following:

How to apply ACLS protocol or algorithm in a patient

presents of symptoms suggestive of ACS? What is the right

technique and sequence should be followed? And does

this reduce the mortality of those patients?

4. WHY this study is necessary

The goal in studying ACS delay is to improve health

outcome by understanding why and how people get care

during an ACS event where basically time is muscle; the

longer it takes to get care, the less heart muscle survives,

and more disability ensues (5). It is important also because

ACLS aims to impart both cognitive knowledge and

psychomotor skills of CPR and to provide a standardized

care to cardiac arrest victims in accordance with the specific

guidelines (6). So, it is important to apply the right technique

of ACLS when dealing with patient who present with ACS

symptoms.

5. Segment that underlines the research

question that should be answered (based on the

problem describe earlier):

The Acute Coronary Syndromes Algorithm outlines the

assessment and management steps for a patient presenting

with symptoms suggestive of ACS also it provides general

guidelines that apply to the initial triage of patient based on

symptoms and the 12-lead ECG

Application of ACLS Algorithm

1-Identify of chest discomfort suggestive of ischemia (step1)

2- EMS assessment, care, transport and hospital prearrival

notification (step2)

3-Immedaite ED assessment and treatment (step3)

4-Classification of patient according to ST segment analysis

(steps 5, 9 and 11)

5-STEMI (steps 5 through 8)


29


6. Describe steps of the right technique of this

method point by point:

1-identification of chest discomfort suggestive

of ischemia

The most common symptoms of myocardia ischemia and

infarction is retrosternal chest discomfort. The patient may

perceive this discomfort more as pressure or tightness than

actual pain.

Symptoms suggestive of ACS may also include:

A-uncomfortable pressure, fullness, squeezing, or pain in

the center of the chest lasting several minutes (usually more

than a few minutes)

B-Chest discomfort spreading to the shoulders, neck, one

or both arms or jaw.

C-Chest discomfort spreading into the back or between the

shoulder blades.

D-Chest discomfort with light-headedness, dizziness,

fainting, sweating, nausea or vomiting.

E-Unexplained, sudden shortness of breath, which may

occur with or without chest discomfort.

2-EMS assessment, care, transport and hospital

prearrival notification

EMS responders may perform the following assessment and

actions during the stabilization, triage and transport of the

patient to an appropriate facility:

A-Monitor and support airway, breathing and circulation

(ABCs) and this include:

a-Monitoring vital signs and cardiac rhythm

b-Being prepared to provide CPR

c-Using defibrator if needed

B-Administer aspirin and consider oxygen if O2 saturation

is less than 94%. Also give nitroglycerin, and morphine if

discomfort is unresponsive to nitrites.

C-Obtain 12-lead ECG; interpret or transmit for interpretation

D-Complete a fibrinolytic checklist if indicated.

E-Provide prearrival notification to the receiving facility if

ST elevation

3-Immedaite ED assessment and treatment:

The high-performance team should quickly evaluate the

patient with potential ACS on the patient arrival in the ED.

Withing the first 10 minutes, obtain 12-lead ECG (if not

already performed before arrival) and assess the patient.

The first 10 minutes:

Assessment and stabilization the of the patient in the first

10 minutes should include the following:

A-Check vital signs and evaluate oxygen saturation

B-Establish IV access

C-Take a brief focused history and perform a physical

examination

D-Complete the fibrinolytic checklist and check for

contraindications, if indicated.

30


E-Obtain a blood sample to evaluate initial cardiac marker

levels, electrolytes, and coagulation

F-Obtain and review portable Chest X-ray (less than 30

minutes after the patient arrival in the ED). This should not

delay fibrinolytic therapy for STEMI or activation of PCI

team.

Note: The result of cardiac markers, chest x-ray, and

laboratory studies should not delay reperfusion therapy

unless clinically necessary. e.g., suspected aortic dissection

or coagulopathy.

Patient general treatment:

Unless allergies or contraindications exist, 4 agents may be

considered in patient with ischemic-type chest discomfort:

-Oxygen if hypoxemic (O2 % less than 94%) or signs of

heart failure

-Aspirin

-Nitroglycerin

-Opiate (e.g. morphine if ongoing discomfort or no response

to nitrite)

4-Classification of patient according to ST

segment Deviation:

In general, the patients will present from one of these three

groups:

A-STEMI (ST-segment elevation myocardial

infarction): ST segment elevation greater than 1 mm (0.1

mV) in 2 or more contiguous precordial leads or 2 or more

adjacent limb leads -OR- New or presumed new left bundle

branch block

B-High-risk unstable angina (UA) or NSTEMI

(non-ST-segment elevation myocardial

infarction):

Ischemic ST-segment depression of 0.5 mm (0.5 mV) or

greater -OR- Dynamic T wave inversion with pain or

discomfort / Transient ST elevation of 0.5 mm or greater for

less than 20 minutes.

C-Intermediate or low risk UA: Normal or non-

diagnostic changes in ST segment or T wave that are

inconclusive and require further risk stratification / Includes

people with normal ECGs and those who have ST-segment

deviation in either direction that is less than 0.5 mm or T

wave inversion of 2 mm or 0.2 mV or less

The ECG Classification of ischemic syndromes is not meant

to be exclusive. A small percentage of patients with normal

ECG may be found to have MI, for example if the initial ECG

is nondiagnostic and clinical circumstances indicate (e.g.

ongoing chest discomfort), repeat the ECG. Management is

based on the results of the ECG.

-ECG shows ST-segment elevation:

Confirm how much time has passed since the onset of

symptoms.

If less than 12 hours has elapsed, do the following:

● Develop a reperfusion strategy based on the

31


patient's and the hospital's criteria. Unless impossible, the

patient should be taken to the cardiac catheterization

laboratory for PCI

● Continue adjunctive therapies.

● If indicated, add the following treatments:

o ACE inhibitors/angiotensin receptor blocker

(ARB) within 24 hours of symptom onset

o HMG-CoA reductase inhibitor (statin therapy)

Results of cardiac markers, chest x-ray, and laboratory

studies should not delay reperfusion therapy unless there

is a clinical reason (7).

Start adjunctive treatments for STEMI, as indicated:

• Beta-adrenergic receptor blocker

• Clopidogrel

• Heparin (unfractionated heparin or low-molecular-

weight heparin / UFH or LMWH)

-ECG shows ST depression or dynamic T-wave

inversion

Start adjunctive treatments for NSTEMI, as indicated:

• Nitroglycerin

• Beta-adrenergic receptor blocker

• Clopidogrel

• Heparin (UFH or LMWH)

• Glycoprotein IIb/IIIa inhibitor

If more than 12 hours has passed since the patient's onset

of symptoms, do the following:

1. Admit patient to the hospital

2. Assess risk status

Continue ASA, heparin, and other therapies as indicated

(ACE inhibitors, statins) for the high-risk patient

characterized by:

• Refractory ischemic chest pain

• Recurrent or persistent ST deviation

• Ventricular tachycardia

• Hemodynamic instability

• Signs of pump failure

-ECG shows normal ECG or nonspecific ST-T

wave changes

Consider admitting the patient to hospital or to a monitored

bed in ED

TIMI risk STRATIFICATION for ACS:

The Thrombolysis in Myocardial Infarction (TIMI) Score is

used to determine the likelihood of ischemic events or

mortality in patients with unstable angina or non-ST-

segment elevation myocardial infarction (NSTEMI) (8).

Each of the following criteria constitutes one point for TIMI

scoring (6):

• Age > 65 years

32


• Three or more risk factors for coronary artery disease

(CAD) (family history of CAD, hypertension,

hypercholesterolemia, diabetes mellitus, tobacco use)

• Known CAD (stenosis ?50%)

• Aspirin use in the past 7 days

• Severe angina (?2 episodes in 24 hours)

• ST deviation ?0.5 mm

• Elevated cardiac marker level

The risk of death / MI / urgent revascularization by Day 14

(rounded to nearest %) based on TIMI score is as follows:

• 0-1: 5%

• 2: 8%

• 3: 13%

• 4: 20%

• 5: 26%

• 6-7: 41%

What if the patient presents with cardiac arrest

and ACS?

We would apply the ACLS protocol for cardiac arrest, and

once the patients return of spontaneous circulation Restore

(ROSC) either by1- monitoring pulseand blood pressure or

by2-abrupt sustained increase in PETCO2 (typically ? 40

mm Hg) or 3- spontaneous arterial pressure waves with intra-

arterial monitoring then we will start post-cardiac arrestcare

along with the treatment of ACS algorithm (9).

SEE Pictures below.

33


34


References

1. Bueno, H., 2020. Epidemiology of Acute Coronary

Syndromes. [online] Oxford Medicine Online.

2. Emedicine.medscape.com. 2020. Acute Coronary

Syndrome: Practice Essentials, Background,

Etiology.

3. MSD Manual Professional Edition. 2020. Overview

Of Acute Coronary Syndromes (ACS) -

Cardiovascular Disorders - MSD Manual Professional

Edition

4. Uptodate.com. 2020. Uptodate. [online] Available at:

<https://www.uptodate.com/contents/advanced-

cardiac-life-support-acls-in-adults?

5. https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC5660295/#:~:text=The%20goal% 20in%

20studying%20ACS,cardiac%20death %20is%20the

%20highest.

6. https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC3271556/

7. Lorraine Anne Liu, R., 2020. Acute Coronary

Syndromes Algorithm

8. Emedicine.medscape.com. 2020. Thrombolysis In

Myocardial Infarction (TIMI) Score: Thrombolysis

In Myocardial Infarction (TIMI) Score.

9. https://international.heart.org/en/our-courses/acls-

provider-course

35

acls protocol for acute coronary syndrome

Documents