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Emergency Department
MRN_________________________
Surname_____________________
Given Names_________________
Date of Birth__________________
ST elevation Myocardial
Infarction (STEMI) PATHWAY
YES
ST elevation
or presumed new left
yes
bundle branch block (LBBB)?
NO
CHEST PAIN ASSESSMENT
Using the table of signs & symptoms below, identify the risk group that your patient falls into and proceed
to the management principles on page 3.
HIGH RISK features- requires only one feature to be HIGH RISK NSTEACS
Repetitive or prolonged (>10 mins) ongoing chest pain or discomfort
Elevated level of at least one cardiac biomarker (troponin or creatinine kinase-MB isoenzyme CKMB)
Persistent or dynamic ECG changes of ST segment depression 0.5mm or new T wave inversion 2 mm
Transient ST segment elevation (0.5mm) in more than two contiguous leads
Haemodynamic compromise systolic BP <90mmHg, cool peripheries, diaphoresis, Killip Class > 1, and/or new onset
mitral regurgitation.
Sustained Ventricular Tachycardia (VT)
Syncope
Left ventricular systolic dysfunction (left ventricular ejection fraction < 0.40)
Prior Percutaneous Coronary Intervention (PCI) within 6 months or prior Coronary Artery Bypass Grafting (CABG).
Presence of known diabetes (with typical symptoms of ACS); or
kidney disease (estimated glomerular filtration rate < 60 mL/min) (with typical symptoms of ACS).
INTERMEDIATE RISK features- any of the following features AND DO NOT meet the criteria for HIGH
RISK NSTEACS
Chest pain or discomfort within the past 48 hours that occurred at rest, or was repetitive or prolonged (but currently
resolved)
Age > 65 years
Known coronary heart disease prior myocardial infarction with left ventricular ejection 0.40, or known coronary lesion
more than 50% stenosed.
No high-risk changes on ECG ( see above)
Two or more of the following risk factors- known hypertension, family history, active smoking or hyperlipidaemia.
Presence of known diabetes (with atypical symptoms of ACS)
Chronic kidney disease (estimated glomerular filtration rate < 60 mL/min) (with atypical symptoms of ACS); or
Prior aspirin use
LOW RISK features- Any clinical features consistent with ACS without ANY Intermediate risk or high
risk features. This includes;
Onset of anginal symptoms with the last month
Worsening in severity or frequency of angina
Lowering of anginal threshold.
NON CARDIAC
Continue ED management and find cause of symptom. Exit pathway. Complete Clinical management summary.
NB: Always consider differential diagnosis of chest pain such as pulmonary embolus or pericarditis
MRN _________________________
Surname _____________________
Given names _________________
DOB _________________________
STEMI
Admit to CCU with a monitored bed
Consult with specialist..
Consider early transfer to a referral centre for patients with ALL STEMIs, ongoing pain,
clinically unstable, large area of myocardium at risk, known poor left ventricular function and
renal impairment.
Continuous Cardiac preferably with ST segment monitoring.
Full resuscitation equipment to be immediately available.
Record HR, BP, RR, SpO2, 15 minutely prn until stable
Aspirin 300mg orally STAT then 100mg daily AND
Clopidogrel 300mg orally STAT.
Anginine 300 - 600ug SL if systolic BP > 100mmHg
Morphine 2.5mg increments until painfree
Consider GTN infusion as per product guide
Thrombolysis
INDICATIONS FOR USE:
History of cardiac ischaemic
pain lasting for at least 10-15
minutes, onset within 12
hours and not completely
responsive to buccal nitrates.
ECG changes:
ST elevation > 1mm in 2
adjacent limb leads
ST elevation>2mm in 2
adjacent pre cordial leads
New left bundle branch block
Heparin
Other medications
Complications
Investigations
APPT (mandatory check at 6
hrs)
IV Cannula
Baseline Bloods
2nd Troponin ( 8 hrs post
Relative
Risk of bleeding
- Current use of anticoagulants: the higher the INR, the higher the
risk of bleeding
- Non-compressible vascular punctures
- Recent major surgery (< 3 weeks)
- Traumatic or prolonged (>10 mins) CPR
- Recent (<4weeks) internal bleeding (eg GIT, UT)
- Active peptic ulcer
Risk of intracranial haemorrhage
- History of chronic, severe, poorly controlled hypertension.
- Severe uncontrolled hypertension on presentation (>180mmHg
systolic or > 110mmHg diastolic)
- Ischaemic stroke more than 3 months ago, dementia, or known
intracranial abnormality not covered in contraindications.
Other
- Pregnancy
NB: The potential benefit versus the relative risk should always
be considered with relative contraindications.
METALYSE (TNK)
Pts wt (kg)
TNK (mg)
TNK u/s
<60
30
6000
60-70
35
7000
70-80
40
8000
80-90
45
9000
>90
50
10,000
Give IV Heparin 5000us stat bolus
Reconstitute Heparin 10,000 units in 100mls of Normal Saline (100us/ml)
Start Heparin infusion at 10mls/hr.
Check APPT in 6 hours time and titrate heparin rate to maintain APPT at 60-80 secs
Continue infusion for 24 hours
Betablocker- Metoprolol 25mg BD or atenolol 50 mg daily (dependent on BP)
Statin- Atorvastatin 20mg daily and increase prn
ACEi- Perindopril 2mg daily and increase as per product instruction
Observe closely for further chest pain, hypotension, arrhythmias, pulmonary oedema and
cardiogenic shock. If any of these complications arise, consult with a specialist physician.
If after 60-90 mins, patients with large infarcts have not clinically reperfused, as indicated by
failure of >50% ST elevation resolution, urgently contact a physician to discuss rescue
Percutaneous Coronary Intervention (PCI), further thrombolysis or other therapy.
Titrate heparin infusion to maintain APPT at 60-80 seconds.
Time to be taken __________
X2
FBC, UECs, troponin, total CK (for 48 hours in patients with AMI)
Lipids/BSL
YES
Time to be taken _______
Fasting within 24 hours of admission
CXR
12 lead ECG
Repeat & review PRN at 60 minutes following completion of thrombolysis and then daily
Monitoring
Parameters Temp,
HR, BP, RR, SpO2,
INVESTIGATIONS
12 lead ECG
CXR
Coronary
Angiography
Exercise stress test
IV Cannula
Baseline Bloods
2nd Troponin
(mandatory 8 hrs
post symptom onset)
Lipids
BSL
MEDICATIONS
Pain relief
Antiplatelets
LMWH (clexane)
Other oral
medications to
consider
See product information
for specific directions to
prepare the solutions
and to calculate the
infusion rate according
to weight.
Patient information
sheet
Cardiac Rehabilitation
HIGH RISK
MRN _________________________
Surname _____________________
Given names _________________
DOB _________________________
INTERMEDIATE RISK
LOW RISK
Admit CCU
Monitored bed
If unstable, consult with
specialist and consider early
transfer to referral centre
Continuous Cardiac
Continuous Cardiac
As required
60 minutely or PRN
As outpatient if indicated
X1
FBC, UECs, troponin,
YES
Time to be taken ________
Fasting within 24 hours of
admission
As outpatient if indicated
X1 prn
FBC, UECs, troponin,
YES
Time to be taken _____
Not applicable
58799
MRN
Surname
Given Names
Date of Birth
Sex
Please affix Patient Identification Label Here
ACS Clinical
Management Summary
Hospital name ___________________________
Emergency Department clinician to complete
PRESENTATION DATE
HOSPITAL READMISSION?
Hospital ID
(If known)
PRESENTATION TIME
no
MEDICATIONS GIVEN IN ED
Aspirin 300mg given?
Antiplatelet therapy
Yes
No
Clopidogrel
Antithrombotic
Betablockers
Clexane
Yes
No
Allergy/contraindicated
IV Tirofiban
Combination
IV Heparin
Warfarin
Contraindicated
Contraindicated
Contraindicated
None
None
PATHOLOGY
Was the troponin measured 8-12 hours post symptom onset?
Was the troponin elevated
STEMI
IF A STEMI
a) Acute revascularisation?
HIGH
tPA
0-30
NO
NO
INTERMEDIATE
Thrombolysis
YES
YES
PTCA
SK
31-45
rPA
46-60
LOW
nil
tNK
61-75
76-90
>90
NSTEMI
Unstable angina
negative
No - not indicated
Time of test
positive
not done
No
No
Other
equivocal
unable to exercise
Yes
Yes
SEPARATION
No
No
Contra-indicated
Contra-indicated
Died in hospital
Home
No
No
Anginine
Statin
Beta Blocker
Yes
Yes
Yes
No
No
No
Contra-indicated
Contra-indicated
Contra-indicated
FAXED - YES
FACT SHEET
Chest pain
Chest pain
Ph: 1300 36 27 87