Cardiovascular Medicine Book

Circulatory Disorders

Electrocardiogram

Myocardial Infarction

Symptoms

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Acute Coronary Syndrome Immediate ManagementAka: Myocardial Infarction Assessment, Ischemic Chest Pain Management, Immediate Myocardial Infarction Management, Immediate MI Management

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  1. History: Targeted Brief
    1. Duration of pain
    2. Prior Myocardial Infarction
    3. Cardiac Risk Factors
    4. Thrombolytic Contraindications
  2. Exam: Targeted Brief
    1. Signs of right or left sided Heart Failure
    2. New murmur or pericardial rub
    3. Assess tissue perfusion, systemic Blood Pressure
    4. Asymmetry of peripheral pulses
  3. Diagnosis
    1. EKG in Acute MI within 5 minutes
    2. Consider Echocardiogram in Acute MI if no delay
    3. Portable Chest XRay within 30 minutes
    4. Labs
      1. Electrolytes
      2. ProTime
      3. Partial Thromboplastin Time (PTT)
    5. Serum Cardiac Markers
      1. Troponin I
  4. Immediate Assessment
    1. ABC Management
    2. Mnemonic: IV-O2-Monitor
      1. Vitals with Oxygen Saturation
      2. Start Intravenous Access
      3. Cardiopulmonary monitor
    3. Consider Differential Diagnosis
      1. See Chest Pain
  5. Management: Immediate
    1. Mnemonic: "MONA" greets all patients
      1. Morphine Sulfate IV 2-5 mg every 5-30 min prn
        1. Pain not relieved with 3 Sublingual Nitroglycerins
      2. Oxygen by Nasal cannula at 4 liters per minute
      3. Nitroglycerin
        1. Sublingual Nitroglycerin 0.4 mg
        2. Nitroglycerin paste (start with 1/2 inch)
        3. Low threshold to switch to Nitroglycerin Drip
      4. Non-enteric coated Aspirin 325 mg PO
        1. Dipyridamole (Persantine) for Aspirin sensitivity
    2. Cardiology Consultation
  6. Management: Evaluate 12 lead Electrocardiogram (EKG)
    1. High Risk Indications: Myocardial Infarction Protocol
      1. ST Elevation MI (Q-Wave MI)
      2. New (or presumed new) Left Bundle Branch Block
    2. Moderate Risk Indications: Myocardial Ischemia Protocol
      1. Non-ST elevation MI (Non-Q-Wave MI)
      2. ST depression or dynamic T Wave inversion
      3. High Unstable Angina Risk
    3. Low Risk: Non-diagnostic Electrocardiogram Protocol
      1. Absent ST segment or T Wave changes on EKG
      2. Low Unstable Angina Risk
  7. References
    1. (2000) Circulation 102(suppl I):I

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