Consider the spectrum of illnesses within ACS

ACS - General Mx Principles (below)

Nausea and Vomiting

Pulmonary Oedema

Inadequate Perfusion: Cardiogenic Causes EDA and GTN Administration

Arrhythmias: VF / Pulseless VT Bradycardia SVT - Adequately Perfused SVT - Not Adequately Perfused / Unstable Ventricular Tachycardia Accelerated Idioventricular Rhythm

Acute Coronary Syndrome - General Management Principles

Assess for requirements for:

• Pain relief/nitrates • Antiplatelet Rx • Control of hypertension

		Antiplatelet See Contra's and Precautions Aspirin Aspirin 300mg oral					Pain Relief See Contra's and Precautions Morphine Pain relief as per Pain Relief until pain free
Nitrates See Contra's and Precautions GTN Previous Nitrates   No Previous Nitrates BP >110: GTN 600mcg S/L/Buccal   BP >110: GTN 300mcg S/L/Buccal If symptoms continue and BP remains >110: - Repeat GTN 600mcg S/L/ Buccal, 5 Minutely   If symptoms continue and BP remains >110: - Repeat GTN 300mcg S/L/, Buccal 5 Minutely           BP >90: GTN Patch 10mg (0.4mg/hr) upper torso/arms - If BP falls <90, remove patch							Hypertension +/- symptoms See Contra's and Precautions Morphine Aspirin - Systolic BP >160 or - Diastolic BP >100 Control pain as per Pain Relief GTN 300mcg S/L/Buccal - Repeat GTN 300mcg 5 minutely if hypertension persists

General Mx Principles - Special Notes

GTN is a potent venodilator that can decrease venous return therefore decreasing right ventricular (RV) filing and fibre stretch with a reduction in cardiac output. The use of GTN is contraindicated in Inferior and RV infarcts.

Up to 50% of Inferior AMIs have RV involvement and cannot compensate to a drop in venous return due to myocardial insufficiency.

Signs of an Inferior AMI include ST elevation in leads II and III. Bradycardia is not unusual in an Inferior AMI due to the involvement of the right coronary artery and the SA / AV nodes.

Nitrates are contraindicated in bradycardia (HR < 50) due to the Pt’s inability to compensate to a decrease in venous return by increasing HR to improve cardiac output. - C.O. = HR x SV