The patient with chest pain that reaches PS, in the case of an ACS, presents
a retrosternal pain that can be perceived as oppressive and as a sense of
chest tightness, accompanying the symptoms with other signs of alarm:
Sense of pressure or constriction or pain in the center of the thorax
which generally lasts at least 15 minutes;
Pain radiating at the neck, jaw, shoulders, back, epigastrium and arms;
Sense of discomfort in the chest with dizziness, syncope, sweating, nausea
or dyspnoea, general malaise, sense of death, anxiety, facies terrea
Other situations to take into account for their lethal potential are aortic
dissection, acute pericarditis with cardiac tamponade, pulmonary embolism
and esophageal ruptures.
When the patient reaches the first aid garrison it is necessary to evaluate
his/her health conditions and to maintain the patient's vital functions (see BLS) by controlling and adjusting the arterial pressure, the heart rate and
the respiratory frequency, the hemogas.
It is therefore necessary to proceed with the execution of the 12-lead
cardiac pathway (ecg), collecting the patient's medical history.
In the meantime, having examined the tracing, it is necessary to evaluate whether there are signs of chest pain with STEMI or NSTEMI, that is, if the ST tract of the ECG is supersized, with a certain diagnosis, in this case of SCA, otherwise it will talk about NSTEMI, which is also a dangerous condition.
Therefore, the ACLS protocol is applied, ie if there is a cardiac electrical
activity if the peripheral pulse is missing, it is necessary to:
a) Evaluate ABC, from the initials of the English words Airway, Breathing,
Circulation, ie if the airways are pervades, if there is breath and
circulation (see first_soccorso) and if the heart is in ventricular
fibrillation proceeds with defibrillation.
At this stage, it has been seen from experience that there is no need for an
orotracheal intubation, since most of the time it is sufficient to properly
ventilate the patient with an Ambu ball, also because the same thrust
maneuvers are performed on the chest to ensure the cardiac output (heart
stop condition) are able to ensure a movement of pressure on the lungs and a
sort of ventilation.
b) Then we proceed with the practice of "M.A.N.O.", which in medical technical
jargon means:
administer morphine (2-4 mg repeatable) to quell pain,
administer Aspirin for fibrinolysis (eye to patients with ulcer and dosed at
160-325 mg)
administer the Nitroderivatives if the pressure allows it and is> 90 mmHg
practice oxygen therapy that is never denied to anyone, dosed at 4 liters /
minute.
c) Reading the route in the meantime performed to group patients in 3 classes:
1) ST segment elevation or patient presenting a left bundle branch block (usually
means that the coronary artery supplying the left branch is obstructed): we are
faced with a myocardial lesion with an elevated STEMI IMA ST.
In these patients, acute reperfusion therapy is indicated (class I if the start
of therapy occurs within 12 hours from the onset of symptoms and age is below
75 years, class Iia if greater than 75, class I 1b after 12 Patients with
posterior infarction may have ST sub-segmented in V1-V4 by posterior IMA and
high and hyperacute T waves, and additional treatments with beta-blockers,
clopidogrel and low-weight heparin or molecular weight can be used at this
stage.
2) Fibrinolytic therapy as a reperfusion strategy takes place within 30 minutes.
3) Angioplasty or PTCA.
The goal of coronary PTCA, from the time the 118 doctor saw the patient is to intervene within 90 minutes.
It is the patients who have not undergone T-wave or inversion of the T wave at
the ecg track, this tract is strongly suspected by myocardial ischemia,
unstable high-risk angina, non-STV-like IMA - NSTEMI / UA
1) For these patients should be considered therapy with Beta-blockers,
clopidogrel, high or low molecular weight heparin, glycoprotein IIb / IIIa
inhibitors.
These patients are sibylline, in the sense that it is still an SCA
but the patient must first be framed if at high risk and transits into UTIC
only for admission and treatment, where he can do cardiac catheterization and
PTCA or CABG.
These patients remain under observation due to the presence of unstable angina criteria, recent onset or because they are troponin positive (remember that troponin is the most sensitive marker of myocardial infarction). They can be treated or as patients of group B (unstable angina to high-altitude-NSTEMI/UA) if there are signs and criteria that can make people think about risk, otherwise they must be discharged after 8-12 hours of observation, with agreement that in the meantime no electrocardiographic changes have occurred and serum markers absent.
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