General Approach to All Patients

Chest Pain - Suspected Cardiac Ischemia

Basic Life Support

  • Supplemental oxygen
  • Assist patient in self-administration of previously prescribed Aspirin
  • Assist patient in self-administration of previously prescribed Nitroglycerin
    • Contraindicated if systolic BP < 90 mm Hg
    • Contraindicated if use of a Phosphodiesterase-5 (PDE5) inhibitor within last 24 hours (Viagra or Levitra); 48 hours for Cialis
  • Repeat patient assisted Nitroglycerin administration every 5 minutes as needed for continued chest pain (provided SBP remains > 90 mm Hg) with assessment of patient before and after each NTG dose

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Perform 12 lead ECG immediately:
    • Identify the presence of ECG changes suggestive of Acute Myocardial Infarct (AMI)
    • If STEMI criteria are present initiate STEMI Alert (see following page)
  • Aspirin 324 mg PO, chewed if patient is able to swallow
    • Aspirin is contraindicated if allergic
  • Nitroglycerin 0.4 mg spray or tablet SL, every 5 minutes as needed for chest pain
    • Contraindicated if systolic BP < 90 mm Hg
    • Contraindicated if use of a Phosphodiesterase-5 (PDE5) inhibitor within last 24 hours (Viagra or Levitra); 48 hours for Cialis
    • Use with caution in Acute Inferior Wall MI, or Right Ventricular infarct (ST elevation in V4R)
    • Be prepared to administer NS 250 ml boluses IV if hypotension develops
  • Fentanyl (Sublimaze) 1 mcg/kg (maximum 50 mcg) slow IV; repeat once after 5 minutes as needed (maximum 100 mcg total dose) if no chest pain relief after 3rd Nitroglycerin dose
    • Contraindicated if systolic BP < 90 mm Hg
    • Use with caution if right ventricular or posterior wall MI (ST elevation in posterior leads with marked depression V1 thru V4)
  • If runs of Ventricular Tachycardia occur:
    • Amiodarone 150 mg IV Piggyback over 10 minutes
    • Isolated PVC’s do not require treatment
  • For patients with severe nausea or vomiting:
    • Ondansetron (Zofran), 4 mg slow IV or 4 mg Oral Disintegrating Tablet (ODT) by mouth

STEMI Alert (ST Elevation Myocardial Infarction)

A STEMI Alert will be instituted for patients having chest pain or ischemic equivalent symptoms for < 12 hours, and any of the following:

  • ST segment elevation ≥ 1mm in two or more contiguous leads
  • Computer interpretation of “Meets ST Elevation MI criteria” on 12 lead ECG
  • New Left Bundle Branch Block (confirmed by comparing to prior ECG)

Accomplish the following as part of the STEMI Alert process:

  • Determine if the patient has a Cardiologist and a hospital preference
  • Based on patient preference or proximity, transmit the 12 lead ECG to the appropriate hospital destination
    • During the radio call to the ED, convey the name of the patient's Cardiologist
  • Transport STEMI Alert patients to a PCI (Percutaneous Coronary Intervention) capable hospital based on patient preference or proximity (if patient has no preference)
    • PCI capable hospital campuses in and around Orange County:
      • Dr. P. Phillips Hospital
      • Florida Hospital Altamonte
      • Florida Hospital Orlando
      • Health Central Hospital
      • Orlando Regional Medical Center
      • Osceola Regional Medical Center
    • The following hospitals function as part of the Florida Hospital STEMI receiving network, and can arrange rapid interfacility transport of STEMI Alert patients when primary transport by EMS is not operationally feasible:
      • Florida Hospital (FH) Apopka, FH East, Florida Hospital Celebration Health and FH Kissimmee