Does the ARC provide any guidance on the resuscitation, pre-hospital and emergency care of patients with acute coronary syndromes?
The management of patients with Acute Coronary Syndromes in the pre hospital and emergency care setting has been an area of increased research activity over the last 10 years. It is an area that has often been overlooked in guidelines focused on the management of acute coronary syndrome that have tended to focus on immediate and definitive therapeutic interventions once a clear diagnosis has been established.
The current COSTR process devoted a dedicated Task Force formed from the outset to address 25 topics related to the acute initial management of acute coronary syndromes drawing on expert reviewers from Africa, Asia, Australia, Europe, North America, and South America. The 2010 COSTR has produced an expanded review the available evidence in the area of out of hospital and emergency care of ACS. A complete systematic review of all literature is contained in this document.
For the first time the Australian Resuscitation Council has develop guidelines in this area based on the 2010 COSTR on ACS. Comprehensive guidelines for the diagnosis and treatment of ACS with and without ST elevation have been published by the Cardiac Society of Australia and New Zealand (CSANZ) and the National Heart Foundation (NHF). This section on ACS has been developed to compliment the CSANZ and NHF guidelines.
There are a number of new evaluations that should be highlighted since initial 2005 COSTR that have been outlined in the 2010 document. These include:
Presentation with ACS
- In isolation the clinical history, clinical examinations, biomarkers, ECG criteria and risk scores are unreliable for the identification of patients who may be safely discharged early in the emergency setting.
- Chest Pain Observations Units (CPUs) have an important role in the safe and effective evaluation of patients presenting with possible ACS. The use of a protocol that includes serial evaluation o f physical findings, symptoms, ECG, biomarker testing coupled with further provocative testing or imaging procedures are recommended to identify patients who required admission for further testing and treatment.
- The use of pre- hospital ECG for the diagnosis of ST elevation myocardial infarction is recommended and can be interpreted by a variety of methods including by trained non medical staff in the field, remote transmission or with computer assistance.
Initial Medical Therapy
- Supplemental oxygen should be initiated for breathlessness, hypoxaemia or signs of heart failure or shock however hyperoxaemia may be harmful in uncomplicated myocardial infarction.
- Response of chest pain to nitrate therapy is not reliable for diagnostic purposes.
- Cannabinoids and non-steroidal anti-inflammatory drugs other than aspirin should not be administered as they may be harmful in patients with suspected ACS.
- Aspirin may be given by dispatchers or bystanders provided true allergy or a bleeding disorder can be excluded.
- Newer anti-platelet agents have an important role in the early management of ACS.
- Clinical reperfusion networks that include emergency medical services and hospitals with an agreed approach to ST Elevation Myocardial Infarction (STEMI) management can be beneficial in achieving best outcomes for patients with ACS.
- Primary Percutaneous Coronary Intervention (PPCI) is the preferred reperfusion strategy for STEMI when it is performed in a timely manner by an experienced team.
- Fibrinolysis continues to be an important treatment modality for many patients when PPCI is not available.
- Acceptable first medical contact to PPCI delays varies depending on the infarct territory, age of the patient, and duration of symptoms.
- Rescue Percutaneous Coronary Intervention (PCI) should be performed if fibrinolysis fails.
- Patients may be directed to PPCI capable facilities in the pre hospital setting bypassing closer Emergency Departments if PPCI can be delivered in a timely manner.
- Patients with successful fibrinolysis but not in a PCI-capable facility should be transferred for angiography and possible PCI at ideally 6–24 h after fibrinolysis. However immediate routine PCI after fibrinolysis or combination fibrinolysis (‘facilitated’) is not recommended.
- Immediate angiography and PCI is a reasonable approach to patient with return of spontaneous circulation (ROSC) and may be a part of a standardised protocol for the post arrest care of patients.
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