Acute Coronary Syndrome (ACS) | Acute Management | ABCDE

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Acute coronary syndrome (ACS) refers to a range of acute myocardial ischaemic states including:

  • ST-elevation myocardial infarction (STEMI)
  • Non-ST elevation myocardial infarction (NSTEMI)
  • Unstable angina

Myocardial infarction (MI) can be classified as either type 1 or type 2. Type 1 MIs are caused by plaque rupture whilst type 2 MIs occur secondary to decreased supply (e.g. anaemia, hypoxaemia, hypotension) or increased demand (e.g. arrhythmias such as atrial fibrillation with rapid ventricular response).

ACS is life-threatening and must be recognised and treated in a timely manner. Remember: time is myocardium!

This guide provides an overview of theΒ recognitionΒ andΒ immediateΒ managementΒ ofΒ ACS using anΒ ABCDEΒ approach.

TheΒ ABCDEΒ approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure

Each stage of the ABCDE approach involvesΒ clinicalΒ assessment,Β investigationsΒ andΒ interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

This guide has been created to assist students in preparing for emergencyΒ simulationΒ sessionsΒ as part of their training,Β it is not intended to be relied upon for patient care.


Clinical features of ACS

Symptoms

Typical symptoms associated with ACS include:

  • Chest pain
  • Referred painΒ­: chest pain can radiate to the epigastrium, arm, neck and jaw.
  • Shortness of breath
  • Palpitations
  • Nausea and vomiting
  • Sweating
  • Syncope

Clinical signs

Typical clinical signs associated with ACS include:

  • Tachycardia
  • Tachypnoea
  • Pallor
  • Evidence of impaired myocardial function: hypotension, raised jugular venous pressure (JVP), coarse crackles on chest auscultation and additional heart sounds (e.g. pan-systolic murmur).

Tips before you begin

GeneralΒ tipsΒ for applying anΒ ABCDEΒ approachΒ in an emergency setting include:

  • Treat all problemsΒ as you discover them.
  • Re-assessΒ regularly and after every intervention to monitor a patient’s response to treatment.
  • Make use of the team around you byΒ delegating tasksΒ where appropriate.
  • All critically unwell patients should haveΒ continuous monitoringΒ equipment attached for accurateΒ observations.
  • Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
  • If you require senior input,Β call for help earlyΒ using an appropriateΒ SBARR handoverΒ structure.
  • Review resultsΒ as they become availableΒ (e.g.Β laboratory investigations).
  • Make use of your localΒ guidelinesΒ andΒ algorithmsΒ in managing specific scenarios (e.g.Β acute asthma).
  • AnyΒ medicationsΒ orΒ fluidsΒ will need to beΒ prescribedΒ at the time (in some cases you may be able to delegate this to another member of staff).
  • Your assessment and management should beΒ documentedΒ clearly in the notes, however, this shouldΒ not delayΒ initial clinical assessment, investigations and interventions.

Initial steps

Acute scenarios typically begin with aΒ briefΒ handoverΒ from a member of theΒ nursing staffΒ including theΒ patient’s name,Β age,Β backgroundΒ and theΒ reasonΒ theΒ reviewΒ has been requested.

You may be asked to review a patient with ACS due to chest pain and/or shortness of breath.

Introduction

IntroduceΒ yourselfΒ to whoever has requested a review of the patient andΒ listenΒ carefullyΒ to their handover.

Interaction

IntroduceΒ yourselfΒ to theΒ patientΒ including yourΒ nameΒ andΒ role.

AskΒ how the patient is feelingΒ as this may provide some useful information about their currentΒ symptoms.

Preparation

Make sure theΒ patient’sΒ notes,Β observationΒ chartΒ andΒ prescriptionΒ chartΒ are easily accessible.

Ask for anotherΒ clinicalΒ memberΒ ofΒ staffΒ toΒ assistΒ you if possible.

If the patient isΒ unconsciousΒ orΒ unresponsive, start theΒ basic life supportΒ (BLS)Β algorithmΒ as per resuscitation guidelines.


Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

  • Look for signs ofΒ airwayΒ compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
  • Open the mouthΒ andΒ inspect: look for anything obstructing the airway such as secretions or a foreign object.

Interventions

Regardless of the underlying cause of airway obstruction, seekΒ immediate expert supportΒ from an anaesthetist and the emergency medical team (often referred to as the β€˜crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airwayΒ using aΒ head-tiltΒ chin-lift manoeuvre:

1.Β Place one hand on the patient’s forehead and the other under the chin.

2.Β Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3.Β Inspect theΒ airwayΒ for obviousΒ obstruction. If an obstruction is visible within the airway, use aΒ fingerΒ sweepΒ orΒ suctionΒ to remove it.

Jaw thrust

If the patient is suspected to have sufferedΒ significantΒ traumaΒ with potential spinal involvement, perform aΒ jaw-thrustΒ rather than a head-tilt chin-lift manoeuvre:

1.Β Identify the angle of the mandible.

2.Β With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3.Β Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

ToΒ insertΒ anΒ oropharyngealΒ airway:

1.Β Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2.Β Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180Β°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3.Β Advance the airway until it lies within the pharynx.

4.Β Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1.Β Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2.Β Lubricate the NPA.

3.Β Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4.Β If any obstruction is encountered, remove the tube and try the left nostril.

Other interventions

If the patient has clinical signs ofΒ anaphylaxisΒ (e.g. angioedema, rash) commence appropriate treatment as discussed in ourΒ anaphylaxis guide.

CPR

If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Breathing

Clinical assessment

Observations

Review the patient’sΒ respiratoryΒ rate:

  • AΒ normalΒ respiratory rate is betweenΒ 12-20 breaths per minute.
  • Patients with ACS may be tachypnoeic in an attempt to increase myocardial tissue oxygenation.

Review the patient’sΒ oxygen saturationΒ (SpO2):

  • AΒ normal SpO2Β rangeΒ isΒ 94-98%Β in healthy individuals andΒ 88-92%Β in patients withΒ COPDΒ who are at high-risk ofΒ CO2Β retention.
  • Hypoxaemia may occur due to cardiac failure and secondary pulmonary oedema.

Auscultation

Auscultate both lungs:

  • Reduced air entry bilaterally suggests significant airway compromise and the need for critical care input.
  • Crackles or crepitations on auscultation may represent pulmonary oedema due to impaired cardiac function.

Percussion

Percuss the chest to assess for dullness associated with pleural effusion (e.g. secondary to cardiac failure).

Investigations and procedures

Arterial blood gas

Take anΒ ABGΒ ifΒ indicatedΒ (e.g. low SpO2) to quantify the degree of hypoxia.

An ABG should not delay the management of ACS.

Chest X-ray

A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for evidence of pulmonary oedema. A chest X-ray should not delay the emergency management of ACS.

See ourΒ CXR interpretation guideΒ for more details.

Interventions

Oxygen

Administer oxygen if the patient has a low SpO2. This typically involves the use of aΒ non-rebreathe maskΒ with an oxygen flow rate ofΒ 15L. If the patient has COPD and a history of CO2Β retention you should switch to aΒ venturi maskΒ as soon as possible andΒ titrate oxygen appropriately.

If the patient is conscious, sit themΒ uprightΒ as this can also help with oxygenation.

Continuous positive airway pressure

Continuous positive airway pressureΒ (CPAP) should be considered for patients who do not improve after supplemental oxygen and intravenous diuretics (see below). Commencing CPAP is a skill beyond the scope of most junior doctors and should always involve more senior doctors.

CPR

If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Circulation

Clinical assessment

Pulse

Assess the patient’s pulse:

  • Tachycardia is a common feature of ACS.
  • Bradycardia is a late sign and often precedes cardiac arrest.

Blood pressure

Assess the patient’s blood pressure:

  • Patients may be hypertensive due to increased sympathetic activity and pain.
  • Hypotension is a late sign and represents cardiac failure.

Inspection

Inspect the patient from the end of the bed: they may appear in pain and clammy/pale.

Fluid balance assessment

Calculate the patient’s fluid balance:

  • Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
  • Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.

Investigations and procedures

Intravenous cannulation

Insert at least oneΒ wide-bore intravenous cannulaΒ (14G or 16G) and take blood tests as discussed below.

See ourΒ intravenous cannulation guideΒ for more details.

Blood tests

CollectΒ blood testsΒ after cannulating the patient including:

  • Troponin: to help confirm the diagnosis of myocardial infarction.
  • FBC: to screen for anaemia and signs of infection.
  • U&Es: to assess renal function and electrolyte levels.
  • CRP: to screen for evidence of infection.
  • Serum glucose: to identify hyperglycaemia which should then be treated to improve outcomes.
  • LFTs: to assess liver function (e.g. ischaemic hepatitis secondary to cardiac failure).
  • Coagulation screen: to assess for coagulopathy.

Record an ECG

In the context of ACS, an ECG can provide valuable information as to the sub-type of ACS. Typical findings in each of the subtypes of ACS include:

  • STEMI: ST elevation and/or new left bundle branch block (LBBB)
  • NSTEMI: T wave inversion and/or ST depression
  • Unstable angina: often there are no specific ECG abnormalities

Interventions

Morphine

Morphine has a dual purpose in ACS treatment, both as a coronary artery vasodilator and as an analgaesic.

Nitrates

Nitrates, such as glyceryl trinitrate spray, cause coronary artery vasodilation and improve cardiac perfusion.

If the patient is hypotensive, nitrates are contraindicated due to their vasodilatory effects.

Aspirin and clopidogrel

Aspirin (300mg) and clopidogrel (300mg) are administered to try and improve blood flow through the coronary vessels by inhibiting platelet aggregation.

Diuretics

If clinical signs of pulmonary oedema are present (e.g. shortness of breath, coarse bibasal crackles) consider administration of an intravenous diuretic (e.g. furosemide):

  • Furosemide increases diuresis and aids the clearance of pulmonary oedema.
  • If a patient is hypotensive, diuretics should not be administered in a ward setting and urgent critical care input should be sought.

Fluid resuscitation

Hypovolaemic patients requireΒ fluidΒ resuscitation:

  • Administer a 500ml bolus of Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins.
  • Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus,Β reassessΒ for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administrationΒ of fluid boluses up toΒ four timesΒ (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.

Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (i.e. persistent hypotension).

See ourΒ fluid prescribing guideΒ for more details onΒ resuscitation fluids.

Percutaneous coronary intervention (PCI)

Patients with clinical evidence of STEMI require urgent PCI and should be discussed with the on-call interventional cardiologist as soon as possible.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Disability

Clinical assessment

Consciousness

In the context of ACS with hypotension, a patient’s consciousness level may be reduced.

Assess the patient’s level of consciousness using the AVPU scale:

  • Alert: the patient is fully alert, although not necessarily orientated.
  • Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
  • Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
  • Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Pupils

Assess the patient’s pupils:

  • Inspect the size and symmetry of the patient’s pupils
  • Assess direct and consensual pupillary responses

Drug chart review

Review the patient’s drug chart for medications which may cause a reduced level of consciousness (e.g. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications).

Investigations and procedures

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia).

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.

Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≀4.0 mmol/L should be treated if the patient is symptomatic.1

See our blood glucose measurement guide for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting aΒ CT head for more details.

Interventions

Maintain the airway

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Exposure

It may be necessary toΒ exposeΒ the patient during your assessment: remember to prioritise patient dignity and conservation of body heat.Β 

Clinical assessment

Inspection

Inspect for relevant clues and clinical signs which may indicate increased cardiovascular risk (e.g. cigarettes, xanthelasma, corneal arcus).

Look for any sources of bleeding which may have precipitated a myocardial infarction (e.g. rectal bleeding).

Urine output

Review the patient’s urine output as part of a fluid balance assessment to inform ongoing fluid management.

Temperature

Measure the patient’sΒ temperature:

  • If fever is present, make sure to consider co-existing infection.
  • Patients with ACS may develop a fever as part of a catecholamine response.

Interventions

Catheterisation

Catheterise the patient to closely monitor urine output to guide fluid resuscitation and need for escalation.

CPR

If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Reassess ABCDE

Re-assessΒ the patient using theΒ ABCDE approachΒ to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

DeteriorationΒ should be recognised quickly and acted upon immediately.

Seek senior helpΒ if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you shouldΒ not delay seeking help if you have concerns about your patient.

Use an effectiveΒ SBARR handoverΒ to communicate the key information effectively to other medical staff.


Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Revisit history taking to explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.

See ourΒ history taking guidesΒ for more details.

Review

Review theΒ patient’s notes,Β chartsΒ andΒ recent investigation results.

Review the patient’sΒ current medicationsΒ and check any regular medications areΒ prescribed appropriately.

Document

ClearlyΒ document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See ourΒ documentation guidesΒ for more details.

Discuss

Discuss the patient’s current clinical condition with aΒ seniorΒ clinicianΒ using anΒ SBARRΒ style handover.

QuestionsΒ which may need to be considered include:

  • Are any further assessments or interventions required?
  • Does the patient need a referral toΒ HDU/ICU?
  • Does the patient need reviewing by a specialist?
  • Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should beΒ made awareΒ of any patient in their department who hasΒ recently deteriorated.


 

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