ce ; AMERICAN American ASO CTON Heart of CRITICAL-CARE Association. NURSES Acute Coronary Syndromes and Stroke Acute Coronary Syndromes Algorithm Symptoms sugges e of ischemia or infarction 7 EMS assessment and care and hospital preparation * Assess ABCs. Be prepared to provide CPR and defibrillation * Administer aspirin and consider oxygen, nitroglycerin, and morphine if needed * Obtain 12-lead ECG; if ST elevation: — Notify receiving hospital with transmission or interpretation; note ti and first medical contact : * Provide prehospital notification; on arrival, transport to ED/ * Notified hospital should mobilize resources to resp ° If considering prehospital fibrinolysis, | Concurrent ED/cath lab assessment Immediate ED/cath lab (<10 minutes) general treatment * Activate STEMI team upon EMS notification * IfO2 sat <90%, start: * Assess ABCs; give oxygen if needed 4L/min, titrate * Establish IV access * Aspirin 162 to: Perform brief, targeted history, ou fi i 2020 American Heart Association. 20-1120 2020 American Heart Assocation N-1029 (of). PinteST elevation or new or presumably new LBBB; strongly suspicious for injury ST-elevation MI (STEMI) Vi © Start adjunctive therapies as indicated © Donotdelay reperfusion hours | $12 hours Guidelines briana A CA ELT CEA tel tats Algorithm (continued) Non-ST-el validat (ie, TIMI ST depression or dynamic T-wave inversion, transient ST elevation; strongly suspicious for ischemia and/or high-risk score High-risk NSTE-ACS Troponin elevated or high-risk patient Consider early invasive strategy if: | « Refractory ischemic chest discomfort » Recurrent/persistent ST deviation Ventricular tachycardia « Hemodynamic instability Signs of heart failure Start adjunctive therapies (eg. nitroglycerin, heparin) as indicated See AHA/ACC NSTE-ACS Reperfusion goals: Therapy defined by center criteria « FMC-to-bal (PC of patient and loon inflation 10 Ss (NSTE-ACS) Determine risk using | aie q levation ACS ited score or GRACE) Normal ECG or nondiagnostic changes in ST segment or T wave; low-risk score Low-/intermediate- risk NSTE-ACS Consider admission to ED chest pain unit or to appropriate bed for further monitoring and possible intervention peeFibrinolytic Contraindications for STEMI Contraindications for fibrinolytic use in STEMI consistent with the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction* Absolute Contraindications ¢ Any prior intracranial hemorrhage Known structural cerebral vascular lesion (eg, arteriovenous malformation) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months — Exceptacute ischemic stroke within 4.5 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head trauma or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months || * Severe uncontrolled hypertension (unresponsive to emergency therapy) ¢ For streptokinase, prior treatment within the previous 6 months Relative Contraindications * History of chronic, severe, poorly controlled hypertension ¢ Significant hypertension on presentation (systolic blood pressure greater than 180 mm Hg or diastolic blood pressure greater than 110 mm Hg) History of prior ischemic stroke more than 3 months ¢ Dementia | * Known intracranial pathology not covered in absolute contraindications | © Traumatic or prolonged (more than 10 minutes) CPR ° Major surgery (less than 3 weeks) | © Recent (within 2 to 4 weeks) internal bleeding | © Noncompressible vascular punctures | © Pregnancy * Active peptic ulcer * Oralanticoagulant therapy *Viewed as advisory for clinical decisi Abbreviations: CPR, cardiopulm | infarction.i ke Identify signs and symptoms of possi strol Activate emergency responst v Critical EMS assessments and actions Assess ABCs; give oxygenif needed Initiate stroke protocol Perform physical exam “ ! Perform validated prehospital stroke screen and stroke severity tool « Establish time of symptom onset (last known normal) * Triage to most appropriate stroke center * Check glucose; treatifindicated “ i % * Provide prehospital notification; on arrival, transport to brain imaging suite Note: Refer to the expanded EMS stroke algorithm. Y ED or brain imaging suite* Immediate general and neurologic assessment by hospital or stroke team * Activate stroke team upon EMS notification * Prepare for emergent CT scan or MRI of brain upon arrival * Stroke team meets EMS on arrival * Assess ABCs; give oxygen if needed * Obtain IV access and perform laboratory assessments * Check glucose; treat ifindicated * Review patient history, medications, and procedures * Establish time of symptom onset or last known normal * Perform physical exam and neurologic examination, including NIH Stroke Scale rCi eurological Scale : and go, ‘straight to the brain imaging suite. _<_ Does brain imaging > \ showhemorrhage? > a Consider alteplase Initiate intracranial hemorrhage rotocol Consider EVT * Perform CTA * Perform CTP as indicatedEmergency Medical Ser Acute Stroke LOTT Te) Transport time | to EVT-capable stroke center will ‘ not disqualify for thrombolytic, g Total transport | time from scene | to nearest CSC is <30 min total and within maximum time permitted by EMS. ice LT) Se ery tren) Pouca’ Presentation =gastowrfPNT ea CU CUCU in Acute Ischemic Stroke Options to Treat Arterial Hypertension in Patients With Acute Ischemic Stroke Who Are Candidates for Emergency Reperfusion Therapy’ {0} COR2b LOE Patient otherwise eligible for emergency reperfusion therapy except that BP is >185/110 mm Hg: * Labetalol 10-20 mg IV over 1-2 minutes, may repeat 1 time; or * Nicardipine 5 mg/h lV, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h; when desired BP reached, adjust to maintain proper BP limits; or ¢ Clevidipine 1-2 mg/h lV, titrate by doubling the dose every 2-5 minutes until desired BP reached; maximum 21 mg/h ¢ Other agents (eg, hydralazine, enalaprilat) may also be considered If BP is not maintained <185/110 mm Hg, do not administer alteplase Management of BP during and after alteplase or other emergency | | reperfusion therapy to maintain BP <180/105 mm Hg: | | ° Monitor BP every 15 minutes for 2 hours from the start of alteplase therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours If systolic BP >180-230 mm Hg or diastolic BP >105-120 mm Hg: ° Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg/min; or ° Nicardipine 5 mg/h lV, titrate up to desired effect by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h; or * Clevidipine 1-2 mg/h lV, titrate by doubling the dose every 2-5 minutes until desired BP reached; maximum 21 mg/h !f BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside Abbreviations: AIS, acute ischemic stroke; BP, blood pressure; COR, Class of Recommendation; IV, intravenous; LOE, Level of Evidence. Different treatment options may be appropriate in patients who have comorbid conditions that may benefit from rapid reductions in BP, such as acute coronary heart failure, aortic dissection, or preeclampsia/eclampsia. Data derived from Jauch et al.? i 1. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early men agate of acute ischemic stroke: a guideline for healthcare professionals from the America Association/American Stroke Association. Stroke. 2019:50(12):e344-e418. dot: 10-1 e STR.0000000000000211 . Col . Jauch EC, Saver JL, Adams HP Jr, etal; for the American Heart Association suroke Cos s Council on Cardiovascular Nursing, Council on Peripheral Vascular Diseaceiees sos Clinical Cardiology. Guidelines for the early management of patients itt \20o stroke: a guideline for healthcare professionals from the American Hea Stroke Association. Stroke. 2013;44(3):870-947. doi: 10.1161/STR.0b013e3182