Chest Pain No

• Pressure/Squeezing/Tightness/Heaviness that worsens on exertion?

• Retrosternal, radiating to the neck, jaw, shoulders or arms?
• Known history of CAD or previous MI?

Yes
B
Yes

Yes
ECG finding of new ST-segment elevation > 1mm
or a presumed onset of new LBBB A Candidate for fibrinolysis?

No No Refer to PCI Capable Facilities

New or presumably new transient ST-segment

depression (≥0.1 mV) or T wave inversion Yes
(≥0.2 mV) in multiple precordial leads
Fixed Q waves A Do serial 12L ECG and Troponin Admit to ICU
ST-segment depression of 0.05-0.1 mV
or T wave inversion >0.1 mV

Progression or
Repeat 12L ECG persistence of
Send for Trop I symptoms
Observe accompanied by
ECG changes

Source:
Give Proceed with fibrinolysis Contraindications for fibrinolysis: 1. Harrison’s Principles of Internal Medicine
1. Aspirin 80mg/tab, 4 tabs chewed Pre-meds: • Previous ICH or stroke of unknown origin at anytime 20th edition. Chapters 11: Chest
discomfort. Pages 73-80.
2. Clopidogrel 75mg/tab, 4 tabs chewed 1. Diphenhydramine 50mg IV • Ischemic stroke in the preceding 6 months 2. Harrison’s Principles of Internal Medicine
3. Enoxaparin 1mg/kg IV, then q12h SC 2. Hydrocortisone 100mg Iv • CNS damage or neoplasms or AV malformations 20th edition. Chapter 269: ST-Segment
Elevation Myocardial Infarction. Pages
4. Atorvastatin 40-80mg/tab OD • Recent major trauma/surgery/head injury within the 1872-1884.
3. Braunwald’s Heart Disease. A Textbook of
Fibrinolytic preceding month Cardiovascular Medicine 11th edition.
If SBP > 90, give the ffg: 3. Streptokinase 1.5mU plus PNSS to complete • Gastrointestinal bleeding within the past month Chapter 56: Approach to the Patient with
Chest Pain. Pages 1056-1066.
5. ISDN /tab SL, every 5 mins for up to 3 doses 100cc in a soluset to run in 60 mins IV • Known bleeding disorder (excluding the menses) 4. 2017 ESC Guidelines for the management
6. Captop5mgril 25mg/tab ½ tab q8h Do 12L ECG before, every 15 mins during infusion • Aortic dissection of acute myocardial infarction in patients
presenting with ST-segment elevation
and after fibrinolysis • Non-compressible punctures in the past 24 hrs
If not in acute failure and HR >55, may give: Hook to cardiac monitor if available
7. Metoprolol 50mg/tab 1/2tab q6h (target HR 50-60) Monitor VSQ15min
PGH
Refer to PCI capable facility
MDH
If O2 saturation < 90%, give supplemental oxygen support
MCM
PHC
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