ACC GUIDELINES Bundle (free trial)

Treatment ÎÎPrehospital EMS providers should administer 162-325 mg aspirin (ASA) (chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient. Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (I-C) ÎÎHealth care providers should instruct patients with suspected ACS for whom NTG has been prescribed previously to take not more than one dose of NTG sublingually in response to chest discomfort/pain. (I-C) ÎÎIf chest discomfort/pain is unimproved or is worsening 5 min after one NTG dose has been taken, it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access EMS before taking additional NTG. (I-C) ÎÎIn patients with chronic stable angina, if symptoms are significantly improved by one dose of NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely. (I-C) ÎÎPatients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for greater than 20 min, hemodynamic instability, or recent syncope or presyncope should be referred immediately to an ED. (I-C) ÎÎOther patients with suspected ACS who are experiencing less severe symptoms and who have none of the above high-risk features, including those who respond to an NTG dose, may be seen initially in an ED or an outpatient facility able to provide an acute evaluation. (I-C) ÎÎIt is reasonable for health care providers and 9-1-1 dispatchers to advise patients without a history of ASA allergy who have symptoms of ACS to chew ASA (162-325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non–entericcoated formulations. (IIa-B) ÎÎIt is reasonable for health care providers and 9-1-1 dispatchers to advise patients who tolerate NTG to repeat NTG every 5 min for a maximum of 3 doses while awaiting ambulance arrival. (IIa-C) ÎÎIt is reasonable that all prehospital EMS providers perform and evaluate 12-lead ECGs in the field (if available) on chest pain patients suspected of ACS to assist in triage decisions. ECGs with validated computer-generated interpretation algorithms are recommended for this purpose. (IIa-B) ÎÎIf the 12-lead ECG shows evidence of acute injury or ischemia, it is reasonable that prehospital advanced cardiac life support (ACLS) providers relay the ECG to a predetermined medical control facility and/or receiving hospital. (IIa-B) 6

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