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1 CG01 VERSION 1.0 1/12 Guideline ID CG01 Version 1.1 Title Approved by Acute Coronary Syndromes and Stable Angina Clinical Effectiveness Group Date Issued 01/10/2014 Review Date 31/09/2017 Directorate Authorised Staff Medical Ambulance Care Assistant Emergency Care Assistant Student Paramedic Advanced Technician Paramedic (non-ecp) Nurse (non-ecp) ECP Doctor Clinical Publication Category Guidance (Green) - Deviation permissible; Apply clinical judgement 1. Scope 1.1 This clinical guideline covers the assessment and management of patients with recent onset chest pain or discomfort of suspected cardiac origin. 2. Background and Definitions 2.1 Coronary heart disease (CHD) is the most common cause of death in the UK, with around one in five men and one in seven women dying from the disease. CHD is also the most common cause of premature death. Although the death rate from CHD has been decreasing since the early 1970s, the death rate in the UK is still higher than many countries in Western Europe. 2.2 Over 2 million people are living with CHD in the UK, with around 275,000 people suffering a myocardial infarction every year. 2.3 Acute Coronary Syndrome (ACS) is defined as a condition in which there is an event in a coronary artery with plaque rupture or erosion, or coronary dissection, with the formation of an intra-coronary thrombus. The term therefore encompasses both unstable angina and myocardial infarction.

2 CG01 VERSION 1.0 2/ ST-elevation myocardial infarction (STEMI) is defined as myocardial infarction with raised ST segment. The criteria for STEMI is at least 1mm elevation of the ST segment in contiguous limbs leads or 2mm elevation of ST segment in at least 2 contiguous chest leads. A 1mm raise in an ST segment in an isolated lead could be physiological and have no clinical significance. 2.5 The term chest pain is used throughout this guideline to mean chest pain or discomfort. 3. Guidance 3.1 Assessment Patients suffering from chest pain of suspected cardiac origin are at high risk of VF arrest. Ensure a defibrillator is taken to the scene and if ACS is suspected the defibrillator must remain with the patient until handover at hospital Check immediately whether the patient currently has chest pain. If they are pain free, check when their last episode of pain was, particularly if it was within the last 12 hours Determine whether the chest pain is likely to be cardiac related and therefore whether this guideline is relevant, by considering: History of the chest pain; Presence of cardiovascular risk factors; History of ischaemic heart disease and any previous treatment; Previous investigations for chest pain; The nature of the pain (PQRSTA) Initially assess for any of the following symptoms, which may indicate an ACS: Pain in the chest and/or other referred areas (for example the arms, back or jaw) lasting longer than 15 minutes; Chest pain associated with nausea and vomiting, marked sweating, breathlessness or particularly a combination of these; Chest pain associated with haemodynamic instability; New onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently with little or no exertion, and with episodes often lasting longer than 15 minutes.

3 CG01 VERSION 1.0 3/ Do not: Use people s response to glyceryl trinitrate (GTN) to make a diagnosis, as there is no evidence that this is a reliable indicator that pain is of a cardiac origin; Assess symptoms of an ACS differently in men and women; not all people with an ACS present with central chest pain as the predominant feature; Assess symptoms of an ACS differently in ethnic groups; although the risk of ACS is higher in some ethnic groups, there are no major differences in symptoms Take a resting 12-lead ECG as soon as possible. Unless the patient presents with typical symptoms of acute myocardial infarction (AMI) this is often best achieved before moving the patient. 3.2 Diagnosis Following assessment identify which pathway best fits the patient s presentation: 3.3 Pathway Management of ST elevation or LBBB with history and signs of AMI should start as soon as it is suspected, and should not delay transfer to hospital. Follow the STEMI Care Pathway detailed in Appendix The preferred treatment for STEMI is Primary Percutaneous Coronary Intervention (PPCI); refer to Appendix 2 for details of local care pathways.

4 CG01 VERSION 1.0 4/ In East and West Divisions pre-hospital thrombolysis remains available on a small number of strategically placed vehicles. When PPCI is not available in these Divisions due to either the excessive travel time to a centre, service disruptions or adverse weather, pre-hospital thrombolysis should be considered (see Appendix 3 for checklist). Standard Operating Procedure C17: Emergency Availability of Tenecteplase (TNK) details how to request a vehicle carrying TNK. Within North Division, the patient must instead be transported to the nearest ED for consideration of thrombolysis. Pathway 1 Pathway 2 Pathway 3 ST elevation in two or more anatomically contiguous leads (1mm raised in limb leads or 2mm in chest leads) or LBBB with history and symptoms of AMI. No ST elevation and patient currently has cardiac chest pain or No ST elevation and patient is currently pain free, but had cardiac chest pain in the last 12 hours and 12 lead ECG is abnormal e.g. Q waves and T wave changes. Patient had chest pain in the last 12 hours, but is now pain free and 12 lead ECG is normal Deliver generic patient care: Record pain score and offer entonox whilst obtaining IV access; The preferred analgesia is intravenous morphine. Continue entonox if unable to administer morphine (oral morphine may be considered if IV access cannot be achieved); Administer GTN in accordance with JRCALC guidelines; Administer 300mg aspirin in accordance with JRCALC guidelines. Monitor pulseoximetry. Do not routinely administer oxygen; oxygen should only be administered when oxygen saturation are less than 94%, aiming for an SpO 2 of 94-98%. For people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, aim to achieve a target SpO 2 of 88-92%, using capnography where available; Monitor people with acute chest pain, using clinical judgement to decide on the frequency of observations: Check pain relief is, record second and subsequent pain scores and administer further analgesia as required; Pulse and blood pressure; Oxygen saturations; Repeat 12 lead ECG; Minimise on-scene time; Convey to nearest available ppci centre under emergency driving conditions with an ATMIST pre-alert.

5 CG01 VERSION 1.0 5/ A defibrillator must remain with the patient during the transfer at hospital, in case it is required. It is not necessary to apply defibrillator pads to ACS patients as a precaution in case they should experience a cardiac arrest either en-route to hospital, or during the journey between the vehicle and the catheter laboratory. The exception would be if the senior clinician caring for the patient deems that they are at immanent risk of cardiac arrest. 3.4 Pathway Patient requires urgent assessment at nearest appropriate acute hospital Emergency Department (or Coronary Care Unit where local arrangements exist). Deliver generic care as detailed in Section Pathway NICE guidelines recommend that if an ACS is suspected and the patient has had chest pain in the last 12 hours and are now pain free with a normal resting 12- lead ECG, they should be referred for urgent same-day assessment. Options for urgent same-day assessment are dependent on the availability of local pathways. Contact acute hospital medical assessment or coronary care unit to discuss case and agree care plan. This may require the patient to attend an Emergency Department. The need for ambulance conveyance should be determined on a case by case basis by the senior clinician on-scene. 3.6 National Ambulance Clinical Quality Indicator Ambulance clinicians must ensure that the high quality of care they deliver is reflected through the achievement of the National ACQI for the management of STEMI, which is divided into three components: The percentage of patients suffering a STEMI who are directly transferred to a centre capable of delivering primary percutaneous coronary intervention (PPCI) and receive angioplasty within 150 minutes of call; The percentage of patients suffering a STEMI receiving thrombolysis within 60 minutes of call; The percentage of patients suffering a STEMI who receive an appropriate care bundle The care bundle for STEMI includes: Administration of aspirin in accordance with JRCALC; Administration of GTN in accordance with JRCALC; Recording of two pain scores; Providing analgesia; Recording pulse oximtery (SpO 2 ).

6 CG01 VERSION 1.0 6/12 4. Documentation 4.1 In line with Trust Policy, a Patient Clinical Record must be completed and annotated appropriately. Clinicians must ensure that the STEMI care bundle detailed in is delivered to all appropriate patients. Any exceptions, such as GTN not being administered due to hypotension, must be recorded in the procedural exclusions section. Any deviation from this clinical guideline must be recorded, with any potential or actual adverse event reported through the incident reporting system. 5. References 1. National Institute for Health and Clinical Excellence (2010) Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE.

7 CG01 VERSION 1.0 7/12 Appendix 1 - STEMI Care Pathway Obtain resting 12 lead ECG as soon as possible If unable to confirm ST elevation, however AMI is clinically suspected, convey to local ED under emergency driving with pre-alert requesting urgent review on arrival. (If telemetry available seek advice if required) Chest pain of suspected cardiac origin ECG interpretation by ambulance clinician JRCALC Analgesia GTN Aspirin Oxygen Pain Scores Ambulance clinician recognises ST elevation or LBBB and patient symptomatic of AMI Current cardiac chest pain without ST elevation or concerning acute ECG changes in the absence of chest pain Pathway 1 Pathway 2 Pre-alert PPCI centre and confirm acceptance. Convey under emergency driving conditions. Consider pre-hospital thrombolysis if PPCI is not available (within East/West Division). Convey to local appropriate ED/CCU. Pre-alert as appropriate Additional Treatment: IV access. Monitor ness of pain relief. Anti-emetic if required for treatment of nausea and vomiting

8 CG01 VERSION 1.0 8/12 Appendix 2 - PPCI Centre Locations, Availability and Contact Numbers Operating Period Pre-alert / Cath Lab Phone Bristol Heart Institute 24/7 Cheltenham General Mon-Fri (Excluding Bank holidays) RESTRICT Derriford 24/7 Dorset County Great Western Mon-Fri 09:00-17:00 (Excluding Bank holidays) Mon-Fri (Excluding Bank holidays) John Radcliffe, Oxford 24/7 Musgrove Park 24/7 North Devon District No PPCI divert to RD&E Royal Bournemouth 24/7 Royal Cornwall 24/7 Royal Devon and Exeter 24/7 Royal United Bath Mon-Fri (Excluding Bank holidays) Salisbury District Southampton General Mon - Fri hrs (excluding bank holidays) 24/7 Torbay 24/7 (Please give callsign and contact number as part of pre-alert).

9 CG01 VERSION 1.0 9/12 Southampton General Access via Emergency Department ambulance entrance. ACS nurse will escort to Cath Lab / CCU. If no ACS nurse in attendance, immediately notify senior ED staff. Bristol Heart Institute, Bristol If not met at dedicated ambulance entrance doors, ensure the alert buzzer is activated to notify BHI staff of arrival. John Radclifffe, Oxford Enter the John Radcliffe site via Headley Way. At the first roundabout turn right. Drive past the West Wing/Childrens hospital towards the direction of A&E. At the end of the west wing, after the zebra crossing, take the first turning left. Pull up into the ambulance bay, if the PPCI team are not waiting for you at the door press the bell on the left hand side.

10 CG01 VERSION /12 Appendix 3

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