S Hutton, A Inglis, C McKiernan, S Hearns, P Campbell, M Lindsay

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1 Emergency Medical Retrieval Service (EMRS) Standard Operating Procedure Public Distribution Title Acute Coronary Syndrome Version 4 Related Documents Author Alan Exton Reviewer S Hutton, A Inglis, C McKiernan, S Hearns, P Campbell, M Lindsay Aims To outline indications for transfer of patients with acute coronary syndromes To outline treatment regimens for patients with acute coronary syndromes To outline transfer pathways for patients with ACS Background In cases of ST elevation MI (STEMI), the treatment of choice is reperfusion therapy, either by administration of IV thrombolysis or percutaneous coronary intervention (PCI). There are four primary PCI centres in Scotland. The decision as to which reperfusion therapy is appropriate depends largely on theoretical time taken for transfer to primary PCI and contraindications (see appendix 1). If the patient can be transported safely to a PCI centre within 60 minutes of identification of STEMI then this is first-choice. Many EMRS patients are outwith this limit due to remote location and should therefore receive thrombolysis. This decision should be made by responders on scene in discussion with the primary PCI centre. Post-thrombolysis patients should be transferred after discussion with a PCI centre. Thrombolysis may fail to bring about reperfusion, in which case rescue PCI may be the treatment of choice. Patients with nonstemi ACS who do not require reperfusion therapy will still merit discussion and likely transfer to in-patient facilities. Application EMRS Team members Remote and rural Healthcare Practitioners SAS Paramedics 1

2 Patient Escort Patients appropriate for transfer with paramedic escort Cardiovascularly stable patients Patients whose pain / symptoms are easing with standard management STEMI patients who can be delivered to GJNH within 60 minutes of recognition by SAS in whom delay for EMRS activation would extend transfer time to beyond the 60 minute time-frame. Patients appropriate for EMRS activation Patients with ACS / STEMI requiring transfer who have the potential for significant deterioration during transfer or who require critical care intervention. NB Differentiating the above two categories of patient is not always easy. Consideration should always be given to the risk/benefits of EMRS accompanying the patient e.g risk to the patient of additional delay to PCI versus benefit of medical escort. Ultimately activation of the EMRS for such patients is at the discretion of the duty consultant. Patient Triage 1. STEMI Primary PCI ECG changes of ST elevation > or = 2mm in adjacent chest leads and / or ST elevation > or = 1mm in adjacent limb leads or new LBBB 2. Non-STEMI and unstable angina These patients are often more complex to triage than those with obvious STEMI NICE Guideline 94 - Unstable angina and NSTEMI (March 2010) recommends: (R24 section p. 199/360) Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk. Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). A form of risk assessment is useful for discussion with a receiving centre. Often this is done qualitatively during a discussion of the patient's medical history. Formal scoring systems exist and may be useful. NICE recommend GRACE scoring which estimates 6 month risk of death (online or iphone app). (NICE guideline 94), although in practice it is little used by the receiving sites. Ischaemic risk 6 month mortality Triage High* > 6% asap PCI Intermediate 3-6% Within 4 days Low < 3% Default receiving hospital *Plus clinically unstable patients 2

3 GJNH guidelines; patients for direct transfer for PCI Patients with: STEMI (including posterior MI) within 60 minutes of identification STEMI / posterior MI / new LBBB with contraindications to thrombolysis STEMI / posterior MI / new LBBB with cardiogenic shock STEMI / posterior MI / new LBBB > 6hours from onset STEMI / posterior MI / new LBBB with failed thrombolysis NSTEMI / unstable angina who are clinically unstable or who have high ischaemic risk For referrals to other PCI centres, please contact the centre for advice. The referring clinician should discuss with the relevant PCI centre PCI Centres Reperfusion contact Catchment Comments Golden Jubilee National Hospital, Clydebank (GJNH) Hairmyres Hospital, East Kilbride Edinburgh Royal Infirmary Aberdeen Royal Infirmary Raigmore Hospital, Inverness to fax ECGs*: to ECGs: Cardiology Registrar, via CCU; To fax ECGs: ECGs sent from SAS defibs to CCU for interpretation CCU via switchboard on West of Scotland, Within 60 mins See map (Appendix 1) Lothian, Borders, Fife, Forth Valley, Tayside Within 60 mins Grampian, Shetland. Within 70 mins. Highland, Orkney, Western Isles. Within 90 mins to contact the on-call consultant directly do so via CCU on Air transfers, triage to GJNH Primary PCI available: Mon- Thurs,09:00-17:00 Friday 09:00-13:00 * If ECGs are ed or faxed to GJNH, please ensure that you also telephone CCU so that they know to expect it In the West of Scotland for road transfers referral is postcode based (see map Appendix 1) For helicopter transfers GJNH is the preferred site due to the helipad. Primary PCI facilities at Raigmore are not 24 hours after discussion, triage to either ARI or GJNH may be more appropriate. Patients from Fort William (Belford) are sent variously to Edinburgh Royal Infirmary, Raigmore or Aberdeen Royal Infirmary 3

4 Patients appropriate for discussion with default receiving hospital rather than PCI centre Patients with ACS on clinical grounds but not STEMI based on ECG findings Patients with ACS on clinical grounds and long standing left bundle branch block (LBBB) on ECG after discussion with PCI centre Patients with NSTEMI / unstable angina (other than those clinically unstable / high ischaemic risk) Advice to GP (prior to team arrival) High flow oxygen IV access 12-lead ECG Oral aspirin 300mg chewed (unless true aspirin allergy) Discuss with PCI centre re; appropriateness of thrombolysis Fax copy of diagnostic ECG while awaiting transport GJNH guidelines (other centres may vary!) If decision made to thrombolyse*: Tenectaplase (see Appendix 2 for dosages). PLUS 300mg Clopidogrel (75mg if >75 yrs) PLUS Unfractionated Heparin 5000IU IV, (OR LMWH 1mg/kg subcutaneously). A further 2500iu of Heparin should be given if there is a delay of more than 1 hour in transfer time. If not thrombolysed* 600mg Clopidogrel OR Ticagrelor 180mg oral PLUS Unfractionated Heparin 5000IU IV, (OR LMWH 1mg/kg subcutaneously) Sublingual nitrate and/or IV opiate if still experiencing cardiac pain 4

5 Medical management on scene Reassess and determine if patient meets criteria for PCI / thrombolysis Optimise oxygenation Ensure aspirin, Clopidogrel (or Ticagrelor) and heparin have been given Treat any arrhythmias to optimise circulatory status Adequate iv opiate analgesia Nitrates iv infusion if required, 50mg GTN in 50ml start at 1ml/hour titrate to BP Decide if transport is appropriate and liaise with receiving medical team if patient is to be transported Consider invasive arterial monitoring if reason to suspect NIBP monitoring may be problematic (e.g. weather, battery life due to transfer duration) or if patient haemodynamically unstable. NB Consider liaising with PCI centre regarding site of arterial access to avoid compromising potential angiography site. Their normal practice is to use the right side, femoral or radial, therefore these sites should be avoided if possible. References Global Registry of Acute Coronary Events. ACS Risk Model. Backus, Six, Kelder, Gibler, Moll, Doevendans. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department. Curr Cardiol Rev 2011 February; 7(1): 2-8 National Institute for Clinical Excellence. Clinical Guideline 94. March Unstable Angina and NSTEMI. National Institute for Clinical Excellence. Draft Clinical Guideline. Feb Myocardial Infarction with ST-segment-elevation (STEMI) Scottish Intercollegiate Guidelines Network. Guideline 93. Feb Acute Coronary Syndromes. 5

6 Appendix 1. (From WoS Regional Planning Group: WoS Optimal Reperfusion Service Clinical Pathways, 2008) 6

7 Appendix 2 Indications for thrombolysis (where PCI not practical) Typical chest pain >20mins within the last 6 hours and either ST elevation >1mm in 2 limb leads or ST elevation >2mm in 2 chest leads or New left bundle branch block (patients with pre-existing LBBB but symptoms of ACS should be discussed with the reperfusion centre) or Posterior MI dominant R wave and ST depression V 1 -V 3 Absolute contraindications to thrombolysis GI bleeding within last 4 weeks CVA in last 3 months or previous intracranial haemorrhage Major surgery, trauma or head injury within last 6 weeks Other known intracranial pathology Bleeding disorder or active bleeding Prolonged CPR (>30 minutes) Sustained hypertension SBP>180 or DBP>120 Aortic dissection Acute pancreatitis Cavitating lung disease Relative contraindications to thrombolysis Major hepatic or renal disease Anticoagulant therapy without knowledge of recent INR Pregnancy, within 6/52 post-partum or menstruation Non compressible puncture site Known terminal illness Recent retinal laser treatment If BP is only contraindication, treatment with nitrates / opiates / beta-blockade may lower BP to acceptable limits. If in doubt over eligibility for thrombolysis discuss with PCI centre. Thrombolysis All sites carry thrombolytic agent - Tenecteplase Patient Weight <60 Kg <9st 6lb Kg 9st 6lb 11 st Kg 11st 1lb-12st 8lb Kg 12st 9lb-14st 2lb >90 Kg >14st 2lb Dose 30mg (6000U) 35mg (7000U) 40mg (8000U) 45mg (9000U) 50mg (10000U) Volume 6mls 7mls 8mls 9mls 10mls 7

8 GJNH CCU West of Scotland Regional Heart & Lung Centre Interventional Cardiology Emergency Referral Process Optimal Reperfusion Service Recognition of Acute ST Elevation MI Estimated transfer time less than 0 minutes - Primary PCI Estimated transfer time greater than 0 minutes - consider Thrombolysis Arrange immediate transfer via SAS Ask for TIME CRITICAL TRANSFER Full cardiac monitoring to Cath Lab/CCU In thrombolysed* patients DO NOT WAIT TO ASSESS REPERFUSION Advise GJNH via CCU Senior Nurse- GJNH CCU Fax copy of diagnostic ECG while awaiting transport Administer- Aspirin 300mg po Ticagrelor 180mg po or Clopidogrel 600mg po * Clopidogrel 300mg po ( >75 years ~ 75mg ) if thrombolysed Unfractionated Heparin 5000 iu iv or LMWH 1mg/kg s/c Advise GJNH CCU when patient is en route Any equivocal ECGs or clinical presentations can be discussed with GJNH CCU for advice re management. Revised by FTH Approved by MML Apr 2013 * Note 60 minute transfer times above are specific to EMRS 8

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