Acute Coronary Syndromes
ACS spectrum: unstable angina (no biomarker elevation), NSTEMI (troponin elevation, no ST elevation), STEMI (ST elevation → transmural infarction). Symptoms: chest pain/pressure, radiation to arm/jaw, diaphoresis, nausea, dyspnea. Atypical in women, elderly, diabetics: fatigue, nausea, back pain. Diagnosis: ECG within 10 min of arrival, troponin.
STEMI Management
"Time is muscle" — door-to-balloon <90 min. MONA-B: Morphine (pain, anxiety — caution with hypotension), Oxygen (only if SpO2 <90%), Nitrates (unless hypotensive or phosphodiesterase inhibitor), Aspirin (chewed 324 mg), Beta-blocker (unless contraindicated). Reperfusion: primary PCI (preferred) or thrombolytics if PCI not available within 120 min. Dual antiplatelet: aspirin + ticagrelor/clopidogrel. Anticoagulation: heparin.
Lethal Arrhythmias
V-Fib: chaotic, no organized rhythm — IMMEDIATE defibrillation. Pulseless V-Tach: defibrillation. Asystole: flatline — CPR + epinephrine, NO shock. PEA: organized rhythm without pulse — CPR + epinephrine, identify reversible causes (H's and T's). V-Tach with pulse: synchronized cardioversion if unstable, amiodarone if stable. Complete heart block: transcutaneous pacing, atropine.
Cardiac Arrest
BLS: CAB (compression-airway-breathing). High-quality CPR: rate 100–120/min, depth 2–2.4 inches, full recoil, minimize interruptions (<10 sec), switch compressors q2min. AED: analyze rhythm, shock if advised. ACLS: epinephrine q3–5min, amiodarone for refractory VF/pVT. Advanced airway: supraglottic or endotracheal. Capnography: ETCO2 >10 mmHg indicates effective CPR.
Post-Resuscitation Care
Targeted temperature management (TTM): 32–36°C for 24h in comatose post-arrest patients — improves neurologic outcomes. Hemodynamic optimization: MAP ≥65. Oxygenation: avoid hyperoxia (SpO2 94–99%). Ventilation: normocapnia (PaCO2 35–45). Seizure prophylaxis. Glycemic control (140–180). Coronary angiography if STEMI or suspected cardiac etiology.
Important Notes
- "Time is muscle" — every 30 min delay in reperfusion reduces survival by 7.5%. Door-to-balloon <90 min.
- Post-arrest TTM (therapeutic hypothermia) improves survival with good neurologic outcome — start ASAP for comatose patients.
Clinical Tips
- H's and T's of PEA: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Thrombosis (PE/MI), Toxins, Trauma.
Summary
Cardiac emergencies demand rapid ECG, early reperfusion for STEMI, high-quality CPR with defibrillation for cardiac arrest, and targeted temperature management post-resuscitation.
