ACS

1. MONA
   • Morphine 2-4mg IV q5-30min in increments of 2-8mg PRN
     • BP and RR after each bolus
     • Can consider meperidine or other opiod
     • D/C all NSAIDs and avoid all NSAIDs during admission
   • O₂ to sat of 95% if < 90% on presentation
   • SL NTG 0.4mg q5min x3, if non-responsive start IV NTG 5-10mcg/min to 75-100mcg/min (Max 200, consider 1-2min bolus of 400mcg/min to load)
     • Verify NO PDEIs w/i 24-36hr
     • IV Contraindicated w/ SBP < 90; > 30 mmHg change from baseline; Bradycardia or Tachycardia; Suspected RV Infarction
     • Monitor BP and HR q2h while on IV
   • ASA 325mg Chewed and Swallowed on presentation
   • Consider anxiolytics to decrease HR and demand
2. Consider PCI for STEMI
3. Consult ACS for further management

Stroke

Labs

• Conduct NIHSS (National Institutes of Health Stroke Scale)
• Head CT to r/o hemorrhagic stroke
• Monitor BP / O₂Sat
• BG
• BMP
• CBC
• INR / aPTT
• EKG
• Echo
• Pt is NPO until swallow study conducted

Initial Therapies

• Manage BG if abnormal
  • Hypoglycemia can result in stroke SSx
  • Hyperglycemia above 180 mg/dL can result in higher morbidity / mortality
• Consider thrombolytics for ischemic strokes (must r/o hemorrhagic)
• Manage HTN to < 220/120 for non-thrombolytic pts, < 180/105 for thrombolysis
  • IV antihypertensives warranted, do not lower BP excessively, as elevated BP may help perfuse partially occluded areas
  • Agressive BP control can limit stroke recurrence, long-term neuro deficits, an decrease risk of cerebral edema; however concern from above usually wins, attempt to balance (i.e 150s instead of 170s or 110s)

Thrombolysis

Dosing

• Must satisfy inclusion / exclusion criteria below
• 0.9 mg/kg NTE 90mg Total dose
  • 10% (0.09 mg/kg) IVPB over 1min
  • 90% (0.81 mg/kg) IV over 60min
• Give w/i 60min of arrival
• Keep BP < 180/105
  • Monitor q15min x2h then q30min x 6h then q1h x16hr
  • Can begin to lower to outpt goal after 24h
• Avoid all antiplatelets and anticoagulants for 24hr post-admin

SEs

• Bleeding
• Stroke Conversion
• Cerebral Edema

Inclusion Criteria

• Ischemic stroke confirmed by imaging
• < 3hrs from SSx onset
  • Extended interval available, see below
  • Some evidence for imaging-based determination of thrombolysis eligbility here, but not currently in guidelines
• ≥ 18yo

Exclusion Criteria

• Evidence of active internal bleed
• Hx of intracranial hemorrhage
• Previous stroke or head trauma in less than 3mo
• GI or GU hemorrhage in ≤ 21d
• Major surgery in ≤ 14d
• MI in ≤ 3mo
• BP > 185/110 at administration time
• BG < 50 mg/dL
• Plt < 100k
• Current anticoag w/ INR > 1.7 or aPTT > 45s
  • NOACs CI tPA
  • Reversible exclusion criteria

Extended tPA Window

• < 4.5hrs after SSx onset
• Add the following to the exclusion criteria
  • Age ≥ 80
  • Hx of Stroke w/ DM
  • Any recent anticoag use
  • NIHSS > 25

BP Control

• Use common IV antihypertensives discussed in HTN Crisis section
• Labetalol 10-20mg IVPB q10-20min NTE 300mg
• Nicardipine 5mg/hr IV titrated q5min NTE 15 mg/hr
• Nitroprusside 0.5-10 mcg/kg/min titrated (preferable if DBP > 140)

Transfusion for Severe Acute Anemia

• Criteria
  • Acutely Symptomatic
  • Hgb < 8 (some argue 7)
• Admin PRBCs
  • Type and cross before admin
  • 1 U &approx; 300 mL &approx; Δ 1 g/dL Hgb
  • Consider activation of massive transfusion protocol
  • Hemorrhaging / trauma pts may require infusions of FFP and Plt as well to sustain coagulation, strongly consider before using large volumes of crystalloid
  • Pts refusing transfusion can be given high dose iron, B12, and Epo, look up protocol
• Complications
  • Iron Overload
  • Infection (HIV etc, rare)
  • Hyperviscosity syndrome
  • Alloimmunization
  • Volume overload
  • Transfusion reactions