February 9, 2024

Welcome to UH EMS Institute’s Pharmacy Phriday. In this installment, we will review Aspirin (ASA) and its use within the UH protocol’s “Acute Coronary Syndrome” (ACS) algorithm. 

February is National Heart Month, a time when everyone is encouraged to focus on their cardiovascular health. According to the AHA’s 2021 update of heart disease and stroke statistics, heart disease continues to be the greatest health threat to Americans and is still the leading cause of death worldwide. A very early treatment within our EMS protocols for ACS is the administration of Aspirin.

In keeping with the theme of recent installments of this column, where we have been highlighting protocol updates, it is worth mentioning a new protocol within the UH EMS Protocols. The new “Chest Pain” algorithm stresses that not all chest pain is cardiac in nature. It has been added to address other potential causes of chest pain. Treatment of non-cardiac chest pain with Aspirin and other medications in the ACS algorithm can be harmful or deadly for a patient. 

According to a recent AHA article, approximately half of chest pain complaints seen in emergency departments for all age groups were “non-specific.” [1]  However, the evaluation of all patients with such a complaint should focus on the early identification or exclusion of life-threatening causes. Also important to remember is the fact that cardiac or ACS presentations include more than just “chest pain.” Other symptoms, such as pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue, should all be considered as possible cardiac symptoms and investigated as such. When the exam is suggestive of a Myocardial Infarction (MI) or the 12 lead indicates a possible MI, Aspirin is one of the first medications we consider.

Aspirin, also known as acetylsalicylic acid, is a common medication found in most medicine cabinets in homes across the country. It is available in many forms, and many products for use in fever, pain, swelling, colds, and prevention of clotting that can cause strokes or heart attacks in certain patient classes. 

Aspirin works as a platelet aggregation inhibitor and anti-inflammatory agent useful in clotting events. The medication irreversibly blocks a hormone that causes platelets to aggregate, making the blood less sticky. The same hormone can also cause arteries to constrict. By affecting the clotting and possible vasoconstriction, mortality in an MI can be reduced. ASA also has an anti-inflammatory effect that is thought to be beneficial in these emergencies.

Within the UH protocol, 324 mg of chewable ASA is used by the EMT, A-EMT, and paramedic provider in the treatment of an Acute Coronary Syndrome. It would include patients who present with cardiac-type chest pain, a 12-lead ECG indicating a possible MI, or other ACS symptoms (with or without ST elevation).

When administering ASA in the emergency setting, be aware that some patients may have taken ASA prior to EMS’s arrival. It may be due to daily dosing within the last 24 hours, advice from a 911 dispatcher, or other common first aid advice. In such cases, the provider should administer enough ASA to equal the 324 mg total dose recommended in the protocol. 

Aspirin is supplied in the UH drug boxes as a chewable 81 mg tablet requiring 4 tablets to meet the normal dosing. The chewable form is preferred as it is often more palatable and more rapidly absorbed. Due to time-delayed action, enteric-coated or time-delayed tablets are not used in this setting. 

Aspirin should not be given to a patient who is allergic to the medicine. Though an actual allergy to ASA is rare, many patients may confuse a true allergy with side effects they have experienced previously. Due to a risk of bleeding with the use of ASA, it should not be administered to a patient with an active ulcer or GI bleeding, suspected of experiencing a stroke, in cases of trauma, or in cases of ripping or tearing chest pain (this type of pain can often indicate an aortic aneurysm or dissection). 

Some of the most common side effects of ASA are GI irritation and bleeding. A risk of toxicity, lethal dosing, and Reye syndrome (a rare and sometimes fatal disorder associated with aspirin use that can cause swelling in the liver or brain) in the pediatric patient, even with usual doses of ASA, is also possible. For this reason, the medication is generally not recommended for children or teenagers in the prehospital setting and is thus not approved within the UH protocols.

For more tips on the care of our ACS patients, we encourage you to check out this month’s Prehospital Paradigm Podcast series, “STEMI and Interventional Cardiology,” HERE.

Till next week, stay safe!

[1] https://www.ahajournals.org/doi/10.1161/CIR.0000000000001030#d1e775

Sincerely,



The UH EMS-I Team

University Hospitals

September 30, 2022

Dear colleagues:

Welcome to UH EMS Institute’s Pharmacy Phriday.  In this installment we will review Aspirin (ASA) and its use within the UH protocols.

Aspirin, also known as acetylsalicylic acid, is a common medication found in most medicine cabinets in homes across the country.  It is available in many forms, and many products for use in fever, pain, swelling, colds, and prevention of clotting that can cause strokes or heart attacks in certain patient classes. 

Within the UH protocol, 324 mg of chewable ASA is used by the EMT, A-EMT, and paramedic provider in the treatment of an Acute Coronary Syndrome. It would include patients who present with cardiac-type chest pain or other ACS symptoms with or without ST elevation or a 12-lead ECG indicating a possible MI.

Aspirin works as a platelet aggregation inhibitor and anti-inflammatory agent useful in clotting events.  The medication irreversibly blocks a hormone that causes platelets to aggregate, making the blood less sticky.  The same hormone can also cause arteries to constrict.  By affecting the clotting and possible vasoconstriction, mortality in an MI can be reduced.  ASA also has an anti-inflammatory effect that is thought to be beneficial in these emergencies.

When administering ASA in the emergency setting, be aware that some patients may have taken ASA prior to EMS’s arrival.  This may be due to daily dosing within the last 24 hours, advice from a 911 dispatcher, or other common first aid advice.  In such cases, the provider should administer enough ASA to equal the 324 mg total dose recommended in the protocol. 

Aspirin is supplied in the UH drug boxes as a chewable 81 mg tablet requiring 4 tablets to meet the normal dosing.  The chewable form is preferred as it is often more palatable and more rapidly absorbed.  Due to time-delayed action, enteric-coated or time-delayed tablets are not used in this setting. 

Aspirin should not be given to a patient that is allergic to the medicine. Though an actual allergy to ASA only exists in about 1-2% of the population (higher in patients with asthma nearing approximately 26%), many patients may confuse a true allergy with side effects they have experienced previously. Due to a risk of bleeding with the use of ASA, it should also not be administered to a patient with an active ulcer or GI bleeding or suspected of experiencing a stroke. 

The most common side effects of ASA are GI irritation and bleeding.  A risk of toxicity, lethal dosing, and Reye syndrome (a rare and sometimes fatal disorder associated with aspirin use that can cause swelling in the liver or brain) in the pediatric patient, even with usual doses of ASA, is also possible.  For this reason, the medication is generally not recommended for children or teenagers in the prehospital setting and is thus not approved within the UH protocols.

In next week’s Pharmacy Phriday, we will discuss ASA toxicity in greater detail and discuss treatments provided within our protocols.  Do you know what medication we may be reviewing for such cases?

Till next week, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals