2. Substernal , epigastric pain that may radiate to the jaw.

3. Moderate to severe discomfort.

4. Longer duration (>30 minutes) than angina pain.

5. Nausea & vomiting.

6. Diaphoresis.

7. Dyspnea

8. Irregular pulse

10. Anginal patient-not angina: an angina patient in whom the chest pain is more intense than usual will become frightened, convinced that “the big one is happening”. Recommended management follows the steps outlined for AMI.

11. No previous history of chest pain: chest pain developing in a patient with no prior history of acute chest pain normally frightens the patient. It is suggested that the management of chest pain be approached as if it were a angina pectoris, unless it is obviously not of angina origin , as described above.STEP 3: POSITION<br />STEP 4: A-B-C (airway,breathing, circulation).<br />At this point in the AMI, the patient will be experiencing more intense discomfort & may be showing signs of decreased cardiac output (diaphoresis:cool,moist extremities : ashen grey pallor:cyanosis of mucuous membranes and nail bed). A-B-C are assessed and are adequate.<br />STEP 5: D DEFINITIVE CARE.<br />STEP 5 a : ADMINISTRATION OF OXYGEN.<br />Administer oxygen as soon as it is available.evidence sugest that increased arterial o 2 tension decreas he size of infract.o2 delivered through nasal; cannula at 4-6 L/min<br />STEP 5b: SUMMONING OF MEDICAL ASSISTANCE.<br />When an ami is occurring emergency medical services should be activated as soon as possible.<br />STEP 5 c :ADMINISTRATION OF NITROGLYCERINE.<br />If the victim has a history of angina , nitroglycerine which is available with the patient is used immediately. The patients vital sign should be recorded either before the administration of nitroglycerine or shortly thereafter.<br />Nitroglycerine should not be administered in the presence of hypotension.( if systolic bp is below 100.) because it can further decrease the mean arterial pressure. Nitroglycerine acts within 2-4 min. if the pain continues or increases/it alleviates the pain, but the pain returns in a few min then the diagnosis of AMI is considered.<br />STEP 5 d : FIBRINOLYSIS<br />The administration of aspirin has added to the prehospital management of out-of-hospital AMI victims. Aspirin has fibrinolytic preoperties that assists in the process of revascularisatin of the ischemic myocardium . patients should be administered a dose of 325 mg aspirin to chew as soon as it is thought that an AMI is developing.<br />To achive an immediate clinical antithrombotic effect an initial minimum loding dose of 162 mg should be used in AMI. If an enteric coated aspirin is the only preparation available, the first tablet should be chewed or crushjed beforeadministration.<br />STEP 5 e: MONITORING OF VITAL SIGNS.<br />STEP 5 f: RELIEF OF PAIN.<br />Prolong pain in AMI is life threatening. It leades to patient anxiety and contributes to excessive activity of the autonomic nervous system, producing an increase in cardiovascular work load & o2 requirement. In addition, prolonged intense pain is one of the causuatives of cardiogenic shock. Nitroglycerine is inadequate to alleviate the pain . <br />The use of opiod analgesics is recoended for the relief ofpain here. I V administration of 2-5 mg of morphine sulphate reapeated every 5 -15 min provide adequate pain relief and allays apprehension. Additionally morphine increases venous capacitance and systemic vacular resistance,relieving pulmonary congestion & thereby decreasing myocardialoxygen requirement.morphine sulphate may be administered subcutaneously in a dose of 5 – 15 mg.morphine should not be readministered if the respiratory rare is less than 12 breaths per minute.<br />IM injection of thwese analgesics provide adequate pain relief of longer time.IV administration is also considered but readministration is required in a shorter period.<br />Another useful analgesic is a mixture of n2o & o2 which are inhaled.the primary advantage of n2o-o2 is that it provides the patient with a gasseousanalgesic agentthat by itself has little effect on blood pressure.<br />STEP 6: TRANSPORTATION OF THE PATIENT TO THE HOSPITAL.<br />After the patients condition has been stabilized , the patient is transported to primary care facility. The dentist should accompany the patient & remain with the patient until the physician is in attendance. <br />