ACP Academy Section 5: Advanced Clinical Education Cardiology STEMI, N-STEMI, and everything else Ada County Paramedics Block Training April 2008
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, N-STEMI, and everything else
Ada County Paramedics Block Training
April 2008
ACP Academy Section 5: Advanced Clinical Education Cardiology
Contact Information
• Ada County Paramedics– 5870 Glenwood– Boise, ID 83714– Adaparamedics.org– 208-287-2972
ACP Academy Section 5: Advanced Clinical Education Cardiology
• Credit where Credit is due:– Ada County Paramedics:
• Douglas Jay for his donation of materials as well as time.• Jason Creamer, and Jeremy Schabot, both for their time,
and their tireless devotion to raising the bar for paramedics everywhere.
– For Donation of materials and motivation:• Hilton Head F&R, SC: Tom Bouthillet, Lt./NREMT-P• Witham Health Services, Indiana: Andrew J. Bowman, MSN,
NREMT-P• Chris Smith, NREMT-P
ACP Academy Section 5: Advanced Clinical Education Cardiology
Focus Statement
• This block of training will focus on Improving STEMI recognition, improving EMS involvement in E2B/D2B programs, and minimizing false STEMI team activations
ACP Academy Section 5: Advanced Clinical Education Cardiology
Disclosure Statement
ACP Academy Section 5: Advanced Clinical Education Cardiology
Terminology
• PH ECG/PH 12 lead: Pre-hospital ECG• PCT: Pre-hospital Cardiac Triage• STEMI: S-T segment Elevation Myocardial
Infarction• N-STEMI: Non S-T segment Elevation
Myocardial Infarction• D2B: Door to Balloon (PTCA)• E2B: EMS to Balloon• SRC: STEMI Receiving Center
– (Primary PCI capable with surgical capability)
ACP Academy Section 5: Advanced Clinical Education Cardiology
All Hail the Great S-T Segment
(or …all you wanted to know about the ST segment but didn’t
know to ask…)
ACP Academy Section 5: Advanced Clinical Education Cardiology
Understanding the ST segment
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
Measuring ST ChangesMeasuring ST Changes• Baseline is correctly determined by finding the T-P to T-P
segment. (If TP not measureable, then preceeding P-R interval can be used.)
• ST changes are measured 0.08 sec after the “J-point”.• Changes must be present in 2 or more leads of a “lead group”
to be significant.• ST elevation or depression of 1 mm or greater in frontal plane
leads is considered significant.• ST elevation or depression of 2mm or greater in precordial
leads is considered significant.• ST elevation of 0.5mm or greater in R precordial leads is
considered significant.
ACP Academy Section 5: Advanced Clinical Education Cardiology
T-wave Changes in IschemiaT-wave Changes in Ischemia
• Appear within seconds of onset of AMI• Appear over zone of ischemia• May be tall and or deeply inverted depending
on location of ischemia• Symmetry is important finding in ischemia• Are associated with prolonged QT interval• Often associated with ST depression• Rapidly revert to normal after anginal attack• Persist in q-wave infarct.
ACP Academy Section 5: Advanced Clinical Education Cardiology
T-Wave Changes in IschemiaT-Wave Changes in Ischemia
Peaked, Symmetrical T-WavesPeaked, Symmetrical T-Waves
ACP Academy Section 5: Advanced Clinical Education Cardiology
T-wave changes in IschemiaT-wave changes in Ischemia
Inverted T-wavesInverted T-waves
ACP Academy Section 5: Advanced Clinical Education Cardiology
T-Wave Changes In IschemiaT-Wave Changes In Ischemia
Tall, symmetrical T-Waves With ST ElevationTall, symmetrical T-Waves With ST Elevation
ACP Academy Section 5: Advanced Clinical Education Cardiology
ST Depression in IschemiaST Depression in Ischemia• ST depression is a sign of myocardial ischemia
and can appear in setting of ischemia from any cause.
• Onset is usually within first hour of AMI, or more rapidly in other causes of ischemia.
• Often associated with T-wave changes• Can resolved rapidly with reversal of ischemia.• May persist in setting of AMI.• Mimics include: Coronary artery spasm, acute
pericarditis, ventricular aneurysm.
ACP Academy Section 5: Advanced Clinical Education Cardiology
Types of ST DepressionTypes of ST Depression
ACP Academy Section 5: Advanced Clinical Education Cardiology
ST Elevation in AMIST Elevation in AMI
• Abnormal ST elevation is an ECG sign of Abnormal ST elevation is an ECG sign of myocardial injury.myocardial injury.• Usually occur Usually occur within 20-40minuteswithin 20-40minutes following onset of following onset of
infarction.infarction.• Changes in diastolic resting potential of injured cells Changes in diastolic resting potential of injured cells
causes downward shift of T-Q interval.causes downward shift of T-Q interval.• As AMI progresses ST elevation begins returning to As AMI progresses ST elevation begins returning to
baseline, as Q waves and flipped T-waves develop.baseline, as Q waves and flipped T-waves develop.
• ST Elevation mimics: pericarditis, early ST Elevation mimics: pericarditis, early repolarization, LVH with strain pattern.repolarization, LVH with strain pattern.
ACP Academy Section 5: Advanced Clinical Education Cardiology
Reciprocal Changes?• Reciprocal ST segment
depression: In the setting of STE AMI, ST segment depression located in leads distant from the infarction is termed reciprocal change or reciprocal ST segment depression.
• Reciprocal change is useful – diagnostically— its presence strongly
suggests AMI– prognostically— patients with such a
finding have larger infarcts, lower resultant ejection fractions, and higher rates of death.
• Sometimes hard to differentiate form ST depression
ACP Academy Section 5: Advanced Clinical Education Cardiology
S-T changes and their location?
ACP Academy Section 5: Advanced Clinical Education Cardiology
Cardiac Anatomy in Relation to Coronary Artery
Cardiac Anatomy in Relation to Coronary Artery
Rightcoronary
artery
Septal wallV1-V2
Left anterior descending artery
Anterior wallV3-V4
Left main coronary artery
Circumflex artery
Lateral wallI, aVL, V5-V6
ACP Academy Section 5: Advanced Clinical Education Cardiology
Associations Between Changes on12-Lead ECG and Cardiac AnatomyAssociations Between Changes on12-Lead ECG and Cardiac Anatomy
aVF inferiorIII inferior V3 anterior V6 lateral
aVL lateralII inferior V2 septal V5 lateral
aVRI lateral V1 septal V4 anterior
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
Inferior MI Localization
aVF inferior
III inferior
V3 anterior
V6 lateral
aVL lateral
II inferior V2 septal V5 lateral
aVRI lateral V1 septal V4
anterior
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
Lateral MI Localization
aVF inferior
III inferior
V3 anterior
V6 lateral
aVL lateral
II inferior V2 septal V5 lateral
aVRI lateral V1 septal V4
anterior
ACP Academy Section 5: Advanced Clinical Education Cardiology
Lateral MI
ACP Academy Section 5: Advanced Clinical Education Cardiology
Septal MI Localization
aVF inferior
III inferior
V3 anterior
V6 lateral
aVL lateral
II inferior V2 septal V5 lateral
aVRI lateral V1 septal V4
anterior
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
Inferior MI Localization
aVF inferior
III inferior
V3 anterior
V6 lateral
aVL lateral
II inferior V2 septal V5 lateral
aVRI lateral V1 septal V4
anterior
ACP Academy Section 5: Advanced Clinical Education Cardiology
Inferior MI
ACP Academy Section 5: Advanced Clinical Education Cardiology
NOTE 1: Inferior wall supplied by either the right (85% to 90% of people) or left coronary artery.
NOTE 2: If there is acute injury in inferior leads (II, III, aVF), unknown whether left or right coronary artery is blocked.
NOTE 3: KEY — you must obtain a RIGHT-RIGHT-SIDED ECGSIDED ECG at once.
Posterior View of the HeartPosterior View of the Heart
HOW TO GET HOW TO GET RIGHT-SIDED ECG?RIGHT-SIDED ECG?
Leads II, III, aVF
(from left left coronary coronary arteryartery)
Lateral wall
Inferior wall
Right coronary Right coronary arteryartery
Posterior descending
artery
Posterior wall
Circumflexartery
ACP Academy Section 5: Advanced Clinical Education Cardiology
Right Ventricular InfarctionRight Ventricular Infarction
• Inferior lead changes RV infarction?–Use lead V4R (ST elevation >1 mm)
• Clinical significance:–Increased mortality–Preload dependencePreload dependence
• Vasodilators (Nitrates, MSO4Nitrates, MSO4) may cause severe hypotension
• What is management of RV infarction?–Increase PRELOAD!! (FLUIDS)Increase PRELOAD!! (FLUIDS)
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, N-STEMI, and STEMI Mimics
ACP Academy Section 5: Advanced Clinical Education Cardiology
Three “I”s
• Ischemia
• Injury
• Infarction
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACUTE CORONARY SYNDROMES
No ST elevation ST elevation
Unstableangina
NSTEMI STEMI
Spectrum of CAD
Stableangina
Source (Photos): Davies MJ. Heart. 2000;83:361-366.
CAD = coronary artery disease; NSTEMI = non-ST-segment elevation myocardial infarction;STEMI = ST-segment-elevation myocardial infarction.
ACP Academy Section 5: Advanced Clinical Education Cardiology
What is STEMI?
• S-TS-T EElevation MMyocardial Infarction– Can we measure the ST segment accurately?– What does the ST segment look like?
• WE CANT CALL A CODE STEMI IF WE DON’T KNOW HOW TO EVALUATE AN ST SEGMENT
ACP Academy Section 5: Advanced Clinical Education Cardiology
N-STEMI?
• N-STEMI is an MI that does not show ST elevation
• You cannot call an N-STEMI a STEMI, regardless of how strongly you suspect the MI.
• You can call “Medical Stat” (Discussed later)
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI Mimics
• Things that make you go … HMMMM
• Things that look (at first glance) Like a STEMI or other MI pattern, but are NOT.
• Thinks that will cause you to INAPPROPRIATELY call a Code STEMI– Increase “false positive rates”
• Still may be deadly serious conditions
ACP Academy Section 5: Advanced Clinical Education Cardiology
The basics of doing the 12 lead
ACP Academy Section 5: Advanced Clinical Education Cardiology
The Basic 12 Lead
ACP Academy Section 5: Advanced Clinical Education Cardiology
Lead Placement for a Right-sided ECG
Lead Placement for a Right-sided ECG
ACP Academy Section 5: Advanced Clinical Education Cardiology
The Right Ventricular LeadsThe Right Ventricular Leads
ACP Academy Section 5: Advanced Clinical Education Cardiology
KEY POINT!
• BE SURE TO WRITE ON ECG THAT IT WAS A RIGHT SIDED ECG!
ACP Academy Section 5: Advanced Clinical Education Cardiology
Posterior ECG?
ACP Academy Section 5: Advanced Clinical Education Cardiology
The importance of serial 12 leads
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI MIMICS
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
Most common causes of STEMI mistakes
• RBBB/LBBB
• Pericarditis
• LVH
• Electrolyte Imbalances
• Drug Effects
ACP Academy Section 5: Advanced Clinical Education Cardiology
Bundle Branch/Fascicular Bundle Branch/Fascicular BlocksBlocks
• LBBB always indicates cardiac disease or injury.• Just not always ACUTE injury• Just not always MI, other “Mimics” can also cause
BBB
• “Making the diagnosis of acute infarction in the presence of left bundle-branch block can be problematic…”– PROBLEM: Patients with (suspected new)
LBBB tend to be REALLY BAD MI’s.
ACP Academy Section 5: Advanced Clinical Education Cardiology
Bundle Branch/Fascicular Blocks Right Bundle Branch Block
• Do not rely on presence of “rabbit ears” for Do not rely on presence of “rabbit ears” for diagnosis of RBBB. Will miss many RBBBs.diagnosis of RBBB. Will miss many RBBBs.
ACP Academy Section 5: Advanced Clinical Education Cardiology
AMI with BB? AMI with BB? • AMI should be no problemAMI should be no problem
• RBBB does not change S-T segment RBBB does not change S-T segment alterationsalterations
• LBBB can make things more interestingLBBB can make things more interesting
ACP Academy Section 5: Advanced Clinical Education Cardiology
Again with the serial ECGs???
• Even though the LBBB makes initial ST evaluation difficult, the serial changes noted make this diagnostic for MI.
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI MimicsSTEMI Mimics• PericarditisPericarditis
1.1. No reciprocal changes. There will only be No reciprocal changes. There will only be S-T elevation, no depression.S-T elevation, no depression.
2.2. The myocardium is not involved. No The myocardium is not involved. No changes will be noted to the QRS complex.changes will be noted to the QRS complex.
3.3. Changes isolated to the S-T-T wavesChanges isolated to the S-T-T waves
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI MimicsSTEMI Mimics• Pericardial EffusionPericardial Effusion
1.1. Distinctive patternDistinctive pattern
2.2. Changing polarity of Changing polarity of Q-R-SQ-R-S
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI MimicsSTEMI Mimics• HyperkalemiaHyperkalemia
– Progressive changes to de- & repolarizationProgressive changes to de- & repolarization– T wave peaks, then widens/flattensT wave peaks, then widens/flattens– PR interval prolongs, and P wave flattensPR interval prolongs, and P wave flattens– QRS widens alsoQRS widens also
ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 6.1 mEq/L
ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 7.2 mEq/L
ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 9.1 mEq/L
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI MimicsSTEMI Mimics• HypokalemiaHypokalemia
– ST depression with prominent U-wavesST depression with prominent U-waves– Prolonged repolarizationProlonged repolarization– T waves flattenT waves flatten– Can mimic reciprocal changesCan mimic reciprocal changes
ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 2.5 mEq/L
ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 1.5 mEq/L
ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 0.9 mEq/L
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI MimicsSTEMI Mimics• Cardiac Glycosides-DigoxinCardiac Glycosides-Digoxin
– Digitalis effect-”scooped” ST segmentDigitalis effect-”scooped” ST segment
• Anti-dysrhythmic agentsAnti-dysrhythmic agents– Based on where they workBased on where they work– QT prolongation is commonQT prolongation is common
• Psychotropic agents (i.e.TCA’s)Psychotropic agents (i.e.TCA’s)– Increase QRS durationIncrease QRS duration– Lengthen QT intervalLengthen QT interval
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI Mimics
• Well, Kinda anyway
• Pacemakers
ACP Academy Section 5: Advanced Clinical Education Cardiology
ACP Academy Section 5: Advanced Clinical Education Cardiology
The Problem
• Research has recognized that half of patients with myocardial infarction do not arrive early enough (90 minutes) to PCI…– Door to Balloon time <90 minutes is a class I
Intervention in STEMI
• Numerous strategies to improve the “Door to Balloon” time have evolved.
ACP Academy Section 5: Advanced Clinical Education Cardiology
The Solution
• New strategies have involved a player previously ignored in cardiac care… EMS!
• Local cardiology groups and hospitals have committed to involving EMS in improving time to PCI!
• This has a direct measurable effect on mortality!!!– Only if the system works and EMS does its
part!
ACP Academy Section 5: Advanced Clinical Education Cardiology
Key to this is Pre-Hospital Cardiac Triage
And accurate 12 lead interpretation!
DON’T TELL ANYONE, BUT EMS HAS BEEN DOING 12 LEADS FOR ALMOST 40 YEARS!!!
ACP Academy Section 5: Advanced Clinical Education Cardiology
First field First field 12 lead12 lead
Seattle Medic OneSeattle Medic One
Circa 1969Circa 1969
ACP Academy Section 5: Advanced Clinical Education Cardiology
WHY 12 leads?
• 12 leads are the KEY to open the DOOR to PCI!!!!!
• PARAMEDICS ARE THE KEYMASTERS• WHO IS THE GATEKEEPER?
– ER Docs– Cardiologist– Bean Counters!!!
• TRUE STORY: EMS has 1 chance to impress and right now that chance is slipping away…
ACP Academy Section 5: Advanced Clinical Education Cardiology
The KEYMASTER and the GATEKEEPER?
12 Leads!!!!12 Leads!!!!
ACP Academy Section 5: Advanced Clinical Education Cardiology
Time to Treatment in PCI(Nallamothu 2007 NEJM 357:1631)
What this means:What this means:Beyond a D2B ≤90 Minutes…Beyond a D2B ≤90 Minutes…
Every 15-minutes of Delay Every 15-minutes of Delay MortalityMortality
ACP Academy Section 5: Advanced Clinical Education Cardiology
Why the big push for PCI?????
ACP Academy Section 5: Advanced Clinical Education Cardiology
D2B Alliance Goal
• “To achieve a door-to-balloon (D2B) time of 90 minutes for at least 75%75% of non-transfer primary PCI patients with ST-elevation myocardial infarction (STEMI) in all participating hospitals performing primary PCI”
• National baseline about 50%50% rate D2B 90 with out systems approach
ACP Academy Section 5: Advanced Clinical Education Cardiology
NEW CONCEPT IN PCI
• No longer just Door to Balloon (D2B)….
• Now EMS to Balloon (E2B)….
ACP Academy Section 5: Advanced Clinical Education Cardiology
Onset of symptoms of
STEMI
9-1-1EMS
dispatch
EMS on-scene
Understanding the Intervals
ACPACP
S2B: S/S Onset to BalloonS2B: S/S Onset to Balloon
E2B: EMS to BalloonE2B: EMS to Balloon
C2B: Call to BalloonC2B: Call to Balloon
D2B:D2B: Door to Balloon
Hospital
BB
AA
LL
LL
OO
OO
NNR2R: Recognition (12 lead) to Re-perfusion
ACP Academy Section 5: Advanced Clinical Education Cardiology
Isn't just doing PH 12 leads enough?
• In a nutshell: NO• Implementation of PH 12 leads by itself did
not significantly impact D2B times.• PH 12 leads only shown to make a
difference in a SYSTEMS/PROTOCOL driven approach– Otherwise the 12 leads gather dust
• Fortunately SARMC/SLRC are interested in a SYSTEM
ACP Academy Section 5: Advanced Clinical Education Cardiology
Pre-hospital Cardiac TriagePre-hospital Cardiac Triage
Similar to nation’s current trauma systems:
sick pts = special care at specialty centers with specialty team activation
ACP Academy Section 5: Advanced Clinical Education Cardiology
30-30-30 GoalE2B≤90 Conceptual Framework
< 30 minutes for Emergency Med Services (EMS)
< 30 minutes for the Emergency Department (ED)
< 30 minutes for the Cardiac Cath Lab (CCL)
ACP Academy Section 5: Advanced Clinical Education Cardiology
EMS Transport <20 min
Onset of symptoms of
STEMI
9-1-1EMS
dispatch
EMS on-scene• Mandatory 12-lead ECGs• TRANSMIT 12-leads
1 minute
PCIcapable
Not PCIcapable
Code STEMI and Rapid CCT Transfer
STEMI TriageHospital Destination
Guidelines
TIME LOST!!!
CCTRequired
BEST PRACTICES : Golden hr = E2B/D2B within 1st 60 min
Total ischemic time for E2B/D2B GOAL: within 120 minTotal ischemic time for E2B/D2B GOAL: within 120 min
Patient EMS
E2B <90 min?: EMS Treat and transport to PCI Capable hospital
Dispatch
????? Time10min
ACP approach for Transport of Patients With STEMI and Initial Reperfusion Treatment
ACPACP
SLRMCSLRMC
SARMCSARMC
SLMMCSLMMCSAEMCSAEMCVAMCVAMCWVMCWVMCMMCMMC
Code STEMI and Direct to PCI
Med STAT- ED MD triage t PCI
ASA?
EMS
PH 12 lead transmission
ACP Academy Section 5: Advanced Clinical Education Cardiology
CODE STEMI is the “Level 1 Trauma” of the Cardiac World
“Medical Stat” is the Level II and Level III
ACP Academy Section 5: Advanced Clinical Education Cardiology
SO WHERE IS ACP?
• 2/2008 review for prior 6 months• Total Charts Reviewed: 88
– CODE STEMI charts reviewed: 28– Other Chest Pain/DX of AMI charts (No Code STEMI called): 60
• 3 charts out the 60 showed STEMI on EMS12 lead
• Results:– Fail to recognize/report rate: 2.6%– Of Code STEMI Called
• STEMI continued at hospital: 21 (75%)• STEMI cancelled: 7 (25%)
• False Negative Rate -2.6%• False Positive rate: -25%
– Goal is 5%
ACP Academy Section 5: Advanced Clinical Education Cardiology
CAN WE DO CAN WE DO BETTER?BETTER?
(and what happens if we don’t???????)
ACP Academy Section 5: Advanced Clinical Education Cardiology
So what's the big deal?
• False Positives: (calling Code STEMI inappropriately) ?– $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$– Urgent and “less emergent” PCI are bumped
for the “code STEMI– Cardiologist taken away from PCI and other
duties– WHOLE SYSTEM GETS ACTIVATED
• If 12 lead is not received, activation continues anyway
ACP Academy Section 5: Advanced Clinical Education Cardiology
So what's the big deal?
• False Negatives: (No Code STEMI Called)– MD does not see 12 lead, it sits and gathers
dust. – Consistently exceeding D2B >90 min– Increased mortality
ACP Academy Section 5: Advanced Clinical Education Cardiology
3 layers of Safety Net
• Cognitive Detection – The paramedic and his 12 lead is a beautiful
thing
• Automated Detection– “*** ACUTE AMI *****”
• Emergency Department Screening– MD review to prevent false positives and to
pick up on STEMI mimics that still need urgent care
ACP Academy Section 5: Advanced Clinical Education Cardiology
3 Levels of Notification
CODE STEMI Medical STAT
Business as UsualRoutine Radio report
ACP Academy Section 5: Advanced Clinical Education Cardiology
Obt
ain
and
Tra
nsm
it 12
lead
Inclusionary Criteria Inclusionary Criteria Suspicion for ACS S/S AND
ST Elevation 2mm in 2+ contiguous Leads Exclusionary Criteria Exclusionary Criteria
NO QRS greater than 0.11 ORNO LBBB
Inclusionary Criteria Inclusionary Criteria Automatic Detection : “Acute MI”
Paramedic DiscretionSuspicion for ACS S/S
AND (Any of the following):Global ST Changes
N-STEMIST Elevation in 1 mm in Inferior Leads
ST Depression or Inverted Ts in contiguous leads Questionable Reciprocal Changes
Presumed New LBBBInverted T-Waves or ST depression in 2+ contiguous leads
Hyper-acute T waves present in 2+ contiguous leads.Exclusionary Criteria Exclusionary Criteria
NONE
CODE STEMI
Medical STAT
PH ECG Eval
Radio Report
Radio Report
Proposed ACP protocol to reduce E2BProposed ACP protocol to reduce E2B
ACP Academy Section 5: Advanced Clinical Education Cardiology
Medical State
• Medical State can also be used on other time sensitive emergencies…– Respiratory Failure with CPAP– Field ETT placed– “RT at bedside”– “MD at bedside”
ACP Academy Section 5: Advanced Clinical Education Cardiology
Closing Thoughts
“However, it is becoming increasingly clear that the emergency medical services (EMS) have an important role in STEMI patient care, and that a three-way partnership involving EMS, EM departments, and the CCL has substantial potential to increase access to PCI for STEMI and simultaneously reduce door-toballoon times.”
Tom Bouthillet, FF/NREMT–P
STEMISystems, Issue 2, May 2007
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?
Click for answer
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?
• 26 y/o male presenting to EMS after arrest for probation violation.
• He is in booking, suddenly complains of chest discomfort.
• EMS is notified.
• Smokes a pack a week approx for 3 years
• No other history
• No reported drug use/abuse
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?
Click for answer
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?
Click for answer
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?
ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?
• 45 y/o male with chest pain, nausea, vomiting, and dizziness while in bed.
• B/P 80/40
• HR regular and tachycardic
• Has not been to a doctor since he was in the army 20 years previous
• Notably obese. Smokes
ACP Academy Section 5: Advanced Clinical Education Cardiology
On final unrelated thought
• A recent review showed that less than 5% of patients who received NTG SL by ACP received NTG Paste in follow up.
• The benefits of NTG paste are significant– You don’t have to do a full 3 doses to initiate
it.
• Please consider it in the future.
ACP Academy Section 5: Advanced Clinical Education Cardiology
Now for Hands on…Now for Hands on…
• Entering Names
• Right sided and posterior 12 lead placement
• Transmission of 12 leads
• Scenarios?