STEMI, N-STEMI, and Everything else

This is a DRAFT of STEMI training for E2B.
NOTE: The CODE STEMI is not the same thing as STEMI, it is a process and TRIAGE tool, where STEMI is a DX.

1. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, N-STEMI, and
everything else
Ada County Paramedics
Block Training
April 2008

2. ACP Academy Section 5: Advanced Clinical Education Cardiology
Contact Information
•Ada County Paramedics
–5870 Glenwood
–Boise, ID 83714
–Adaparamedics.org
–208-287-2972

3. 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

4. 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

5. ACP Academy Section 5: Advanced Clinical Education Cardiology
Disclosure Statement

6. 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)

7. 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…)

8. ACP Academy Section 5: Advanced Clinical Education Cardiology
Understanding the ST
segment

9. ACP Academy Section 5: Advanced Clinical Education Cardiology

10. ACP Academy Section 5: Advanced Clinical Education Cardiology

11. 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.

12. 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.

13. ACP Academy Section 5: Advanced Clinical Education Cardiology
T-Wave Changes in IschemiaT-Wave Changes in Ischemia
Peaked, Symmetrical T-WavesPeaked, Symmetrical T-Waves

14. ACP Academy Section 5: Advanced Clinical Education Cardiology
T-wave changes in IschemiaT-wave changes in Ischemia
Inverted T-wavesInverted T-waves

15. 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

16. 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.

17. ACP Academy Section 5: Advanced Clinical Education Cardiology
Types of ST DepressionTypes of ST Depression

18. 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.

19. 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

20. ACP Academy Section 5: Advanced Clinical Education Cardiology
S-T changes and their location?

21. ACP Academy Section 5: Advanced Clinical Education Cardiology
Cardiac Anatomy in Relation to
Coronary Artery
Right
coronary
artery
Septal wall
V
1
-V
2
Left anterior
descending artery
Anterior wall
V
3
-V
4
Left main
coronary
artery
Circumflex
artery
Lateral wall
I, aVL, V
5
-V
6

22. ACP Academy Section 5: Advanced Clinical Education Cardiology
Associations Between Changes on
12-Lead ECG and Cardiac Anatomy
aVF inferiorIII inferior V
3
anteriorV
6
lateral
aVL lateralII inferior V
2 septal V
5 lateral
aVRI lateral V
1
septalV
4
anterior

23. ACP Academy Section 5: Advanced Clinical Education Cardiology

24. ACP Academy Section 5: Advanced Clinical Education Cardiology
Inferior MI Localization
aVF inferiorIII inferior V
3
anteriorV
6
lateral
aVL lateralII inferior V
2 septalV
5 lateral
aVRI lateral V
1 septalV
4 anterior

25. ACP Academy Section 5: Advanced Clinical Education Cardiology

26. ACP Academy Section 5: Advanced Clinical Education Cardiology

27. ACP Academy Section 5: Advanced Clinical Education Cardiology
Lateral MI Localization
aVF inferiorIII inferior V
3
anteriorV
6
lateral
aVL lateralII inferior V
2 septalV
5 lateral
aVRI lateral V
1 septalV
4 anterior

28. ACP Academy Section 5: Advanced Clinical Education Cardiology
Lateral MI

29. ACP Academy Section 5: Advanced Clinical Education Cardiology
Septal MI Localization
aVF inferiorIII inferior V
3
anteriorV
6
lateral
aVL lateralII inferior V
2 septalV
5 lateral
aVRI lateral V
1 septalV
4 anterior

30. ACP Academy Section 5: Advanced Clinical Education Cardiology

31. ACP Academy Section 5: Advanced Clinical Education Cardiology
Inferior MI Localization
aVF inferiorIII inferior V
3
anteriorV
6
lateral
aVL lateralII inferior V
2 septalV
5 lateral
aVRI lateral V
1 septalV
4 anterior

32. ACP Academy Section 5: Advanced Clinical Education Cardiology
Inferior MI

33. 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 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
Circumflex
artery

34. ACP Academy Section 5: Advanced Clinical Education Cardiology
Right Ventricular Infarction
•Inferior lead changes è RV infarction?
–Use lead V
4
R (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)

35. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, N-STEMI, and STEMI
Mimics

36. ACP Academy Section 5: Advanced Clinical Education Cardiology
Three “I”s
•Ischemia
•Injury
•Infarction

37. ACP Academy Section 5: Advanced Clinical Education Cardiology
ACUTE CORONARY SYNDROMES
No ST elevation ST elevation
Unstable
angina
NSTEMI STEMI
Spectrum of CAD
Stable
angina
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.

38. 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

39. 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)

40. 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

41. ACP Academy Section 5: Advanced Clinical Education Cardiology
The basics of doing the 12
lead

42. ACP Academy Section 5: Advanced Clinical Education Cardiology
The Basic 12 Lead

43. ACP Academy Section 5: Advanced Clinical Education Cardiology
Lead Placement for a
Right-sided ECG

44. ACP Academy Section 5: Advanced Clinical Education Cardiology
The Right Ventricular LeadsThe Right Ventricular Leads

45. ACP Academy Section 5: Advanced Clinical Education Cardiology
KEY POINT!
•BE SURE TO WRITE ON ECG THAT IT
WAS A RIGHT SIDED ECG!

46. ACP Academy Section 5: Advanced Clinical Education Cardiology
Posterior ECG?

47. ACP Academy Section 5: Advanced Clinical Education Cardiology
The importance of serial 12 leads

48. ACP Academy Section 5: Advanced Clinical Education Cardiology

49. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI MIMICS

50. ACP Academy Section 5: Advanced Clinical Education Cardiology

51. ACP Academy Section 5: Advanced Clinical Education Cardiology
Most common causes of STEMI
mistakes
•RBBB/LBBB
•Pericarditis
•LVH
•Electrolyte Imbalances
•Drug Effects

52. 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.

53. ACP Academy Section 5: Advanced Clinical Education Cardiology
Bundle Branch/Fascicular Blocks
Right Bundle Branch Block
•Do not rely on presence of “rabbit ears” Do not rely on presence of “rabbit ears”
for diagnosis of RBBB. Will miss many for diagnosis of RBBB. Will miss many
RBBBs.RBBBs.

54. 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

55. 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.

56. ACP Academy Section 5: Advanced Clinical Education Cardiology

57. ACP Academy Section 5: Advanced Clinical Education Cardiology

58. 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

59. ACP Academy Section 5: Advanced Clinical Education Cardiology

60. ACP Academy Section 5: Advanced Clinical Education Cardiology

61. 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

62. ACP Academy Section 5: Advanced Clinical Education Cardiology

63. 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

64. ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 6.1 mEq/L

65. ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 7.2 mEq/L

66. ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 9.1 mEq/L

67. 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

68. ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 2.5 mEq/L

69. ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 1.5 mEq/L

70. ACP Academy Section 5: Advanced Clinical Education Cardiology
Potassium Level: 0.9 mEq/L

71. 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

72. ACP Academy Section 5: Advanced Clinical Education Cardiology

73. ACP Academy Section 5: Advanced Clinical Education Cardiology

74. ACP Academy Section 5: Advanced Clinical Education Cardiology

75. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI Mimics
•Well, Kinda anyway
•Pacemakers

76. ACP Academy Section 5: Advanced Clinical Education Cardiology

77. 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.

78. 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!

79. 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!!!

80. ACP Academy Section 5: Advanced Clinical Education Cardiology
First field First field
12 lead12 lead

Seattle Medic OneSeattle Medic One
Circa 1969Circa 1969

81. 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…

82. ACP Academy Section 5: Advanced Clinical Education Cardiology
The KEYMASTER and the
GATEKEEPER?
12 Leads!!!!12 Leads!!!!

83. 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

84. ACP Academy Section 5: Advanced Clinical Education Cardiology
Why the big push for PCI?????

85. 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

86. ACP Academy Section 5: Advanced Clinical Education Cardiology
NEW CONCEPT IN PCI
•No longer just Door to Balloon (D2B)….
•Now EMS to Balloon (E2B)….

87. ACP Academy Section 5: Advanced Clinical Education Cardiology
Onset of
symptoms of
STEMI
9-1-1
EMS
dispatch
EMS on-scene
Understanding the Intervals
ACP
ACP
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
NN
R2R: Recognition (12 lead) to Re-perfusion

88. 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

89. 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

90. ACP Academy Section 5: Advanced Clinical Education Cardiology
30-30-30 Goal
E2B≤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)

91. ACP Academy Section 5: Advanced Clinical Education Cardiology
EMS Transport <20 min
Onset of
symptoms of
STEMI
9-1-1
EMS
dispatch
EMS on-scene
•Mandatory 12-lead ECGs
•TRANSMIT 12-leads
1 minute
PCI
capable
Not PCI
capable
Code STEMI and
Rapid CCT
Transfer
STEMI Triage
Hospital Destination
Guidelines
TIME
LOST!!!
CCT
Required
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
????? Time
10
min
ACP approach for Transport of Patients With STEMI
and Initial Reperfusion Treatment
ACP
ACP
SLRMCSLRMC
SARMCSARMC
SLMMCSLMMC
SAEMCSAEMC
VAMCVAMC
WVMCWVMC
MMCMMC
Code STEMI and
Direct to PCI
Med STAT- ED
MD triage t PCI
ASA?
EMS
PH 12 lead transmission

92. 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

93. 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%

94. ACP Academy Section 5: Advanced Clinical Education Cardiology
CAN WE DO BETTER?CAN WE DO BETTER?
(and what happens if we don’t???????)

95. 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

96. 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

97. 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

98. ACP Academy Section 5: Advanced Clinical Education Cardiology
3 Levels of Notification
CODE STEMI
Med
ic
a
l
ST
A
T
Business as Usual
Routine Radio report

99. ACP Academy Section 5: Advanced Clinical Education Cardiology
O
b
t
a
in


a
n
d

T
r
a
n
s
m
it

1
2

le
a
d
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 OR
NO LBBB
Inclusionary Criteria Inclusionary Criteria
Automatic Detection : “Acute MI”
Paramedic Discretion
Suspicion for ACS S/S
AND (Any of the following):
Global ST Changes
N-STEMI
ST Elevation in 1 mm in Inferior Leads
ST Depression or Inverted Ts in contiguous leads
Questionable Reciprocal Changes
Presumed New LBBB
Inverted 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
ST
AT
PH ECG Eval
Radio Report
Radio Report
Proposed ACP protocol to reduce E2BProposed ACP protocol to reduce E2B

100. 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”

101. 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

102. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?
Click for
answer

103. 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

104. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?

105. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?
Click for
answer

106. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?
Click for
answer

107. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?

108. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?

109. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?

110. ACP Academy Section 5: Advanced Clinical Education Cardiology
STEMI, Medical SAT, or Other?STEMI, Medical SAT, or Other?

111. 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

112. 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.

113. 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?