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AHA changes acceptable time to primary PCI from 90 to 120 minutes for acute STEMI

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Thanks to Ivan Rokos, M.D. for pointing out an important change in the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention.

Photo credit: Code STEMI Web Series at First Responders Network

For years now many have complained about the AHA's official recommendation that primary PCI for acute STEMI be accomplished within 90 minutes of first medical contact (which can be a Critical Access Hospital 1 or 2 hours away from a PCI hospital or a volunteer BLS EMS system in the rural setting).

There are two main reasons the 90-minute standard for rural patients is problematic.

You could argue that it's time to change the recommendation from 90-minutes to 60-minutes for walk-in patients at PCI hopsitals (which I agree with). But even so, for many patients the mortality benefit of primary PCI over fibrinolytic therapy persists well past 90-minutes.

It's also important to remember that many patients have contraindications to fibrinolytic therapy, meet high-risk criteria (pulmonary edema, hypotension, tachycardia) that make primary PCI necessary, and that up to 30% of patients who receive fibrinolytic therapy will have "failed fibrinolysis" (their symptoms and ST-elevation will not resolve after being given clot-busing drugs indicating that they have not been reperfused).

In other words, all hospitals need (in the words of Jodi Doering, R.N.) "a Plan A, a Plan B and a Plan C." This is far too important to leave to chance. There is mounting evidence that transfer PCI takes too long and that rural hospitals are not achieving door-in to door-out (DIDO) times of less than 30-minutes so there is plenty of room for improvement and my intent here is not to blame the guidelines for preventable delays.

Having said that it's simply not possible for some patients who would benefit from primary PCI to have their infarct-related artery opened up on the cath table within 90-minutes of first medical contact (which, let's face it, is not even being measured in the vast majority of STEMI "systems" — the word "systems" in scare quotes because if it's not measured it's not a system.)

Which brings me to the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (free full text).

5.2.2.2. Primary PCI of the Infarct Artery: Recommendations

  • Class I

    1. Primary PCI should be performed in patients within 12 hours of onset of STEMI. (Level of Evidence: A)

    2. Primary PCI should be performed in patients with STEMI presenting to a hospital with PCI capability within 90 minutes of first medical contact as a systems goal. (Level of Evidence: B)

    3. Primary PCI should be performed in patients with STEMI presenting to a hospital without PCI capability within 120 minutes of first medical contact as a systems goal. (Level of Evidence: B)

    4. Primary PCI should be performed in patients with STEMI who develop severe heart failure or cardiogenic shock and are suitable candidates for revascularization as soon as possible, irrespective of time delay. (Level of Evidence: B)

    5. Primary PCI should be performed as soon as possible in patients with STEMI and contraindications to fibrinolytic therapy with ischemic symptoms for less than 12 hours. (Level of Evidence: B)

  • Class IIa

    1. Primary PCI is reasonable in patients with STEMI if there is clinical and/or electrocardiographic evidence of ongoing ischemia between 12 and 24 hours after symptom onset. (Level of Evidence: B)

  • Class IIb

    1. Primary PCI might be considered in asymptomatic patients with STEMI and higher risk presenting between 12 and 24 hours after symptom onset. (Level of Evidence: C)

  • Class III: HARM

    1. PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI without hemodynamic compromise. (Level of Evidence: B)

The following statement accompanies the change in guidelines:

"Several reports have shown excellent outcomes for patients with STEMI undergoing interhospital transfer where first medical contact–to-door balloon time modestly exceeded the systematic goal of <90 minutes. In these reports, the referring hospital and the receiving hospital established a transfer protocol that minimized transfer delays, and outcomes were similar to those of direct-admission patients. On the basis of these results, the PCI and STEMI guideline writing committees have modified the first medical contact–to-device time goal from 90 minutes to 120 minutes for interhospital transfer patients, while emphasizing that systems should continue to strive for times ≤90 minutes. Hospitals that cannot meet these criteria should use fibrinolytic therapy as their primary reperfusion strategy."

This is an important change that every state, Critical Access Hopsital and rural EMS system should make note of and take steps to act upon.

The lives of our rural STEMI patients may depend upon it! 

See also:

AHA Mission: Lifeline

Code STEMI Web Series at First Responders Network

Posted by on December 30, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

The importance of data collection and sharing

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Cross-posted from the Follow the Crew blog at CodeSTEMI.tv.

We had a wonderful time in Dearborn. I was welcomed as a brother at Dearborn Fire Department and got to learn about an awesome fire-based EMS system which made me happy. In addition, we met some motivated and passionate caregivers at Oakwood Hospital.

They are doing some awesome things in Dearborn and it's clear they're doing a great job treating STEMI patients. However, there's one area that created some cognitive dissonance for me and it's data sharing (or lack thereof) between the hospital and the EMS system.

One of the first questions I asked when we arrived at Oakwood was whether or not they had a multi-disciplinary STEMI meeting. "Absolutely!" we were told. Every Wednesday morning and all the stakeholders were present from emergency medicine, nursing, cardiology and administration.

"What about EMS?" Blank stare.

Finally I was told, "We have an EMS liaison." Unfortunately, it soon became clear that it wasn't enough. The bottom line is that the EMS Chief does not have a seat at the adult table in this hospital. That doesn't mean it isn't a great hospital.

I dragged my feet before writing this blog post because I don't want to cause any offense or ruffle any feathers. However, we are the First Responders Network. We tell stories from the point of view of EMS. The bottom line is that everyone we met at Oakwood talked about their extraordinary door-to-balloon times (less than 60 minutes and even less than 40 minutes) but we still haven't seen it on paper in context.

The door-to-balloon times at Hilton Head Hospital hang on the wall of the emergency department (warts and all).

As Carl Sagan said, "Extraordinary claims require extraordinary evidence." Another quote from Thom Dick comes to mind. "Your agency is not the best in the nation. It's not the best in the state, either. In fact, it's probably not very good at all, unless you can prove it." We're not doing a commercial for Oakwood Hospital we're telling the story of their system which includes EMS and their interaction with EMS.

Every EMS system has room for improvement and my own EMS system is far from perfect. We have our own politics and our own struggles. In some areas Dearborn Fire Department and Oakwood Hospital are better than we are. Having said that, when it comes to quality and process improvement I'm a bit of a skeptic, and justifiably so. I'll spare you the details but I still don't know the actual "call received" time in my own EMS system.

The bottom line is, you might be the best EMS system or the best hospital on Earth.

Don't tell me. Show me.

Posted by on December 24, 2011 • Filed under: Emergency Communications, ems-topics, patient-management • Tagged: , , , ,

90 Year Old Male CC: Chest Discomfort

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HAPPY HOLIDAYS!

Here's an interesting case submitted by a faithful reader who wishes to remain anonymous.  As usual, some details may have been changed to protect patient confidentiality.

You are called to the residence of a 90 year old male.  Prior to your arrival, he was met by a BLS crew, walking around his apartment in no obvious distress.  Upon questioning, he admits to some sub-sternal "chest discomfort" starting four hour prior to calling EMS.  As your partner starts to get vitals, you continue your history and learn that the discomfort started while "sitting in a cab on the way home".  The discomfort is non-radiating, and not reproducable.

Your partner obtained the following vitals:

  • BP:          130/90
  • Pulse:     100+, very weak
  • RR:          18 regular
  • Skin:          "unremarkable"
  • Lungs:     clear bilaterally
  • SpO2:      99% on high flow O2

The patient receives 162 mg of ASA (per regional protocol), and as you get additional history your partner starts to put the leads on:

  • Discomfort began while at rest in the cab
  • Nothing makes the discomfort better or worse
  • Pt can only describe an uncomfortable feeling in his chest
  • Discomfort does not travel anywhere
  • Pt rates it as 7/10
  • Discomfort began four hours prior to calling EMS

The only medication he admits to taking is Plavix. His history is significant for DVT (for which he says he takes the Plavix) and Previous MI with CABG (time unknown).

You acquire the following rhythm strip and 12 lead ECG and begin your transport:

 

While the "data quality prohibits interpretation message" is given, you attempt to get a better tracing but this is the best you can get.  In addition, you are unable to get IV access.

The nearest hospital is a community non-PCI center about 10 minutes away, and the closest PCI center is 20 minutes away.

 

WHAT ARE YOUR IMPRESSIONS ABOUT THIS PATIENT?

WHAT IS YOUR INTERPRETATION OF THE ECG, AND WHAT ARE THE DIFFERENTIALS?

HOW WOULD YOU TREAT THIS PATIENT?

WHERE WOULD YOU TAKE THIS PATIENT?

 

Posted by on December 22, 2011 • Filed under: ems-health-safety, ems-topics, patient-management • Tagged: , , , , , ,

18 year old male: Structure Fire Rehab – Conclusion

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Apologies for the delay, your author has been working nights and on the road traveling! We now return you to your regularly scheduled program.

This is the conclusion to 18 year old male: Structure Fire Rehab.

On the Attack Line - (c) 2011 Michael Herbert

When we left off, we had a young firefighter in our rehab area with an elevated heart rate and positive orthostatics.

He admitted to consuming energy drinks and not hydrating well, however, he had no real complaints. A 3-Lead and 12-Lead were acquired.

A look at the initial 3-Lead shows a heart rate of around 190, with P-waves buried in the preceding T-waves. The notes from the rehab officer indicate this was acquired while the patient was standing. The differentials for this rhythm include sinus tachycardia and SVT. However, given the patient's age and recent activity sinus tachycardia is the more likely diagnosis.

The 12-Lead acquired confirms our suspicions, as once the patient was sat down the rate decreased and the P-waves became more  obvious. This is sinus tachycardia with rate related ST/T-wave changes. There is no apparent ischemia or injury present. Some readers noted the rSR' in V1 and V2, however, these are most likely due to lead positioning (one intercostal space too high).

After 15 minutes of rehab he's had a water and a sports drink, with some improvement in his vital signs and no real complaints. However, they are not what we would like!

  • Pulse: 160, regular at the radials; 180 when standing
  • BP: 112/74
  • Resps: 20, unlabored
  • SpO2: 94% r/a
  • SpCO: 0%

The rehab officer was then asked by a line officer if the young firefighter could return to duty.

The most important consideration is our general impression of the patient and our findings from our physical assessment. In this case the rehab officer felt the patient had overexerted himself, was dehydrated, and was not fit for duty.

Instead, the rehab officer had the patient continue with oral intake of water and sports drinks (alternating), and reassessed the patient at regular intervals. After 30 minutes in rehab the following 3-Lead was obtained:

Put Me In Coach! - Final 3L

This is an uncomplicated sinus tachycardia. The patient's vitals were as follows:

  • Pulse: 100, regular at the radials; unchanged when standing
  • BP: 118/80
  • Resps: 16, unlabored
  • SpO2: 98% r/a
  • SpCO: 0%

At this point the fire was well under control and overhaul was in progress. The rehab officer did not allow the firefighter to return to duty, instead recommending he be transported for evaluation. The firefighter adamantly denied compaints and ultimately refused transport. He was educated on the importance of rehydration and the detrimental effects of sodas and energy drinks during exertion.

In this case IV fluids were withheld in favor of PO fluid replacement. Policies for rehydration may differ by department, however, if the patient is able to drink PO fluids, these should be preferred over IV supplement. Many marathons and triathlons have begun favoring PO over IV rehydration as well.

This course of treatment may surprise many of our readers, however, there is no data to support favoring IV fluids over PO fluids in a patient with hemodynamic changes secondary to exertion. IV fluids should instead be considered when there is symtomatic cardiovascular instability or the patient cannot effectively rehydrate orally1,2.

If your department is involved in the rehab of firefighters, you should have an NFPA 1584 compliant policy3,4 in-place with appropriate rehydration protocols.

A 24 hour call-back found the firefighter in good health and without complaint.

  1. Casa DJ, et al. Intravenous versus oral rehydration during a brief period: responses to subsequent exercise in the heat. Med Sci Sports Exerc. 2000; 32(1):124-33. [PubMed]
  2. van Rosendal SP, et al. Intravenous versus oral rehydration in athletes. Sports Med. 2010; 40(4):327-46. [PubMed]
  3. National Fire Protection Association (NFPA) 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises. Quincy, Mass: NFPA, 2008. [Overview]
  4. McEvoy M. The Elephan on the Fireground: Secrets of NFPA 1584-Compliant Rehab. Fire Engineering. Aug 2008; 161(8). [Full Text]
Posted by on December 7, 2011 • Filed under: ems-topics, fire-rescue-topics, firefighter-safety-health, firefighting-operations, patient-management • Tagged: , , , , , ,

90 year old male CC: “Possible stroke” – Conclusion

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This is the conclusion to 90 year old male CC: "Possible stroke". You might want to go back and familiarize yourself with the details of the case. Let's take another look at the 12-lead ECG.

Now with the computerized interpretive algorithm.

On Facebook I had asked whether or not this ECG showed signs of ischemia.

This ECG shows ST-depression in the lateral leads (I, aVL, V5 and V6) and modest ST-elevation in the right precordial leads (V1-V3). That's because it shows a strain pattern or secondary repolarization abormality due to left ventricular hypertrophy.

According to at least one study this is the most common cause of ST-elevation in chest pain patients. Hence, it is a very important pattern for paramedics to recognize in the field (although it's rare for LVH with strain to fool the GE-Marquette 12SL interpretive algorithm).

How would we know it's a strain pattern?

When we look at any 12-lead ECG we should consider the Six Step Method (or some other standardized approach).

Here we see that the patient is in sinus rhythm with a normal frontal plane axis. The QRS duration is < 120 ms so it's not a bundle branch block or paced rhythm.

At this point we might pick up on ST-depression in the lateral leads but it's too early to call it ischemia. We need to consider other possible causes. Since left ventricular hypertrophy often presents with ST-depression in the lateral leads that is a likely culprit.

Let's add the depth of the S-wave in lead V2 with the height of the R-wave in lead V5 (or V6 — they're both about the same). Is the result equal or greater than 35 mm?

Yes!

You don't need calipers for this because it doesn't have to be perfect. 35 mm is 7 large blocks so eye-ball it. The S-wave in lead V2 is at least 4 large blocks deep (it's actually more than 5 but this is the "fast and dirty" method) and the R-wave in lead V6 is at least 3 large blocks in amplitude. That's greater than 35 mm so you've met the criteria.

There are other criteria for LVH but this is the most important for ruling out STEMI mimics because LVH is usually an anterior STEMI mimic so the most important issue here is the depth of the S-waves in the right precordial leads (V1-V3). With a "strain pattern" the deeper the S-waves the more pronounced the secondary ST-T abnormality in the opposite direction.

Conversely, the taller the R-waves, the more pronounced the ST-depression and T-wave inversion. A lot of people talk about the shape of the ST-segments and T-waves in the presence of LVH, how it should be asymmetrical and upwardly or downwardly concave. That's ususally true but it's not always the case.

In this case the "strain pattern" is fairly modest. The ST-elevation in V1-V3 is not particularly impressive. Other times the result can be quite profound.

If you're still not clear on what a "strain pattern" is with LVH, take a look at the precordial leads. The QRS complex starts out negative in lead V1 and ends up positive in lead V6. The transition lead is lead V4 (which is equiphastic). As the QRS complex transitions from negative to positive, the T-wave transitions from positive to negative.

That's what we call a "widened QRS/T angle" which means that there is more than 100 degrees difference between the QRS axis and the T-wave axis. Let's take a look at the computerized measurements. The QRS axis is 16 degrees and the T-wave axis is 148 degrees.

To be much simpler about it, with a strain pattern positive QRS complexes have negative T-waves and negative QRS complexes have upright T-waves. (You should not include isoelectric or equiphasic QRS complexes in this analysis).

The general appearance of this 12-lead ECG is one of T-wave discordance. That's a finding that should almost always make you pause and consider that you're dealing with a secondary ST-T abnormality — in other words a STEMI mimic.

This patient received a fairly extensive workup for his near-syncope including a CT scan and nothing was found. He was discharged from the emergency department.

You can find previous posts about left ventricular hypertrophy here.

See also:

The Code STEMI Web Series comes to First Responders Network! 

Posted by on December 6, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

Code STEMI Web TV Series in South Dakota – That’s a wrap!

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I just got back from South Dakota and principal photography for the 2nd episde of the Code STEMI web TV series is complete! What an awesome time! 

We attended the 2nd Annual South Dakota STEMI Summit, visited the two major health systems in South Dakota, interviewed EMTs, paramedics, nurses and physicians, met a STEMI survivor and took in the hospitality! 

The platform for the Code STEMI web series is here. The "follow our crew" blog is here. You can find our Flickr feed with lots of "behind the scenes" images here.

Special thanks to Setla Films, Mission: Lifeline South Dakota, Avera McKennan hospital, Sanford USD Medical Center, Prairie Lakes Healthcare Sysem, Watertown Fire Department, and our sponsor Physio-Control! 

Next stop: Dearborn, Michigan!

*** UPDATE ***

Behind the scenes footage from AHA Scientific Sessions 2011 in Orlando: Mayme Lou Roettig, RN, MSN and Chris Granger, MD (Duke University and North Carolina's RACE program) talk about the critical role EMS plays in the early treatment and triage of acute STEMI patients here.

“Things are shifting more and more into paramedics playing the key role in providing the initiation of these time-dependent processes for improving care.”

Posted by on December 3, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , ,