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2013 STEMI Guidelines: EMS is Accountable

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On Monday, the American College of Cardiology Foundation and the American Heart Association released the 2013 Guidelines for the Management of ST-Elevation Myocardial Infarction. Their last updates to these guidelines were in 2004 and 2006, so this is an important milestone.

If you have been following our blog and podcast, most of the changes will not be earth shattering. We have long been advocates of evidence based STEMI care, which has put us at the bleeding edge as the guidelines take time to catch up. What does this mean for you, our readers?

Our readers have been ahead of the game! We're constantly impressed by your breadth and depth of knowledge.

The 2013 guidelines makes these changes, which we've covered before, to the identification of STEMI:

The honest answer is we probably would not have written a post about these guidelines if it were not for the following gem, buried on page 10 in the section on Regional Systems of Care (emphasis mine):

"For patients who call 9-1-1, direct care begins with FMC, defined as the time at which the EMS provider arrives at the patient’s side. EMS personnel should be accountable for obtaining a prehospital ECG, making the diagnosis, activating the system, and deciding whether to transport the patient to a PCI-capable or non–PCI capable hospital."

Folks, a joint task force of cardiologists has just placed the responsibility for the diagnosis and activation of a STEMI in the hands of EMS providers!

Many systems are already ahead of the game when it comes to STEMI care, but others lag behind.

We've taken responsibility for the care of cardiac arrest victims and now is the time we acknowledge the critical role we play in STEMI care.

  • Does your system acknowledege paramedic diagnosis of STEMI?
  • Are you ready to take on the responsibility of diagnosis and activation of STEMI?
Posted by on December 20, 2012 • Filed under: ems-topics, patient-management, Training • Tagged: , , , , , , , ,

51 year old female CC: Near Syncopal Episode – Conclusion

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This is the conclusion to a 51 year old female CC: Near Syncopal Episode. If you haven't read the first part we highly recommend it!

When we left off, our crew was attending to a 51 year old female who had almost passed out in a stadium tunnel during a college football game. We received a few questions as to the type of football, which could be important to the diagnosis, so we will clarify that this was an American Football game.

Our crew had found her to be hypotensive, first bradycardic and then tachycardic, with concerning changes on the 12-Lead.  A nasal cannula at 4 L/min was initiated and they established bilateral IV's and were rapidly infusing nomal saline to restore perfusion.

Let's take a look at the initial rhythm strip:

Wouldn't Want to Miss the Big Game - Initial Rhythm

The initial rhythm strip shows a narrow complex tachycardia at ~130 bpm, without clear P-waves. Retrograde P-waves can be seen in numerous complexes T-waves, leading to a presumptive diagnosis of a junctional tachycardia.

Wouldn't Want to Miss the Big Game - Long Rhythm Strip

The longer rhythm strip shows sinus complexes followed by runs of junctional tachycardia. Astute readers will note Wenckebach conduction of the retrograde P-waves!

This finding alone would be highly concerning given our patient's present condition and history, however, when we move onto the 12-Lead her diagnosis is clinched:

Wouldn't Want to Miss the Big Game - Initial 12-Lead

The initial 12-Lead ECG again shows a junctional tachycardia, with markedly hyperacute T-waves and ST-elevation in the anterior precordials with downsloping ST-depression in the inferior leads. The degree of which the T-waves tower over the R-waves in V4 is truely impressive!

The crew immediately recognized the extensive anterior wall infarct with cardiogenic shock, and given the concurrent finding of a junctional tachycardia presumed there to be gross insult to the AV nodal tissue. They placed defibrillation pads on the patient and helped the arriving crew package the patient. The patient was able to follow commands and 324 mg aspirin was given PO. After 1 liter of fluid the patient remained hypotensive and another bolus was started. Oxygen was titrated to maintain an SpO2 of >96%.

Eventually the patient stated she had some dull pressure in her chest, but otherwise denied pain or shortness of breath. An early STEMI notification was given and while enroute to a STEMI receiving center the crew ran multiple 12-Leads, capturing the evolution of the myocardial infarction.

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 1

In this 12-Lead we can clearly see periods of alternating tachycardia and bradycardia, an ominous sign given the evolving MI. V5 and V6 were removed and adjusted closer to V4 and V7 so that defibrillation pads could be placed.

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 2

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 3

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 4

The patient was taken directly to a cath lab suite and found to have a 100% occlusion of the LAD and after the placement of a stent the patient's ECG normalized and her hypotension resolved.

This case illustrates the amazing evolution of an extensive anterior myocardial infarction and highlights the role the LAD can play in AV nodal function. We hope you enjoyed these ECG's as much as we did!

Posted by on November 18, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

76 yom CC: Shortness of breath while walking

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Here is the story.

Patient is a 76 year old male. No known medical history, no meds, excellent physical condition, walks every day.

Two days prior the patient experienced some shortness of breath while walking, but the sensation went away with rest. Approximately 30 minutes prior to EMS arrival, patient walked outside to get the newspaper, bent down, and experienced some mild chest discomfort. The patient walked back inside and felt like someone was "standing on his chest." At this time the patient's spouse called 9-1-1.

At the time of EMS arrival, the patient appears acutely ill. He is slightly diaphoretic but not overly anxious. He admits to 8/10 chest pain and mild dyspnea. He denies nausea, vomiting, or palpitations. No JVD. Breath sounds are clear bilaterally.

Vital signs are assessed:

RR: 18
Pulse: 58
BP: 155/90
SpO2: 98 on RA

The cardiac monitor is attached.

A 12 lead ECG is captured.

What now?

Let us assume for the sake of discussion that you live in a rural community.

You are 25 minutes away from your local receiving hospital (no cath lab) and 55 minutes away from a hospital in the next county over that is capable of primary PCI.

Do you bypass the local community hospital?

Should the cardiac cath lab be activated prior to your arrival?

Who makes the decision?

Posted by on February 20, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , ,