Prehospital STEMI Care

BREMSS EMS Conference

January 14-16, 2010
Definition

ST-elevation Myocardial Infarction

ST Segment
Myocardium
Infarction

Irreversible tissue injury due to

ischemia, or insufficient blood flow.
Infarct
Causes

Coronary Artery
Disease (CAD)
 Embolic
 Coronary Vasospasm
 Aortic Dissection
 Other
Pathophysiology

 Typically results from thrombosis

(clot formation) of a coronary
artery
 Usually due to spontaneous
rupture of a vulnerable
atherosclerotic plaque.
Coronary Thrombosis

Non-occlusive Occlusive
(non-STEMI) (STEMI)
Portrait
of a
Killer
How Does MI Kill?

 VT/VF
 Cardiogenic Shock
 VSD, Cardiac Rupture
 Stroke
 CHF
Diagnosis: EKG

 Characteristic changes
 Often changes on a minute-by minute
basis
 Initial tracing may not be diagnostic
 Typical progression as time passes
Firehats
Tombstones
Normal EKG
MIs Categorized by
Location
 Anterior
 Septal
 Lateral
 Inferior
 Combinations
Standard Lead Placement
Septal Anterior Lateral

Inferior Rhythm Strip

Anterior STEMI
Anteroseptal Infarct
Inferior MI
STEMI Mimics

 Pericarditis
 Early Repolarization
Treatment: Reperfusion
 “Clot-buster”
Medications
– AKA thrombolytics,
fibrinolytics

 Angioplasty
– AKA PTCA, PCI
Treatment Goals

 Thrombolytics – 30 minutes from

arrival to ED (Door to Needle)

 PCI – 90 minutes from arrival

(Door to Balloon; D2B)

NB: Non-EMS patients

Why PCI?

 Lytics are
– Widely available
– Readily delivered
– Cheaper
– No radiation
– No contrast (dye) exposure
But . . .
 PCI results in
– Less mortality
– Less reinfarction / reocclusion
– Less intracranial bleeding
– Less recurrent ischemia

 Also, 20% of patients are not eligible

for thrombolysis.
Contraindications and Cautions for
Fibrinolysis in ST Elevation
Myocardial Infarction*
 Absolute contraindications
– Any prior ICH
– Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
– Known malignant intracranial neoplasm (primary or metastatic)
– Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours
– Suspected aortic dissection
– Active bleeding or bleeding diathesis (excluding menses)
– Significant closed-head or facial trauma within 3 months

 Relative contraindications
– History of chronic, severe, poorly controlled hypertension
– Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mmHg)†
– History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology
not covered in contraindications
– Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks)
– Recent (within 2-4 weeks) internal bleeding
– Noncompressible vascular punctures
– For streptokinase/ anistreplase: prior exposure (more than 5 days ago) or prior allergic reaction to
these agents
– Pregnancy
– Active peptic ulcer
– Current use of anticoagulants: the higher the INR, the higher the risk of bleeding
ICH = intracranial hemorrhage; SBP = systolic blood pressure; DBP = diastolic blood pressure;
CPR = cardiopulmonary resuscitation; INR = international normalized ratio; MI =myocardial infarction.

*Viewed as advisory for clinical decision making and may not be all-inclusive or definitive.
†Could be an absolute contraindication in low-risk patients with MI (see Section 6.3.1.6.3.2).
2004 STEMI Guidelines
Why Are We Here?

When PCI capability is available, the

best outcomes are achieved by
offering this strategy 24 hours per
day, 7 days per week. The systems
goal should be a first medical
contact–to-balloon time within 90
minutes.

Circulation, 1/2008: Focused STEMI Update

This Is A Tall Order

 Note “medical contact” is defined as

“time of EMS arrival on scene” after
the patient calls EMS/9-1-1 or “time of
arrival at the emergency department
door” (whether PCI-capable or non–
PCI-capable hospital) when the patient
transports himself/herself to the
hospital.
BREMSS
Region
 STEMI System Hospitals
Receiving Referring
 Birmingham VAMC  Chilton Medical Center
 Brookwood  Cooper Green Mercy
 Princeton BMC  Lakeland Community
 Shelby BMC Hospital
 St. Vincent’s  St. Vincent’s Blount
 St. Vincent’s East  St. Vincent’s St. Clair
 Trinity  UAB Highlands
 UAB  UAB West
 Walker BMC
STEMI Chain of
Reperfusion
 Symptom onset
 Decision to seek medical attention
 Access medical system
 Arrive ED
 EKG
 Decision
 Notify cath lab
 Cath lab arrival
 Patient to cath lab
 PCI
Total Reperfusion Time

Scene Time 8 10
Transport Time 12 12
Door to EKG 5 -14
EKG to Decision 5 5
Decision to Cath Lab 30 30
Cath Lab/PCI Time 15 15
Total 75 58
Fundamental Equation

Minutes = Muscle
Obviously, even more time can be
saved by diverting from a non-PCI-
capable hospital to a PCI center.
Uncertain Risks
Conclusion