Overview of AHAECC Guidelines

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• Overview of AHA-ECC Guidelines

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• Goals of Prehospital Treatment
• Rapid assessment and recognition of ACS
• Includes detailed history of pain and risk
  factors
• Appropriate treatment of presenting S S
• O2, ASA,ECG, IV, nitrates
• Acquisition of 12 lead ECG
• Fibrinolysis when indicated
• Triage to a PCI centre when indicated
• Rapid transport and continued treatment

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Patient

• Past Practice
• New Guidelines
• No previous NTG Rx
• Previous NTG Rx
• Public Education
• Media
• Primary care physician

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Transport

• Access to 911
• Patient Assessment
• Prehospital 12 Lead
• Prehospital fibrinolysis
• Hospital pre-notification
• Direct to PCI

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Patient Presentation 33 of patients with
confirmed MI present with S S other than chest
discomfort This group compared with those that
present with chest discomfort are

• Longer delay to assessment (8 v 5)
• Less likely to be diagnosed (22 v 50)
• Less likely to receive treatment (25 v 74)
• Most likely to die (23 v 9)

• Likely to be older (74 v 67)
• Women (49 v 38)
• Diabetic (33 v 25)
• Prior heart failure (26 v 12)

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STEMI Complications

• Cardiogenic Shock
• Pulmonary Edema
• Symptomatic Tachycardia
• Symptomatic Bradycardia
• Cardiac Arrest / ROSC
• Reperfusion arrhythmia's

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• Killip Classification
• A clinical estimate of the severity of LV
  dysfunction in the treatment of AMI
• Class 1 No heart failure. No clinical signs of
  cardiac impairment
• Class 2 Heart failure. Diagnostic criteria
  include rales, S3 gallop
• and pulmonary venous
  hypertension with PE up to half of
• lung fields
• Class 3 Severe heart failure. PE with rales in
  all lung fields
• Class 4 Cardiogenic shock. Hypotension (sys lt
  90) and evidence
• of peripheral vasoconstriction
  cyanosis and diaphoresis

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In Hospital

• Standard Protocols
• CODE STEMI
• Choice of Treatment
• Fibrinolysis
• PCI

D N 30 minutes D B 90 minutes
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• Management
• Several issues should be considered in selecting
  the type of reperfusion therapy
• Time From Onset of Symptoms
• Risk of STEMI
• Risk of Bleeding
• Time Required for Transport to Skilled PCI
  Laboratory

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• Management
• Routine Measures
• O2
• NTG
• MS04
• ASA
• Glycoprotein IIb/IIIa inhibitors
• ACE inhibitor
• Angiotensin receptor blocker
• Anticoagulants
  
• Beta-blockers

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Reperfusion

• Fibrinolysis
• Most common drug is TNK
• PCI
• Primary
• Rescue

D N 30 minutes D B 90 minutes
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• Definitions
• Thrombolysis in Myocardial Infarction (TIMI)
• TIMI 0 refers to the absence of any antegrade
  flow beyond a coronary occlusion
• TIMI 1 flow is faint antegrade coronary flow
  beyond the occlusion, although filling of the
  distal coronary bed is incomplete
• TIMI 2 flow is delayed or sluggish antegrade flow
  with complete filling of the distal territory
• TIMI 3 flow is normal flow which fills the distal
  coronary bed completely

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Fibrinolysis

A proteolytic enzyme that is formed from
plasminogen in blood plasma and dissolves the
fibrin in blood clots.
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• Figure 16. Effect of fibrinolytic therapy on
  mortality according to admission
  electrocardiogram. Patients with bundle-branch
  block (BBB) and anterior ST
• segment elevation (ANT ST Elevation) derive the
  most benefit from fibrinolytic therapy. Effects
  in patients with inferior ST-segment elevation
  (INF ST Elevation) are much less, while patients
  with ST-segment depression (ST DEP) do not
  benefit.
• Reprinted with permission from Elsevier
  (Fibrinolytic Therapy Trialists' Collaborative
  Group. The Lancet 1994343311-22) (156).

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• Definitions
• Primary PCI
• Direct to cath-lab without fibrinolysis
• Rescue PCI
• In other patients who do not exhibit clinical
  instability, PCI may also be reasonable if there
  is clinical suspicion of failure of fibrinolysis.
  

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• A common reperfusion dysrhythmia is accelerated
  idioventricular rhythm (AIVR)
• AIVR essentially is just a slow wide-complex
  rhythm ("slow VT", HRlt100).
• It usually causes no symptoms
• or hypotension, is benign, and doesn't need
  treatment.

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Nallamothu et al. 357 (16) 1631, Figure
1     October 18, 2007 NEJM
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Pre-Hospital 12 Lead

• History and physical exam
• Patient 40 kg has signs and symptoms of cardiac
  ischemia? Do a 12 lead ECG
• ZOLL software will interpret findings
• STEMI positive ECG Acute MI
• STEMI negative ECG All other statements

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ZOLL Software

• ZOLL E-series comes with build in software that
  will interpret 12 Lead ECG,
• when Acute MI is displayed
• High specificity (98 )
• time that Acute MI on the Zoll
  printout is a STEMI
• Low sensitivity (75 )
• of all STEMIs that are recognized by the Zoll
  software
• Software misses up to 25 of the cases, it may
  identify these ECGs as e.g.possible anterior
  MI

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Is it a STEMI or not???

• YES if the ZOLL E-series states
• ACUTE MI
• NO if the ZOLL E-series states any other
  statements including the following
• ST ELEVATION CONSIDER INFERIOR INJURY OR ACUTE
  INFARCT
• ST ELEVATION CONSIDER ANTEROLATERAL INJURY OR
  ACUTE INFARCT
• ST ELEVATION CONSIDER INFEROLATERAL INJURY OR
  ACUTE INFARCT
• MARKED T WAVE ABNORMALITY, CONSIDER ANTERIOR
  ISCHEMIA
• ANTEROSEPTAL INFARCT, POSSIBLY ACUTE
• ST ELEVATION CONSIDER ANTEROLATERAL INJURY OR
  ACUTE INFARCT
• MARKED ST ABNORMALITY, POSSIBLE INFERIOR
  SUBENDOCARDIAL INJURY

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12 Lead ECG Documentation

• ACR code 313
• Document ZOLL interpretation
• STEMI positive ECG
• STEMI negative ECG
• Document your interpretation
• Agree
• Note ST elevation, identify which leads (if any)
• Disagree
• Note ST elevation, identify which leads (if any)

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ACR DOCUMENTATION

• Sample 12 Lead Documentation

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ACR DOCUMENTATION

• Sample Fibrinolytic Documentation

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STEMI positive ECG

• Contact CACC to place patch
• CTAS 1

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STEMI negative ECG

• Repeat ECG times 2 en-route if symptoms persist.
• Second ECG in the back of the ambulance prior to
  leaving the scene
• Third ECG at ED arrival BEFORE opening the doors

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What is essential when running DOPAMINE?

• Monitor VS Q 5 minutes
• Titrate to BP and or HR
• A patent IV line, Dopamine will cause local
  necrosis with infiltration.

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• Cardiogenic shock
• Patient with STEMI positive ECG
• (Acute MI) and Systolic BP lt90 mmHg
• Fluid therapy 10 ml/kg titrate to Systolic BP 90,
  reassess chest sounds and BP Q 250 ml.
• If patient develops crackles, or after complete
  fluid bolus of 10ml/kg and has Systolic BPlt90,
  initiate Dopamine therapy.
• Begin at 5 ug/kg/min and increase by 5 ug/kg/min
  every 5 minutes, if required, to achieve a
  Systolic BP of 90 mmHg (20ug/kg/min maximum)

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Future Goals

• Transmission of 12 Lead ECGs to receiving ED,
  PCI lab, BHP
• Direct triage to primary PCI Center
• Trillium Mississauga

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What we can promise.

• That the approach to STEMI patients will be a
  dynamic process, with guaranteed changes over the
  next few weeks, months and years.

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• Thank you