EM025

Emergency Medicine - ST Elevation Myocardial Infarction: Assessment

P1

STEMI Definition: Symptoms suggestive of an acute myocardial infarct accompanied by ECG changes as below: ST elevation > 2mm in two adjacent chest leads OR ST elevation > 1mm in two limb leads OR Presumed New LBBB OR Criteria for Posterior MI STEMI is a time-sensitive diagnosis: TIME = MUSCLE The GOAL is to save heart muscle by preventing an infarct or limiting its size AIM FOR: Door to Needle Time (Thrombolysis) < 30 min Door to Balloon Time (PCI) < 90 min Use a Standard ACLS approach Assess-Intervene-Reassess Assessment and Management occur in tandem D-MIST handover from EMS TRIAGE using SATS tool Known Diabetic - Check Glucose Measure and Record Vital Signs Chest Pain or SOB - Immediate ECG and check Sats CALL DOCTOR TO REVIEW THE ECG Examination: Primary: Assess ABCs then Secondary Head-to-Toe Examination Specifically for STEMI: Screen for: cardiac failure or cardiogenic shock Feel pulse for arrhythmias Exclude other causes of chest pain: Pneumothorax; Pneumonia; Dissection; PE SAMPLE History: Symptoms: Chest Pain; SOB; Diaphoresis; Nausea; Collapse (Beware of silent MI in elderly; DM; Females) Allergies. Medications - Check Adherence. Past Medical History: DM; IHD; HTN. Contraindications to thrombolysis Last Meal. Events surrounding illness INVESTIGATIONS: ECG. CXR. FBC/CUE. Troponin 6 hrs post onset of pain. Indications for Thrombolysis (All 4 Criteria must be met) Clinical picture of imminent MI (Chest pain/SOB/acute LVF) AND Pain/Symptoms onset within 6hrs (Consider within 12hrs if pain persists or there are hyperacute ECG changes) AND ECG shows new changes suggestive of AMI AND No contraindications Relative Contraindications Thrombolyse if onset of pain within 3 hours, imminent damage is extensive or balloon angioplasty is not available Recent internal bleeding (eg PUD) Surgery/Significant trauma < 4 wks Major surgery within 4 wks Other life-threatening illness (RF/Ca) Increased risk of bleeding (Elderly/Severe Anemia/RF/Known Thrombocytopaenia/Severe Sepsis) Prolonged Resuscitation Anticoagulant therapy - Give VitK first Hypertension (SBP > 180; DBP > 100) Treat this then thrombolyse Absolute Contraindications Do Not thrombolyse Strong suspicion of aortic dissection Pericardial tamponade Active GI/internal bleeding Brain tumour, AVM, aneurysm Ischaemic stroke < 6 mnths (not TIA) Previous intracranial bleed Intracranial procedure or Head trauma < 3 weeks Severe known bleeding disorder

Drafted 2010; review January 2013 ref: Rosens Emergency Medicine 7th ed. Tintinalli. 4th ed. AHA/ECC guidelines 2010.

EM025

Emergency Medicine - ST Elevation Myocardial Infarction: Management Stabilise ABCs 100 % O2 Establish IV access Continuous ECG monitoring with Defibrillation capabilities Initial Treatment Aspirin 300 mg PO stat Clopidogrel 300 mg PO stat Contraindications Allergy On warfarin. Planned PCI

P2

GTN for pain/HTN/CCF SL GTN 1 tablet or spray prn Titrate IV Tridil: 50mg in 200ml N/S, start 5ml/hr Oral B Blocker within first 24 hours DOOR TO NEEDLE TIME 30 min

RV Infarction. Taking Viagra. Hypotension CCF. Hypotension. Asthma. Heart Block DOOR TO BALLOON TIME 90 min

Review ECG and Thrombolysis Criteria

Meets criteria for Thrombolysis (STEMI) Specific Indications for Primary PCI? 1. Extensive anterior infarction 2. Infero-Posterior Infarct with associated RV infarct 3. Acute pump failure 4. Cardiogenic shock Long time interval between onset of pain and treatment No Yes

Does not meet criteria for Thrombolysis

STEMI BUT absolute contraindications to thrombolysis Consider Primary PCI

UAP or NSTEMI Follow separate protocol

Primary Balloon Angioplasty (PCI) This is the superior treatment to thrombolysis for STEMI in all situations HOWEVER availability and provision of 24 hour cardiology cover remains a problem in RSA Should be performed within 90 minutes Time = Muscle In our setting it is often more appropriate to thrombolyse the patient due to time constraints

IMMEDIATE THROMBOLYSIS Take informed consent if possible noting risks: - Intracranial Haemorrhage 1-2 % (usually within 24 hrs) - Other haemorrhage 5-10 % (usually within 12 hrs) - Hypotension - Allergic reactions

STREPTOKINASE REGIMEN Insert 2 large bore IV lines Administer 1.5 million IU over 1 hour IV No heparinisation If Hypotension: Bolus IV N/S and lower head of bed If allergic reaction: Stop infusion. Give antihistamine IV phenergan and steroids IV hydrocortisone. Restart cautiously. Thrombolysis must be completed before transfer Monitor at facility for 1 hour before transfer to another hospital - Assess for reperfusion at 90 minutes

FOR PCI - Transfer Review Efficacy of Thrombolysis at 90 minutes Reperfusion is suggested by: Improved chest pain Rapid normalisation of ST segments (halved in 90 min) Reperfusion arrhythmias Early but short lasting rise in serum markers (8-12hrs) Successful Reperfusion: Transfer (ALS practitioners) to secondary level facility Unsuccessful Reperfusion Rescue Balloon Angioplasty PCI Metro East: Call Tygerberg Hospital Cardiology 021-938 4911 Metro West: Call GSH Cardiology C26 021 - 404 2020

Drafted 2010; review January 2013 ref: Rosens Emergency Medicine 7th ed. Tintinalli. 4th ed. AHA/ECC guidelines 2010.