EMERGENCY DEPARTMENT STEMI ALGORITHM

EARLY RECOGNITION

Chest Pain (CP) Acquire 12-lead ECG <10 mins

• Patient is >18 years of age; AND • Chest pain or equivalent consistent with myocardial infarction

Yes

STEMI Identification No STEMI Not Detected

• Time from onset of current episode of pain < 12 hours; AND • Perform serial 12-lead ECGs at 15 minute intervals x3 AND
•12 lead ECG: ST elevation is consistent with an acute STEMI: continuous ST segment monitoring
- At least 2 mm in leads V1-V3 in at least two contiguous leads; OR
- At least 1 mm in at least two other anatomically contiguous leads; AND NOT • if ST segment elevation detected reassess for STEMI
- A Left Bundle Branch block (LBBB), ventricular paced rhythm; OR any other STEMI imitator (See Note 1)

Yes

STEMI Diagnosis & Initial Treatment Consult with Cardiologist

• Place on continuous cardiac monitor • Nitroglycerin 1 spray (0.4mg) sublingual PRN for chest pain. • If CP > 12 hours, consider consultation with cardiologist or
(apply defibrillator pads) May repeat every 5 minutes for a maximum of 3 sprays interventional cardiologist for patients with ongoing symptoms
• Obtain vital signs and oxygen saturation (SaO2) • Morphine IV should only be given for severe of cardiac ischemia; fibrinolysis not indicated
• Apply oxygen for SaO2 < 92% (See Note 2) chest pain unrelieved by nitro • Continue to Stabilize Patient
• Initiate peripheral IV (left arm is the preferred site) • Perform a brief targeted history and physical exam
• Administer chewable Aspirin 162mg

EARLY REPERFUSION

Reperfusion Therapy: Interfacility Drive Time < 60 MIN (see Note 3)

(Target DTBT < 120 MIN)
Yes No

Primary PCI Fibrinolysis

Transfer Immediately to PCI hospital No Assess Fibrinolytic Eligibility
Target DIDO < 30 MIN (See Fibrinolytic Eligibility, Note 5 AND 6)

• Notify PCI hospital of a “STEMI “ and

• Arrange paramedic transport urgently to PCI hospital.
Contact local CACC and notify of a “STEMI”, confirming the highest priority
Administer Fibrinolysis - Target D2N < 30 MIN
• Provide transfer of care communication and documentation (see Note 4) • If >75 years of age, consider half dose fibrinolysis
Suggested antiplatelet and anticoagulant therapy in partnership with your PCI hospital:
Antiplatelet therapy Anticoagulant therapy : Transfer Immediately to PCI hospital
(Suggest ONLY one): • According to best practice in
• Ticagrelor 180 mg PO collaboration with PCI Hospital • Notify PCI hospital of a “post fibrinolysis STEMI patient”
preferred; OR • Arrange paramedic transport urgently to PCI hospital.
• Clopidogrel 600 mg PO Contact local CACC and notify of a “post fibrinolysis STEMI patient”, confirming the highest priority
dose also reasonable; OR • Pharmacoinvasive strategy target <24HR
• Prasugrel 60 mg PO - Provide continuous cardiac monitoring. If patient has not left ED after
fibrinolytic administration repeat ECG 60-90 minutes and thereafter
1. Canadian Cardiovascular Society 2012 Guidelines update for Antiplatelet therapy; Tanguay et al. if new symptoms of chest pain or symptoms consistent with recurrent myocardial infarction
2. ACC/AHA 2013 STEMI Guidelines, O’Gara et al.
- If evidence of a failed reperfusion, arrange emergent paramedic transport to PCI hospital for rescue PCI
• Provide transfer of care communication and documentation (see Note 4)
Suggested adjunctive treatments:
Antiplatelet therapy Anticoagulant therapy
• Clopidogrel 300 mg PO • According to best practice in
(NO Ticagrelor or Prasugrel) collaboration with PCI Hospital

ADDITIONAL NOTES

ECG: Electrocardiogram Reperfusion Targets: Note 3: Factors affecting the 60 minute time Note 6: Fibrinolytic Relative Contraindications
FMC: First Medical Contact recommendation may include: (Discuss options with cardiologist at the PCI hospital
PCI: Percutaneous Coronary Intervention DTBT <90 min : primary PCI presenting directly • Partnership agreement between PCI and non-PCI hospital when there is anticipated prolonged transfer time)
DIDO: Door in Door Out to a PCI hospital from Field • External factors such as weather, road closures, etc. • History of chronic, severe, poorly controlled hypertension
CACC: Central Ambulance Communication Centre DTBT <120 min: presenting to a non PCI with transfer on presentation (Systolic Blood Pressure > 180 mm Hg or
D2N: Door to Needle Time to a PCI hospital for primary PCI Note 4: Key Clinical information Exchange to the Diastolic Blood Pressure > 110 mm Hg)
DTBT: Door to Balloon Time DIDO <30 min: transfers from a non PCI to Receiving Cardiologist or Interventional Cardiologist: • History of prior ischemic stroke > 3 months
ROSC: Return of Spontaneous Circulation a PCI hospital • Time of symptom onset • Dementia
ACR: Ambulance Call Report • Qualifying ECG (copy of ECG with patient’s name) • Known intracranial pathology not covered
D2N <30 min: when treated with fibrinolytic
• If ROSC state time in absolute contraindications
AMI: Acute Myocardial Infarction administration time
• Hemodynamic status • Traumatic or prolonged (> 10 min)
CABG: Coronary Artery Bypass Graft Pharamacoinvasive strategy <24 hr: refers to
• History of AMI/PCI/CABG cardiopulmonary resuscitation
the administration of fibrinolytic therapy either • Medications given and procedures • Major surgery (< 3 weeks)
in the prehospital setting or at a non–PCI-capable • ED records • Recent (within 2 to 4 weeks) internal bleeding
Primary PCI: Performing acute PCI immediately for the hospital, followed by immediate transfer to • Paramedic ACR, if available • Noncompressible vascular punctures
treatment of a STEMI as the primary form of reperfusion. a PCI hospital for early coronary angiography • Transfer of accountability form • Pregnancy
• Active peptic ulcer
Pharmacoinvasive PCI: A planned PCI after Note 1: STEMI Imitators: Note 5: Fibrinolytic Absolute Contraindication • Oral anticoagulant therapy
fibrinolysis. Direct transfer to the cath lab is already • Left bundle branch block (LBBB) • Any prior intra cranial hemorrhage
planned at the time of fibrinolysis. The transfer to the • Ventricular paced rhythm • Known structural cerebral vascular lesion
PCI Hospital is not dependent on the response to the • Pericarditis/Myocarditis (e.g. arteriovenous malformation)
fibrinolysis therapy. • Left ventricular hypertrophy (LVH) • Known malignant intra cranial neoplasm
• Brugada syndrome (primary or metastatic)
Rescue PCI: The emergent transfer post fibrinolytic • Benign early repolarization • Ischemic stroke within 3 month EXCEPT acute
administration for PCI as a mode of reperfusion after ischemic stroke within 4.5 hours
known fibrinolysis failure as evidenced by any of the Note 2: Supplemental Oxygen Administration • Suspected aortic dissection
following: • Oxygen therapy is appropriate for patients who are hypox- • Active bleeding or bleeding diathesis
Persistent or recurrent ST elevation on 12-Lead ECG emic (oxygen saturation <90%) and may have a salutary pla- (excluding menses)
cebo effect in others. Supplementary oxygen may, however, • Significant closed-head or facial trauma within 3 months
•Persistent or recurrent chest pain
increase coronary vascular resistance. Oxygen should • Intracranial or intraspinal surgery within 2 months
•Hemodynamic instability
be administered with caution to patients with chronic
obstructive pulmonary disease and carbon dioxide retention. Produced 2016 by Cardiac Care Network