Transcript PRE-HOSPITAL MANAGEMENT OF ST SEGMENT ELEVATION …

PRE-HOSPITAL MANAGEMENT
OF
ST SEGMENT ELEVATION
MYOCARDIAL INFARCTION
Presented by
Stanley C. Thompson, M.D.
Regional Medical Director
TEAMHealth Midsouth
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All 4 STEMI
charts for
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What will we cover?
Recognition and Diagnosis
EKG Interpretation
Management
Acute Complications
Acute Myocardial Infarction
865,000 MI’s annually (565,000 first time)
 27% of AMI’s are STEMI’s
 75% of STEMI’s have arrhythmia during
transport
 75% of deaths from AMI occur prior to
arrival to hospital
 Prognosis of STEMI has significantly
improved over the last 30 years

Kentucky 8.2%
West Virginia 8%
Louisiana 7.8%
Oklahoma 7.6%
Alabama 7.4%
Mississippi 7.4%
Arkansas 7.1%
Michigan 7.1%
Tennessee 6.9%
Indiana 6.9%
Texas 6.8%
N. Carolina 6.7%
WHAT CAUSES A
HEART ATTACK?
Signs and Symptoms of AMI

Chest discomfort, with or without radiation
to the arm(s), neck, back, jaw, or
epigastrium
 Shortness of breath
 Weakness
 Diaphoresis
 Nausea
 Lightheadedness
Risk Factors for AMI

Increased age
 Male sex
 Heredity
 Race
 Tobacco smoke
 High blood cholesterol
 High blood pressure
Risk Factors for AMI

Physical Inactivity
 Obesity
 Diabetes mellitus
 Stress
 Drinking alcohol in excess
EKG
INTERPRETATION
ANTERIOR LEADS
INFERIOR LEADS
SEPTAL LEADS
LATERAL LEADS
ANTEROSEPTAL LEADS
INFEROLATERAL LEADS
Syndromes that May Cause
STE

MI
 Acute pericarditis
 Benign early repolarization
 Left ventricular hypertrophy
 Bundle branch block
 Cardiomyopathy
 Acute myocarditis
Pericarditis
Left Ventricular Hypertrophy
Benign Early Repolarization
Right Bundle Branch Block
Left Bundle Branch Block
Syndromes that May Cause
STE

Left ventricular aneurysm
 Pre-excitation syndromes
 Hyperkalemia
 Hypothermia
 CNS events
 Acute abdominal disorder
EKG Definition of STEMI

ST segment elevation greater than or equal
to 1mm in 2 or more contiguous limb (axial)
leads or 2mm or more in two or more
contiguous precordial leads
 New bundle branch block (BBB)
A
B
C
ADVANCED EKG
INTERPRETAITONS
Right Ventricular MI
• Typically associated with inferior wall MI
• Mortality of IWMI = 6%
• Mortality of IWMI + RV = 31%
• EKG: ST elevation in V4R (100% specific)
•Very sensitive to preload (and thus nitrates)
• Complications: Hypotension, Complete AV
block, RBBB
Posterior MI

A posterior MI exists if you have ST
elevation in any of leads V7-V9.
 Can be isolated or can occur with inferior or
lateral MI (R coronary or L circumflex A,
respectively)
 Suspect when EKG shows:
– ST depression > 1 mm in V1-V3
– Tall R in V1 or V2
– Tall, upright T wave in V1 or V2
– Indications ST depression in V1-V3
15/16 Lead EKG

Right Sided EKG
– Right sided EKG leads (V1R-V6R) are
positioned in a mirror image fashion from the
standard 12-lead precordial leads
Posterior EKG
– Posterior EKG leads (V7-V9) are applied by
moving V4-V6 in the posterior positions
Pre-Hospital
Management of
STEMI
A
B
C(EKG)
Supportive Care

Most comfortable position, usually sitting
up
 Oxygen
 2 large bore IV’s
 Continuous cardiac monitoring
 Blood pressure checks at frequent intervals
 Pain relief with NTG and/or Morphine
Pre-hospital Medications
Aspirin

Clinical symptoms suspicious of AMI
 160-325mg tablet chewed
 Produces a rapid clinical antithrombotic
effect
 Contraindicated in patient with ASA allergy
and active GI bleed
Pre-hospital Medications
Nitrates

All patients with ongoing ischemic
discomfort
 Increased coronary blood flow
 Given sublingually 0.4mg tabs or 1 spray
every five minutes times three
 Contraindicated in patients with Nitrate
allergies, those on medications for erectile
dysfunction, and patient with SBP<90
Pre-hospital Medications
Morphine

Analgesic of choice for management of pain
associated with STEMI
 Reduces pain and alpha adrenergic response
secondary to pain
 2mg to 4mg IV repeated at 5 to 15 minute
intervals
 Contraindicated in pts allergic, respiratory
depression, caution with hypotension
Acute Complications
of STEMI
Arrhythmias
Ventricular ectopy (PVC’s, V-Tach, V-Fib)
 Lidocaine 1mg/kg recommended for PVC’s
 ACLS algorithms for V-Tach with or
without a pulse, and V-Fib should be
initiated
 Sinus bradycardia (HR<60) should be
treated with Atropine 0.5 to 1mg q 5min prn
max dose 3mg

D
Conduction Disturbances
 2nd
and 3rd degree heart block may occur in
either inferior or anterior MI
 3rd degree heart block rare, but can be seen
in anterior MI
 BBB usually a complication of anterior
infarcts
 Pacing may be required in 2nd degree heart
block not responsive to atropine or in 3rd
degree hearth block
E
Cardiogenic Shock

Hypotension with evidence of impaired
perfusion in setting of AMI
 Left ventricular pump failure begins to
occur when 40% of muscle mass lost
 Seen in 7.5% of AMI
 Mortalility rate of 80%-90%
 Small boluses of IVF’s 250cc-500cc
EKG Review
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