Chest pain/Coronary Syndrome/STEMI 

Assessment

Pediatric Pearls:	Signs & Symptoms:	Differential:
□ Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients.  □ Avoid ASA and nitroglycerin in pediatric patients	□ Pain, discomfort, or pressure between navel and jaw  □ “Heart racing”, “palpitations”, or “heart too slow”  □ CHF signs or symptoms  □ Syncope  □ Severe weakness if > 45 years old  □ Difficulty breathing	□ Angina vs Myocardial infarction  □ Pericarditis  □ Pulmonary embolism  □ Asthma / COPD  □ Aortic Dissection □ Pneumothorax  □ Aortic dissection  □ GI reflux / Hiatal hernia / PUD  □ Esophageal spasm  □ Chest wall injury or pain  □ Pleuritic pain  □ Overdose (sympathomimetic)

Clinical Management Options

EMT-B

• Oxygen target SpO2 92% – 96%   • Perform bilateral blood pressures, if difference between R & L arm SBP is > 20mmHg then consider aortic dissection and withhold Aspirin and Nitroglycerin  • Obtain an EKG and send the EKG to receiving hospital • If the EKG says STEMI, start transport immediately to hospital with cardiac cath ability • Aspirin  • Basic Airway Management as needed

Paramedic

• Vascular access  • Isotonic Crystalloid PRN titrated to SBP > 100 mmHg or MAP > 65  • Push dose Epinephrine for refractory hypotension  • Within 5 minutes of patient contact, 4 lead and 12 lead ECG placement and acquisition  • Nitroglycerin if SBP > 100 mmHg   • Monitor and interpretation of ECG & EtCO2 • Pain Management • EKG faxed to destination hospital if STEMI

Pearls

• Diabetics, females, and geriatric patients can have atypical pain, or generalized complaints. Consider cardiac causes for nausea, vomiting, and weakness.
• Do not administer Nitroglycerin in any patient who used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 48 hours or other PDE erectile dysfunction medications due to potential severe hypotension. 
• Avoid hypoxemia, as it can lead to increased cardiac damage.
• If patient has STEMI, or is going directly to cardiac cath, attempt to establish a second IV but do not delay transport. Transport providers need to minimize scene time to < 15 minutes whenever possible. 
•  STEMI Criteria: 
  • A STEMI/ACO Alert should be called when a patient is currently symptomatic for an acute coronary syndrome event and has new or presumably new ST segment changes: 
    • All Patients: Elevation > 1 mm in two anatomically contiguous leads (Except V2 & V3 in males) 
    • Males: V2 and V3 need 2 mm or more elevation to be concerning for STEMI/ACO 
    • Isolated ST segment depressions in V1-V4 (Posterior Myocardial Infarction) 
    • Any positive findings for Sgarbossa criteria in LBBB or Ventricular Paced patients 
    • Subtle ST segment depression for aVL (Early Inferior MI) 
    • ST Segment elevation in aVL and ST segment depression in III (High Lateral MI) 
  • Use modified Sgarbossa criteria for LBBB or Ventricular Paced patients
    • Concordant ST elevation >1 mm in leads with a positive QRS complex
    • Concordant ST depression >1 mm in V1-V3
    • ST Elevation at the J-point, relative to QRS onset, is at least 1 mm AND has an amplitude at least 25% of the preceding S-wave