Chest Pain/Acute Coronary Syndrome (ACS)/ST-segment Elevation Myocardial Infarction (STEMI)

Table of Contents

Aliases

Heart attack, myocardial infarction (MI)

Patient Care Goals

  1. Identify STEMI quickly
  2. Determine the time of symptom onset
  3. Activate hospital-based STEMI system of care
  4. Monitor vital signs and cardiac rhythm and be prepared to provide CPR and defibrillation if needed
  5. Administer appropriate medications
  6. Transport to appropriate facility

Patient Presentation

Inclusion Criteria

  1. Chest pain or discomfort in other areas of the body (e.g. arm, jaw, and epigastrium) of suspected cardiac origin, shortness of breath, sweating, nausea, vomiting, and dizziness. Atypical or unusual symptoms are more common in women, the elderly and diabetic patients. May also present with CHF, syncope and/or shock.
  2. Some patients will present with likely non-cardiac chest pain and otherwise have a low likelihood of ACS (e.g. blunt trauma to the chest of a child). For these patients, defer the administration of aspirin and nitrates per the Pain Management guideline

Exclusion Criteria

None recommended

Patient Management

Assessment, Treatment, and Interventions

  1. Signs and symptoms include chest pain, congestive heart failure, syncope, shock, symptoms similar to a patient’s previous MI
  2. Assess the patient’s cardiac rhythm – treat pulseless rhythms, tachycardia, or symptomatic bradycardia [see Cardiovascular and Resuscitation guidelines]
  3. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, EMS providers should administer oxygen as appropriate with a target of achieving 94-98% saturation [see Universal Care guideline]
  4. The 12-lead EKG is the primary diagnostic tool that identifies a STEMI; It is imperative that EMS providers routinely acquire a 12-lead EKG within 10 minutes for all patients exhibiting signs and symptoms of ACS
    1. CHEMS STEMI Criteria
    2. The EKG may be transmitted for remote interpretation by a physician or screened for STEMI by properly trained EMS providers with or without the assistance of computer-interpretation
    3. Advance notification should be provided to the receiving hospital for patients identified as having STEMI
      1. Within 5 minutes of 12 lead ECG acquisition
    4. Performance of serial EKGs is suggested when there is a change in the patient’s condition
    5. Obtain right sided and/or posterior ECGs if there is concern for right ventricle or posterior myocardial infarction
    6. All EKGs should be made available to treating personnel at the receiving hospital, whether brought in or transmitted from the field
  5. If STEMI present, place defibrillator pads on patient.
    1. STEMI patients are at high risk for ventricular dysrhythmias or high grade heart block
  6. Administer aspirin; chewable, non-enteric-coated aspirin preferred (324 to 325 mg)
  7. Establish IV access
  8. Nitroglycerin 0.4 mg SL, can repeat every 3 minutes as long as SBP greater than 100 mmHg
  1. The use of nitrates should be avoided in any patient who has used a phosphodiesterase inhibitor within the past 48 hours
  2. Examples are: sildenafil (Viagra®, Revatio®), vardenafil (Levitra®, Staxyn®), tadalafil (Cialis®, Adcirca®) which are used for erectile dysfunction and pulmonary hypertension. Also avoid use in patients receiving intravenous epoprostenol (Flolan®) or treporstenil (Remodulin®) which is used for pulmonary hypertension
  3. Administer nitrates with extreme caution, if at all, to patients with inferior-wall STEMI or suspected right ventricular (RV) involvement because these patients require adequate RV preload
  4. Transport and destination decisions should be based on local resources and system of care
    1. In the case of STEMI, follow regional Time Critical Diagnosis plan

Notes – Chest Pain/Acute Coronary Syndrome (ACS)/ST-segment Elevation Myocardial Infarction (STEMI)