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

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

Patient Safety Considerations

  1. Observe for signs of clinical deterioration: dysrhythmias, CP, SOB, decreased LOC/syncope, or other signs of shock/hypotension
  2. Perform serial 12-lead EKGs (especially any time clinical changes noted)

Notes/Educational Pearls

Key Considerations

Acute coronary syndrome may present with atypical pain, vague or only generalized complaints.

Pertinent Assessment Findings

A complete medication list should be obtained from each patient. It is especially important for the treating physician to be informed if the patient is taking beta-blockers, calcium channel blockers, clonidine, digoxin, blood thinners (anticoagulants), and medications for the treatment of erectile dysfunction or pulmonary hypertension.

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914117 – Medical-Cardiac Chest Pain
  • 9914143 – Medical-ST-Elevation Myocardial Infarction (STEMI)

Key Documentation Elements

  • The time of symptom onset
  • The time of patient contact by EMS to the time of 12-lead EKG acquisition
  • The time ASA administered, or reason why not given
  • The time of STEMI notification

Performance Measures

  • The time of patient contact by to the time of 12-lead EKG acquisition within 10 minutes
  • The time from first diagnostic 12-lead EKG to STEMI notification.
  • Confirmation patient received Aspirin (taken Prior To EMS Arrival, given by EMS, or substantiated by other pertinent negatives)
  • The time of a STEMI patient’s ultimate arrival to a receiving hospital
  • *The time of EMS notification to the time of activation of a cardiac catheterization laboratory
  • *The time of arrival at the PCI center to the time of cardiac catheterization (door-to-balloon time) OR if patient not transported directly to PCI center, the time of arrival at receiving hospital to thrombolytics
  • *The time of prehospital 12-lead EKG acquisition to the time of cardiac catheterization (EKG-to-balloon time)
    • *NOTE: These measures can only be evaluated if EMS documentation can be combined with information provided by the receiving hospital

References

  1. Bosson KN, Kaji AH, Niemann JT, et al. The utility of prehospital EKG transmission in a large EMS system. Prehosp Emerg Care. 2015;19(4):496-503.
  2. De Champlain F, Boothroyd LJ, Vadeboncoeur A, et al. Computerized interpretation of the prehospital electrocardiogram: predictive value for ST segment elevation myocardial infarction and impact on on-scene time. CJEM. 2014;16(2):94-105.
  3. Meine TJ, Roe MT, Chen AY, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE quality improvement initiative. Am Heart J. 2005;149(6):1043-9.
  4. Mission: Lifeline EMS Recognition. American Heart Association. Heart.org. http://www.heart.org/HEARTORG/Professional/MissionLifelineHomePage/Mission-Lifeline-Home-Page_UCM_305495_SubHomePage.jsp. Accessed January 23, 2017.
  5. Nam J, Caners K, Bowen JM, O’Reilly D. Systematic review and meta-analysis of the benefits of out-of-hospital 12-lead EKG and advance notification in ST-segment elevation myocardial infarction patients. Ann Emerg Med. 2014;64(2):176-86.
  6. O’Connor RE, Abudulaziz AAS, Brady WJ, et al. Part 9: acute coronary syndromes. Circulation. 2015;132(18 Suppl 2):S483-500.
  7. Squire BT, Tamaryo-Sarver JH, Rashi P, Koenig W, Niemann JT. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Prehosp Emerg Care. 2014;18(1):1-8.
  8. Verbeek PR, Ryan D, Turner L, Craig AM. Serial prehospital 12-lead electrocardiograms increase identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care. 2012;16(1):109-14.