STEMI
Summary: <br> You have 90 minutes to restore blood flow. <br> <br> <br> <br> Step 1: Obtain EKG and Call STEMI Alert<br> <br> <br> <br> * This activates ED resources as well as cath lab, interventional cardiology, etc<br> <br> <br> <br> Step 2: Stop the Platelets<br> <br> <br> <br> * Dual anti-platelet therapy* Aspirin 325mg chewed (or PR)* Plavix 600mg (not usually given in ED)* Complicates management if patient needs CABG<br> <br> <br> <br> Step 3: Stop the Coagulation Cascade<br> <br> <br> <br> * Heparin 60 units/kg (MAX 4000 units)<br> <br> <br> <br> Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now<br> <br> <br> <br> * If you DON’T have cath lab* Option 1: 30 minutes to give thrombolytics* Option 2: 120 minutes to get them to a different hospital with cath lab<br> <br> <br> <br> Sgarbossa Criteria<br> <br> <br> <br> * Left bundle branch block (LBBB)* PLUS* Concordant ST elevation (>1mm) in leads with positive QRS* OR* Concordant ST depression (>1mm) in leads with negative QRS* Typically V1-V3* OR* Severely discordant ST elevation (>5mm) in leads with negative QRS<br> <br> <br> <br> “MONA”<br> <br> <br> <br> * Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain* Oxygen has been shown to worsen outcomes if given indiscriminately* Not ideal to be giving supplemental O2 when SaO2 is 100%* Nitroglycerine* Nitroglycerine 0.4 mg SL q5min* OR* Nitroglycerin 10mcg/min drip (will need to be titrated UP)* For comparison… * 0.4 mg SL nitroglycerine releases approximately 80mcg/min* Contraindications* Inferior/Right heart infarction* Patients usually preload dependent* Nitro drops preload* Sildenafil (Viagra)* Can cause sudden/severe drop in blood pressure* Hypotension<br> <br> <br> <br> Additional Reading<br> <br> <br> <br> * Round 3 – Chest Pain <a href="http://www.emclerkship.com/round-3-chest-pain/">(EM Clerkship)</a>* The Death of MONA in ACS: Part 1 – Morphine <a href="https://rebelem.com/the-death-of-mona-in-acs-part-i-morphine/">(REBEL EM)</a>* The Death of MONA in ACS: Part 2 – Oxygen <a href="https://rebelem.com/death-mona-acs-part-ii-oxygen/">(REBEL EM)</a>* The Death of MONA in ACS: Part 3 – Nitroglycerine <a href="https://rebelem.com/death-mona-acs-part-iii-nitroglycerin/">(REBEL EM)</a>* The Death of MONA in ACS: Part 4 – Aspirin <a href="https://rebelem.com/death-mona-acs-part-iv-aspirin/">(REBEL EM)</a><br>
