STEMI Redux

The call is for a “heart attack.”

We get dispatched to “heart attacks” fairly often. “Heart attack” is a layman’s way of describing chest pain or stroke or cardiac arrest. It could be anything really. We sometimes even get called for heart attacks in doctors’ offices and it turns out not to be a true heart attack, but some just version of chest pain.

But there is a difference this time. The location of the call is a cardiologist’s office.

“This is going to be a STEMI,” I tell my partner as he hits on the lights. “And I bet they are going to want us to go right to the cath lab.”

I wrote about a similar experience with this office a number of years ago in cath lab, when I lamented that a golfing buddy of a cardiologist could go right from the field to the cath lab, but any regular Joe had to go to the ED where I would have to persuade a doctor to look at my ECG, and then he would have to call a cardiologist to convince him to open the cath lab.

But as my last post STEMI Alert shows, there has been progress in recent years. We can now activate the cath lab from the field. We are still required to go to the ED where the patient gets registered, a hospital 12-lead is done, any appropriate care we haven’t already done is started (such as giving Plavix or starting heparin), and the patient signs the consent form for the procedure.

Sure enough, when we arrive we are led down the hall to the last room where a 12-lead machine is spitting out an ECG. I can see the ST elevation from the doorway. The doctor tells me the patient – a 65-year-old female is having an acute anterior MI. When I ask what medicine she has already gotten, he tells me they have given her aspirin and NTG.

“Are we going to the ED or…?” I ask.

“Right to the cath lab. Dr. Blank is waiting for him in cath lab # 2.”

And it is off to the races. While we transfer her over to our stretcher, the doctor gives her some plavix. Then we are out the door, back in the ambulance and on our way.

Our normal procedure is to call the ED with a STEMI alert. This time I just call and say I am en route from (I name the cardiologist’s office) with an acute STEMI going directly to the cath lab. Can they have someone from the ED meet us at the door and escort us up? I know where the cath lab is, but there are some locked doors that you need an ID swipe to enter.

heart1

I manage to put the patient on oxygen, get a set of vitals, do a 12-lead of my own, and put in an IV and start to run fluid (Her BP is in the 90’s, which she says is low for her), while getting a cursory history (none, she says) on the way in. We talk about what is happening to her – she has a blocked artery in her heart and what they are going to do to open it up – insert a balloon. She is intelligent and has some medical background. When I start to explain why I am putting on the defib pads, she shakes her head and says, “I don’t even want to know.”

She tells me she started feeling badly about an hour earlier so she called her cardiologist (she had to have some history, but I didn’t have time to get into it) and made an emergency appointment. While I wish she had called 911 instead of the cardiologist, at least they recognized what was going on right away and they have the pull to get her right into the cath lab. No need for my interpretation or a stop in the ED.

Our guide from the ED meets us at the door and clears our way up to the cath lab, where we transfer her to their table as the cardiologist holds out a clipboard with the consent form on it.

Instead of staying to watch the procedure this time, I go back downstairs and write up my run form. When I return to the cath lab, while the patient is still on the table, I learn the balloon has been inflated. The blockage is now clear. The stent is in. And the patient is doing well. The patient had a 100% occlusion of the Left Anterior Descending Artery (the LAD) — also know as the Widow Maker, or in the case of female patients, the Widower Maker.

Door-to-balloon time is 28 minutes and 911 call-to-balloon is 60.

Using the STEMI I did the other day as a comparison, bypassing the ED saved 7 minutes.

While these were special circumstances (the patient coming from the cardiologist’s office), I am hopeful that we can build on calls like this one to the next logical step for our area – joining some other progressive areas in the country in making field to the cath lab the routine rather than the exception.

11 Comments

  • Chad says:

    LAME

    Where is the part about treating this pt with this anterior/septal STEMI? High flow 02. How bout an inch of ntg paste, 3 sbl ntg’s each 5 min a part with bp’s in between and a pain scale after each admin. I don’t know maybe 5mg of Morphine to start. Did this pt get to the Cath Lab pain free? If you did a 12 lead and ruled out Right Ventricular MI then why didn’t you go nuts on treating this pt?

  • RobertB says:

    NTG and MS for a patient with a systolic of 90 ? I don’t think so…..

  • medicscribe says:

    Chad-

    Thanks you for your comments. NTG for this patient was contraindicated because her pressure was now in the 90’s, which she said was low for her. Our regional protocols prohibit NTG if the patient’s pressure is less than 100. Also, as you must know from ACLS, NTG is contraindicated in chest pain patients if their BP has dropped 30 mm Hg below their baseline. If our region permitted NTG for BPs in the 90’s I still would have withheld it because her baseline was higher than 120. Additionally the patient was not complaining of pain, just a mild discomfort. (She answered 0 when I asked the pain scale.) All studies show that NTG makes no difference in morbity or mortality in chest pain. One of the dangers of NTG is dropping the patient’s pressure to a point where they cannot recieve drugs like beta blockers that do have an influence in their outcome. With regard to NTG paste, we are not big fans of it due to its unpredicatble absorption so we no longer carry it. As far as high flow 02, again per ACLS this is not indicated in a patient who is Satting normally without respiratory distress. There are new studies coming out that show high flow 02 may be detrimental in MIs. I had her on a cannula at 2 lpm.

    The point of the post was not to dwell on routine treatment, but to talk about the difference between going to the cath lab through the ED and going straight to the cath lab.

    I’m attaching a link to the ACLS Treatment of the patient with acute coronary syndrome for your review.

    Stabilization of the Patient With Acute Coronary Syndromes

    Peter C

  • Chris says:

    I think you’re missing the point Chad. This article is about time rather than treatment.

    I too have gone straight to the cath lab. Great time saver and has done a world of good for some pt’s. Good article!!

  • Bill L. says:

    High flow O2 is debatable. Paste? BP in the 90s, no mention of CP. Why? Perhaps by the time the line was established and the patches were applied they were rolling up to the facility. MS? See above reference CP.

    Sheesh. A little rough on PC this evening.

  • Joann A. says:

    Great article! Thanks for sharing. Not much left for you to do since the cardiologist administered ASA, Plavix & NTG; IV, O2 & cardiac monitoring is really all that’s left with her current status. Makes for a great scene to cath lab time, indeed!
    Excellent work Peter.

  • Joann A. says:

    PS. Chad, it’s easy for people (such as yourself) to armchair-quarterback other medic’s calls, however it’s really lame to do so, especially since you weren’t there to know all the specifics. Show some respect…

  • Darrin B. says:

    “As far as high flow 02, again per ACLS this is not indicated in a patient who is Satting normally without respiratory distress. There are new studies coming out that show high flow 02 may be detrimental in MIs. I had her on a cannula at 2 lpm.”

    I’m just curious as I’ve heard mixed opinions on high flow O2 depending on sat, and I’m by no means questioning you on this as I’m a fairly new EMT and not a medic (although I may go for EMT-I in the somewhat near future). However, could you post some of those links to the studies or guide me in the right direction showing that high flow O2 is actually detrimental. Most of what has been drilled into my head especially in pts with cardiac issues, especially MIs is flood them with oxygen to reduce cardiac irritability due to lack of oxygen. So, I’m just curious to read as to how high flow O2 could actually be detrimental to the pt. Thanks in advance.

  • medicscribe says:

    Hi Darrin-

    Thanks for the question. Here is the citation:

    Heart. 2009 Mar;95(3):198-202. Epub 2008 Aug 15.

    Routine use of oxygen in the treatment of myocardial infarction: systematic review.
    Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M, Beasley R.

    Medical Research Institute of New Zealand, Wellington, New Zealand.

    CONTEXT: International guidelines recommend the routine use of oxygen therapy in the treatment of myocardial infarction (MI). OBJECTIVE: To undertake a systematic review and meta-analysis of randomised placebo-controlled trials of oxygen therapy in MI. DATA SOURCES: Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, EMBASE and CINHAL. STUDY SELECTION: Randomised placebo-controlled trials of oxygen therapy in MI. DATA EXTRACTION: The primary clinical outcome was mortality. RESULTS: Two of 51 potential studies met the inclusion criteria. The one study with substantive clinical outcome data reported that in uncomplicated MI, high-flow oxygen was associated with a non-significant increased risk of death (risk ratio 2.9, 95% CI 0.8 to 10.3, p = 0.08) and a greater serum aspartate aminotransferase level (difference 19.2 IU/ml, 95% CI 0 to 38.4, p = 0.05) than room air. CONCLUSION: The limited evidence that does exist suggests that the routine use of high-flow oxygen in uncomplicated MI may result in a greater infarct size and possibly increase the risk of mortality.

    PMID: 18708420 [PubMed – indexed for MEDLINE]

    Now I wouldn’t change my practice based on this one journal article. You should always follow the protocols and guidelines approved for you by your medical director, but it may give an indication of the direction science may be moving.

    I will likely do a larger post on this topic.

    A couple years ago I addressed it in this post

    http://medicscribe.com/2007/05/oxygen/

    Oxygen

    Thanks again for the question.

    Peter C

  • EMT says:

    why didn’t you go nuts on treating this pt?

    Whacker. You’re learning from a professional here. You’d be much better of reading quietly and contemplating. Hopefully you’ll learn something.

  • John says:

    Great post! Sexy 12lead (yes, I’m a sick cardiac PHREAK).

    Chad…I’m sorry, but please remove head from butt before deciding you want to insult someone who actually knows what they are talking about.

    Please remember… it is about what is doing what is *right* for the patient, not performing skills just because you can.

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