STEMI

EM Clerkship

Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD

Health & Fitness, Science, Education, Medicine, Life Sciences

4.9 • 816 Ratings

🗓️ 17 July 2016

⏱️ 9 minutes

🔗️ Recording | iTunes | RSS

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Summary

You have 90 minutes to restore blood flow.

Step 1: Obtain EKG and Call STEMI Alert

* This activates ED resources as well as cath lab, interventional cardiology, etc

Step 2: Stop the Platelets

* Dual anti-platelet therapy* Aspirin 325mg chewed (or PR)* Plavix 600mg (not usually given in ED)* Complicates management if patient needs CABG

Step 3: Stop the Coagulation Cascade

* Heparin 60 units/kg (MAX 4000 units)

Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now

* 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

Sgarbossa Criteria

* 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

“MONA”

* 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

Additional Reading

* Round 3 – Chest Pain (EM Clerkship)* The Death of MONA in ACS: Part 1 – Morphine (REBEL EM)* The Death of MONA in ACS: Part 2 – Oxygen (REBEL EM)* The Death of MONA in ACS: Part 3 – Nitroglycerine (REBEL EM)* The Death of MONA in ACS: Part 4 – Aspirin (REBEL EM)

Transcript

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0:00.0	Hello, med students. This episode has been sponsored by Freed AI. Do you dread the thought of
0:07.1	endless charting once you become a doctor? Do you think that doctors should be spending more
0:11.9	time with our patients and less time mindlessly writing notes? Freed AI is the product for you. It is a
0:20.4	secure, hippocompliant scribe that anybody can use.
0:24.7	Focus your energy on what matters, providing good patient care.
0:29.5	Use coupon code EM50 to save 50% the first month you try it,
0:34.1	and you can cancel at any time if you decide it's not right for you. You can learn more
0:38.9	at www.gitfreed.a.i. Hello, med students. My name is Zach Olson. Thank you for downloading
0:49.5	this episode of the EM Clerkship Podcast. It's a beautiful morning. The sun is rising. The birds are singing.
0:57.6	You're starting your shift. Nice and relaxed. Fresh cup of coffee in your hand. Walk and pass that
1:03.8	EMS radio again. And you get a call. University Hospital's Ambulance 48 coming to you ALS with a code code stemmy, 62-year-old male, sudden onset of chest pain, rated 8 out of 10, radiating to the right arm.
1:18.9	Past medical history of angioplasty two months ago is showing ST elevation in three leads, currently pulse a 172 BP 102 over 64, respirations of 26.
1:29.6	We have them on 15 liters, O2, and is setting at 95%.
1:32.7	Aspirin and nitro on board, as well as IV established, approximately 10 minutes out.
1:42.4	Welcome to emergency medicine, guys. Are you kidding me? There is no relaxation here. My first shift as an intern. This was me. I literally walked in and my attending gave me a choice between running the code in trauma bay 2 and running a stemmy alert right next door. Today, we're choosing the Stemie.
2:03.6	ST elevation, myocardial infarction. In all of emergency medicine, stemmy is king. On your test,
2:12.9	Stemmy is king. We get hundreds of EKGs every day looking for this specific diagnosis, looking for
2:19.7	that critical pattern, and when you see it, you have to know what to do. In 2013, the American
2:27.3	Heart Association published a set of guidelines on the management of STEME, and today that is what we're going to cover.
2:36.0	But before we get into our approach, first, we need to talk about the actual diagnosis of
2:42.4	STEMI. And what you need to know is that STEMI is purely an EKG finding. You can't count on
2:50.3	elevated troponins or SKMB or anything like that. It's a
	...

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