Greater Hartford EMS Education STEMI Workbook

Greater Hartford EMS Education STEMI Workbook Welcome to The North Central Connecticut EMS Regional STEMI Care Training Program on CT Train. After you have read this workbook, please refer to the email you received for instructions on how to complete the course and assessment for Train Connecticut. Thank you and Good Luck!

Greater Hartford EMS Education STEMI Workbook 2

Hartford Mission: Lifeline STEMI Systems Accelerator Project The American Heart Association (AHA) has partnered with the Connecticut Department of Public Health and Duke Clinical Research Institute on an exciting 18-month project to improve STEMI care in the Greater Hartford Region. Hartford is one of 20 sites across the region that is part of a national efeffort for focused improvement in the area of heart attack systems of care. The Hartford Mission: Lifeline STEMI Systems Accelerator project kicked off on January 18 th, 2013, and included participation from area EMS Agencies and representatives from 14 regional hospitals. This project builds upon the AHA s Mission: Lifeline Program, which refines systems of care for the STEMI patient by engaging multiple entities (i.e., EMS, STEMI referring hospitals, and STEMI receiving hospitals) within the same geographic region. An important aspect of this Mission: Lifeline project is to examine how prehospital STEMI systems of care in Hartford can be improved. Goals for this project include: Improved transfer times between hospitals More timely activation of cath-labs prior to patient arrival Increased speed of reperfusion Implementation of systematic process for the collection of critical patient care data More accurate and consistent feedback to hospital staff and EMS on patient outcomes and performance STEMI Care Exam on TRAINConnecticut The North Central Regional Medical Advisory Committee, in an effort to improve STEMI care, is requiring, as a condition of medical control, all paramedics in the region to review this STEMI workbook and then take a short test on line at TRAINConnecticut, an online exam site sponsored by the Connecticut Department of Public Health. Paramedics will have until the end of 2013 to complete the test. The test can be accessed at : https://ct.train.org Paramedics will have to create an account to take the exam. There is no cost involved. Beginning in 2014, the region will also require as a condition of medical control,that paramedics either take an approved 12-lead class every two years or demonstrate competency in 12-lead interpretation by completing a 12-lead exam that will also be posted on CT Train. 12-lead interpretation and acquisition will also be a required station at all regional skill sessions starting in 2014. 3

STEMI Care EMS Education Workbook: Educational Objectives According to the guidelines presented in the Hartford EMS STEMI Workshop, the provider will be able to properly: 1. Identify all patients who require 12-Lead ECG analysis 2. Perform a 12 lead EKG, specific to manufacturers recommendations 3. Appreciate the importance of correctly performing a 12 Lead EKG 4. Justify the importance of rapid ECG analysis with the ACS patient 5. Interpret EKG waveform changes that identify a patient with an ACS 6. Interpret the three common types of STEMIs. 7. Discriminate between the common STEMI Imposters 8. Discuss the role and limitations of 12 lead computer interpretation with STEMI recognition 9. Assess and discuss the STEMI Alert system 10. Specify the criteria for activation of a STEMI ALERT 11.Demostrate proper radio communication for the STEMI Alert 12. Defend the importance of doing serial 12-leads 13. Define the proper receiving hospital capabilities needed for STEMI patient 14. Analyze the required steps needed for prompt cardiac catheterization lab access 15. Perform proper EPCR entries in relation to the STEMI patient 4

Introduction A ST Segment Elevation Myocardial Infarction (STEMI) is caused by an acute occlusion of a coronary artery. With blood flow impeded, cardiac tissue beyond the affected artery begins to die. Since the dying tissue no longer conducts electricity, a distinctive shape is produced on the ECG. Specific EKG changes used in combination with the patient s history and presentation are used to diagnose the STEMI. This is a true medical emergency, with the patient at risk for sudden cardiac death. Perfusion must be restored to the heart and precious heart muscle is lost with every moment of ischemia. While fibrolytic drugs can be used to try to break up the occlusion, the preferred method is percutaneous coronary intervention (PCI) performed in a cardiac catheterization lab. In the procedure a catheter is guided into the heart either via the groin or the wrist. When the wire crosses the lesion, a balloon is inflated clearing the occlusion and restoring blood flow. The area is subsequently often stented to ensure continued flow. The door-to-balloon time (DTB) is the time the patient enters the hospital to the moment the balloon is inflated in the affected artery. The American Heart Association national goal is 90 minutes or less. The sooner the patient s heart is reperfused, the better their chances for survival and the less damage to the heart muscle. Every minute counts. Currently, nationwide, less than half of all patients with STEMIs have a DTB of 90 min or less. The EMS Role When EMS recognizes a STEMI in the field, and notifies the hospital either by radio patch or transmission, the cath lab can be activated prior to the patient arrival. With enough notification, the patient can often go directly to the cath lab on the EMS stretcher. This single intervention has lead to a marked decrease in door-to-balloon time and improvement in patient outcome. Hospitals in the region now regularly have had door-to-balloon times under 60 minutes and as low as 19 minutes. The American Heart Association, recognizing the role EMS can play, has established a new goal of first medical contact-to balloon time of 90 minutes. (First medical contact is defined as arrival of the first health care provider at the patient s side.) Our goal in the Hartford area is to achieve this first medical contact-to-balloon time of 90 minutes or less. EMS Benchmarks To measure our success, data will be collected on the following performance measures; 1. Paramedic Contact-to-12 Lead: Obtain 12-Lead, appropriately interpret or transmit to physician for interpretation < 10 minutes after first patient contact: Goal 100% 2. Received ASA, per NCEMS Council Guidelines: Goal 100% 3. First Medical Contact-to-Balloon Time <90 Minutes: Goal 100% 4. STEMI Alert called: Goal 100% (Ideally within 10 minutes of patient contact). 5

Importance of Early 12-Lead ECG The initial step of STEMI treatment is achieving the early ECG in patients who have symptoms of acute coronary syndrome (ACS) or patients at risk for ACS. When responding to medical emergencies or known chest discomfort calls, the paramedic needs to have an ECG monitor with them upon initial patient contact. **The goal is to capture the 12-Lead ECG as soon as possible upon first patient contact** To optimize STEMI care: A high quality diagnostic ECG is produced by ensuring proper lead placement. EMS crews need to prepare the skin for lead placement by shaving the chest or using alcohol pads if necessary. Ensure pads are secured in the proper anatomic locations and ask your patient to remain as still as possible during the capture of the 12-Lead ECG. Once a STEMI is recognized, immediately notify the hospital with a STEMI ALERT. Transmit 12-Lead if capable. Do not delay transport once a STEMI has been identified unless destination is unclear. EMS is the dispatcher for the ED and cardiac cath lab when it comes to STEMI care! 6

STEMI Care: Decreasing First Medical Contact -to-balloon Time Time is critical when a patient is suffering a heart attack. Every minute saved between symptom onset and unclogging a blocked artery decreases the likelihood of death and disability. Here are ways EMS can contribute to shortening time-to-balloon: Acquire an early 12-lead ECG on any patient suspected of Acute Coronary Syndrome. Acquire the 12-Lead as soon as possible at first contact with patient. If possible, transmit the 12-lead as soon as possible. It is acceptable to transmit prior to patching. Whether you have the ability to transmit 12-leads or not, EARLY NOTIFICATION is crucial. When requesting a patch, ask CMED for Medical Control for a STEMI Alert. Confirm Medical Control (ask the doctor to identify themselves) and state that you are calling a STEMI Alert or a Possible STEMI alert. If possible, disrobe the patient above the waist and put on a hospital gown. This will facilitate doing 12-leads ECGs and further care. Consider disrobing the patient below the waist including removing shoes to allow for quicker access to the groin if needed for cannulation. Consider attaching defib pads to all STEMIs patients. These patients can be at immediate risk for cardiac arrest. Transport rapidly and safely. If the cath lab is ready for the patient upon your arrival, the hospital may triage you directly to the cath lab. EMS is the dispatcher for the ED and cath lab when it comes to STEMI Care. Notification from 30 minutes out while still in the patient s house is preferred to calling from 2-3 minutes away from the hospital. Early notification saves crucial minutes off a patient s door time to balloon and can result in better outcomes. 7

Who Gets A 12-Lead ECG? Any patient suspected of acute coronary syndrome, including any of the following (but not limited to): Chest pain, pressure or discomfort Radiating pain to neck or left arm. Also right arm, shoulder or back Dyspnea CHF Cardiac Arrhythmias Syncope/near syncope Profound weakness Epigastric discomfort Hyperglycemia in diabetic patients Sweating incongruent with environment Nausea, vomiting Previous cardiac history or other cardiac factors Presence of other anginal equivalents Overdoses Altered Mental Status Patients with Return of Spontaneous Circulation (ROSC) postcardiac arrest. Cast a wide net with your 12- leads. The few minutes it takes to do a 12-lead can be life-saving for STEMI patients, particularly those with atypical symptoms, who might otherwise go unrecognized. 8

12-Lead ECG Proper Lead Placement Proper technique and lead placement is essential to getting an accurate 12-Lead ECG. When monitoring the heart s rhythm, the position of electrode doesn t matter as long as you are getting a good signal. When looking at the condition of the heart, the position of the electrodes is crucial. Electrodes should be applied to the limbs (preferably the ankles and wrists), and the chest leads should go as follows: V1 Fourth intercostal space to right of sternum V2 Fourth intercostal space to left of sternum V4 Fifth intercostal space, left midclavicular line V3 midway between V2 and V4 V5 level with V 4, left anterior axillary line V6 level with V4 left midaxillary line. In female patients, place under the breast, never on the breast. Lay the patient in a position of comfort, preferably supine. Limb leads may be placed on the torso if amplitude is low, but they should be placed as close to the limb as possible. The arm electrodes should be above the level of the deltoid and leg electrodes should be below the level of the umbilicus. Caution: Poor torso positioning may obscure an inferior MI. 9

ECG Acquisition Pearls: Properly prepare skin. If skin is hairy, use a razor to shave at the electrode site. If skin is oily, use alcohol wipe to clean, then dry area. Electrode gel starts drying out as soon as you take it out of the package. The drier the gel, the poorer the conduction. If your monitor doesn t seem to be working, it may be the electrode gel is dried up. Keep electrodes sealed if possible. Have the patient lie as still as possible. Even slight motion can distort a 12- Lead. Other causes of interference are unstable cables and trying to do an ECG while traveling on bumpy roads. If needed, have your partner pull briefly to the side of the road to acquire a clear ECG. 12-Leads are about change. Don t change electrode positions and then compare the new 12-lead to the old 12-lead. The comparison will not be valid. The ECG below shows a wandering baseline caused by patient movement, resulting in an inaccurate computer interpretation. 10

The ST segment of an ECG represents the systolic depolarization of the heart s left ventricle. When the heart is damaged, its electrical and conduction abilities change producing an aberrant complex. ST elevation in the setting of suspected acute coronary syndrome is often caused by an occluded coronary artery. These patients are critically ill and need rapid cardiac catheterization at a primary percutaneous coronary intervention (PCI) center to clear the blockage and restore perfusion to the wounded heart EMS s ability to recognize these patients, obtain a diagnostic 12- lead ECG, and convey that information either by phone and/or transmission to the ED of a PCI center is crucial to preserving heart muscle and preventing mortality. 11

Contiguous Leads Contiguous leads view the same area of the heart. For instance Leads II, III, and avf all view the inferior wall of the heart, and are considered contiguous. Lead I and avl view the lateral wall and are considered contiguous. Chest leads that are next to each other are also considered contiguous. For instance, V4 and V5 are contiguous. ST Elevation should be present in two or more contiguous leads. The chart below highlights leads that are considered contiguous. 12

STEMI Definition for Field Activation STEMI is identified by ECG of good quality with all of the following: ST elevation in 2 or more contiguous leads of >2 mm (V1-V4 ) or > 1 mm (limb or lateral) QRS duration < 0.12 second ***Acute MI*** or equivalent prints on 12-lead and paramedic agrees. If the machine does not read ***Acute MI*** but the paramedic still strongly believes the ECG shows a STEMI, the paramedic may proceed with the activation request. 13

Acquire Serial 12-Leads Acquire serial 12-leads on all patients with suspected Acute Coronary Syndrome. STEMIs are often evolving and are not present on early EKGs. The STEMI may not appear until multiple EKGs are done or the STEMI captured on the 1 st 12-lead may disappear by arrival at the ED. A pre-hospital 12-lead documenting the transient elevation is critical to the in-hospital care of these patients. Note these two 12-leads captured 7 minutes apart on the same patient. A single 12-Lead would have missed the emerging inferior STEMI. The American College of Cardiology/American Heart Association for the management of patients with STEMI recommends serial ECGs in the ED at 5- to 10-minute intervals if the initial ECG is not diagnostic for STEMI but there is a high clinical suspicion. Paramedics should (at a minimum) do a 12-lead on first patient contact, on beginning transportation and on arrival at ED. 14

Computer Interpretation Paramedics should not diagnose STEMI based solely on 12-lead computer interpretation. While the interpretation can by used to support your diagnosis, the computer is not infallible. The computer will not read all STEMIs as ***Acute MI Suspected***. And the computer may read ***Acute MI Suspected*** when the ECG is clearly not a STEMI. The computer is less accurate with wide complex and tachycardic rhythms. It is estimated by some that the computer may miss up to 40% of STEMIs. Here is an example of an anterior STEMI that was missed by the computer. The computer can often miss hyperacute T waves the earliest sign of an emerging STEMI. Here is an example of a 12-lead that was incorrectly read as a STEMI. Paramedics should consider the computer s interpretation, but not rely on it, understanding its limitations. 15

Reciprocal Changes Reciprocal changes occur on the heart wall opposite the site of the myocardial infarction. Reciprocal changes are not always seen, but when they are present, they are indicative of a STEMI. Type of MI Leads Reciprocal Leads Septal V1, V2 No Reciprocal Leads Anterior V3, V4 No Reciprocal Leads Anteroseptal V1, V2, V3, V4 No Reciprocal Leads Lateral I, avl, V5, V6 II, III, avf Anterolateral I, avl, V3, V4, V5, V6 II, III, avf Inferior II, III, avf I, avl Posterior None V1, V2, V3, V4 Here is an example of an Inferior STEMI (II, III, avf) with Reciprocal Changes (I, avl). Here is an example of an Anterior Lateral STEMI (I, avl, V2, V3, V4) with Reciprocal Changes (III, avf). 16

STEMI Destination Guideline 17

Notes: STEMI Destination Guideline 1. Patients in arrest or a compromised airway will go to the nearest facility. 2. Contraindications to fibrinolysis include: History of Intracranial hemorrhage Known structural cerebral vascular lesion (e.g., AVM) Known malignant intracranial neoplasm (primary or metastic) Ischemic stroke within 3 months (except acute ischemic stroke within 3 hours) Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head trauma or facial trauma within 3 months 3. Receiving PCI center must be notified as early as possible. Notification should be made to medical control and include the statement requesting STEMI activation. 4. Consider patient preference/history if multiple primary PCI centers are in similar proximity 5. If patient sustains cardiac arrest during transport to a primary PCI center, continue to that facility unless there are insufficient resources to manage the arrest or the provider is unable to manage the airway. 18

Regional PCI Hospitals Hartford Hospital John Dempsey Hospital New Britain Campus of HCC Saint Francis Hospital Out-of-Region PCI Hospitals Baystate Medical Center (Springfield) Lawrence Memorial Hospital (New London) Saint Mary s Hospital (Waterbury) Waterbury Hospital Yale-New Haven Hospital 19

EMS STEMI Feedback Area PCI hospitals have committed to providing EMS providers with STEMI patient follow-up. Contact Information for follow-up: Hartford Hospital Deborah J. Murphy Deborah.Murphy@hhchealth.org Marcin Dada Marcin.Dada@hhchealth.org John Dempsey Hospital Peter Canning canning@uchc.edu St. Francis Hospital John Quinlavin jquinlav@stfranciscare.org The Hospital of Central Connecticut Dave Buono Justin Lundbye David.Buono@hhchealth.org Justin.Lundbye@hhchealth.org 20

STEMI Alert Procedure 1) Acquire a 12-lead on all patients suspected of Acute Coronary Syndrome (active chest pain or equivalent symptoms (SOB, nausea, etc.) on first contact. 2) If 12-lead is diagnostic for STEMI and paramedic believes patient is having STEMI, contact CMED for STEMI Alert with Medical Control patch, and transmit ECG if possible. If possible and less than 30 minutes from PCI center, do not wait until transporting to call hospital. Failure to notify hospital until 5 minutes out will delay reperfusion. 3) When hospital answers phone, confirm medical control, and state I have a STEMI Alert and am requesting STEMI activation. If you are uncertain the patient is having a STEMI, say I have a Possible STEMI Alert. 4) Describe 12-lead and patient condition. Based on the conversation between paramedic and ED physician and if applicable, the transmitted 12 -Lead, the cath lab will either be activated in advance of arrival, placed on standby or not activated until the physician can make a more detailed assessment at the hospital. 5) Provide Appropriate Care during transport per guideline. Have defib pads ready in case patient goes into unstable ventricular tachycardia or ventricular fibrillation. Consider disrobing patient if time permits. Have latest 12-lead ready to show ED MD on arrival. Be prepared to transport patient to cardiac cath lab on EMS stretcher if given the goahead from ED staff. 6) Please leave copy of PCR and all 12-lead strips at the hospital prior to departing. PCRs should include Time of 911 Dispatch, Time at Patient side, Time of 1 st 12-lead, Arrival at the Hospital, as well as all care rendered. 7) If applicable to hospital, fill out QA/Patient Follow-up form in ED. REMEMBER EARLY NOTIFICATION SAVES LIVES! 21

Acute Coronary Syndromes/Chest Pain 22

Acute Coronary Syndromes p.2 23

More STEMI PEARLS Have Defib Pads Ready. Patients experiencing STEMIs are at high risk to develop Ventricular Tachycardia or Ventricular Fibrillation. Be prepared. ROSC 12-Lead All Cardiac Arrest Return of Spontaneous Circulations should get a 12-Lead. Many of these patients suffered cardiac arrest due to myocardial infarction. If you see a STEMI on the 12-Lead, call in a STEMI Alert. They need to get to the cardiac cath lab. Gowns Remove clothes, top and bottom if able. Consider putting your patient in a hospital gown. This will make it easier to get a quality 12-lead, as well as have access to the patient s chest. It will also save time in the cath lab by allowing quicker access to the groin for cannulation. 24

Common STEMI Patterns Inferior Inferior STEMI (II, III, avf) with Reciprocal Changes (I, avl) An Inferior Wall MI is characterized by ST Elevation in two or more of Leads II, III and avf. In most patients, the inferior wall is supplied by the right coronary artery, which often supplies the AV node and the right ventricle. These patients are at risk for hypotension and heart block. Knowing this paramedics can be prepared for possible complications. Patients suffering from an inferior infarction should only receive nitro after receiving a rightsided 12-Lead to rule out right ventricle infarction (RVI). Nitro is contraindicated in patients with RVI. Patients in third degree block due to infarction of the AV node should receive transcutaneous pacing. Here is a 12-Lead of an Inferior STEMI with 3rd Degree Heart Block: 25

Common STEMI Patterns Anterior Anteriorlateral STEMI (I, avl, V2, V3, V4) with Reciprocal Changes (III, avf) An Anterior Wall MI is characterized by ST Elevation in two or more of Leads V1-V4. The anterior wall is supplied by the left anterior descending artery (LAD). Anterior MIs are often very large and spread into lateral wall of the heart, and can show elevation in V5, V6, as well as I and avl. These patients are at risk for cardiogenic shock. Patients suffering from an anterior will often need cardiac pressors to support their cardiac output. They may also need cardiac pacing if the infarct leads to conduction abnormalities. 26

Common STEMI Patterns Lateral Lateral STEMI (I, avl) with Reciprocal changes (III, avf) A Lateral wall MI is characterized by ST Elevation in two or more of Leads I, avl, V5 and V6. In most patients, the lateral wall is supplied by the circumflex artery. Lateral wall MIs can often be subtle and are often missed if not looked for closely. When reciprocal changes are present in II, III or avf, the presence of an MI is much more likely. Lateral MIs can be isolated or involve other walls of the heart. 27

Common STEMI Patterns Posterior Inferiorlateral STEMI (II, III, avf, V6) with Posterior Involvement (V1, V2, V3) A Posterior MI is characterized by ST depression in Leads V1, V2, or V3. (If the 12-lead is held upside down, and looked at in the mirror or turned over and held up to the light, it will appear to be ST elevation as illustrated here. The posterior wall is supplied in most people by the right coronary artery. Posterior MIs can be seen alone or in conjunction with inferior or lateral MIs. 28

Common STEMI Imposters Left Bundle Branch Block Left Bundle Branch Block (LBBB) is a supraventricular complex that produces ST elevation in V1, V2 and sometimes V3. The QRS complex is > 0.12 seconds. LBBB is a common conduction defect which is caused delayed activation of the left ventricle. In V1 the QS complex is always negative. Here is a LBBB misread as a STEMI by the computer. 29

Common STEMI Imposters Left Ventricular Hypertrophy (LVH) Left Ventricular Hypertrophy (LVH) is an enlargement of the heart muscle that forces the heart to work harder to pump blood. LVH produces ECGs with high amplitude because of the increased electrical activity. It is characterized by deep S waves in V1 and V2 and tall R waves in V5 and V6. The negative deflected QRSs produce ST elevation that can be mistaken for a STEMI. 30

Common STEMI Imposters Early Repolarization Early repolarization can produce widespread ST elevation. It is common in healthy black males less then 40 years of age. It is often characterized by a notched J-point, and concave ST segments. 31

Common STEMI Imposters Pericarditis Pericarditis is an inflammation of the pericardium that surrounds the heart. Patients may complain of chest pain that increases with movement and breathing. On a ECG, pericarditis often produces widespread ST elevation. The ST segment is often concave, producing what is sometimes referred to as a smiley sloped shape. 32

STEMI Resources There are a number of excellent resources on 12-lead Interpretation and STEMI Care. Paramedics are encouraged to continually practice and upgrade their 12-lead interpretive skills. Webcasts STEMI Recognition: Beyond the Basics, EMS World http://www.emsworld.com/webinar/10747611/stemi-recognition-beyond-the-basics On-Line Courses Learn: Rapid STEMI ID, American Heart Association. http://www.heart.org/heartorg/cprandecc/healthcaretraining/ AdvancedCardiovascularLifeSupportACLS/Learn-Rapid-STEMI- ID_UCM_304325_Article.jsp 12-Leads Made Easy, Physio Control University. http://www.centrelearn.com/physio_12-leads.asp Books STEMI Provider Manual, American Heart Association http://www.heart.org/heartorg/cprandecc/healthcareproviders/ AdvancedCardiovascularLifeSupportACLS/STEMI-Provider- Manual_UCM_308744_Article.jsp The 12-Lead ECG in Acute Coronary Syndromes; Tim Phalen and Barbara J. Aehlert, Mosby/JEMS, 2011. 12-Lead ECG for Acute and Critical Care Providers, Bob Page, Prentice Hall, 2005 12-Lead ECG: The Art of Interpretation. Thomas B. Garcia and Neil Holtz, Jones & Bartlett Learning, 2011. Web Sites EMS 12-Lead, http://ems12lead.com/ Dr. Smith s ECG Blog, http://hqmeded-ecg.blogspot.com/ 33

EMS STEMI WORKBOOK REVIEW AND EXAM Name Service 1. When responding to a syncopal episode, a paramedic should always bring which of the following equipment into the scene? a. Cardiac monitor b. Backboard c. Computer in event of refusal d. All of the above 2. Which of the following patients should receive a 12-lead ECG? a. 80-year-old female with weakness and vomiting b. 40-year-old male with unexplained diaphoresis c. 65-year-old male with return of spontaneous circulation post-defibrillation d. All of the above 3. Which describes the proper placement of the limb leads? a. Place Lead I, II, III, and ground on torso b. Place Lead I, II, III, and ground on appropriate limbs at ankles and wrists c. It doesn t matter where they are placed as long as they are on the body d. All of the above 4. When should a 12-Lead ECG first be performed on a patient with suspected ACS? a. En route to the hospital b. Upon first patient contact c. Once patient is in ambulance d. On arrival at the hospital 5. What is the importance of 1 mm ST elevation in leads I and avl? a. Indicative of a posterior MI b. Indicative of an anterior MI c. Indicative of a lateral STEMI d. No significance 6. What is the importance of reciprocal changes in lead I and avl in the presence of elevation in Leads II, III, and avf? a. No significance b. Strong indication of an Inferior MI c. Indicative of lateral ischemia d. Indicative of a posterior MI 7. What type of STEMI is characterized by ST depression in leads V1-V3 a. Inferior b. Lateral c. Anterior d. Posterior 8. What is the significance of widespread ST elevation in all leads? a. Indicative of a massive STEMI b. Likely to be early repolarization or pericarditis c. No significance d. Poor Data quality 34

9. A 59 y.o. female presents with a sudden onset of crushing chest pain. She has a past medical history of CAD. She states her father died of an MI at age 60. You believe the patient is having an anterior STEMI, however the computer does not state ***Consider Acute Infarct*** or the equivalent. What is your next step? a. Transport patient as a non-priority patient b. Begin priority transport c. Notify the hospital that you are requesting STEMI activation with Medical Control d. Reassure patient and obtain a refusal. 10. Why is early notification important? a. Enables the receiving hospital to prepare the cardiac lab for patient arrival b. Decreases door- to-balloon time c. Decreases morbidity and mortality d All of the above 11. What is the criteria for STEMI activation? a. ST elevation in 2 or more contiguous leads of >2 mm (V1-V4 ) or > 1 mm (limb or lateral); with QRS duration < 0.12 second b. QRS duration < 0.12 second b. ***Acute MI*** or equivalent prints on 12-lead whether or not paramedic agrees c. Machine does not read ***Acute MI*** but the paramedic still strongly believes the ECG shows a STEMI d. A and C 12. It is important for a paramedic do serial 12-leads on a patient with suspected acute coronary syndrome because? a. STEMIs are often evolving b. STEMI captured on the 1 st 12-lead may disappear by arrival time to the hospital c. All of the above d. None of the above 13. Which hospitals are receiving facilities with PCI capability? a. Hartford Hospital, John Dempsey Hospital, New Britain Campus of HCC, Saint Francis Hospital b. Bradley Memorial, Bristol Hospital, Charlotte-Hungerford, Johnson Memorial Hospital c. Manchester Memorial, Middlesex, Rockville Hospital, William Backus Hospital, Windham Hospital d. All hospitals have PCI capability 14. Your STEMI patient suffers a cardiac arrest en route to a PCI center. You are 10 minutes from a non PCI center and 15 from a PCI center. You have sufficient help to do CPR in the back of the ambulance and are able to successfully manage the patient s airway. Where do you transport the patient? a. To the closet facility. b. To the PCI center c. To the closest hospital to the patient s home address d. None of the above. 15. What information should be documented on a STEMI Care PCR? a. 12-Lead strips attached to PCR b. Time of 911 Dispatch, Time at Patient Side and Time of 1st 12-Lead EKG acquisition c. All care rendered by paramedic d. All of the above 35