Aspen Medical STEMI Guideline PDF

aspen medical ST-Elevation Acute Myocardial Infarction Guideline Indications Reperfusion is to be considered for all patients with classic ongoing ischemic chest pain and ECG criteria indicating STEMI, as demonstrated on a 12-Lead ECG Time of onset of pain :5 12 hours and any of the12-Lead...

aspen medical ST-Elevation Acute Myocardial Infarction Guideline Indications Reperfusion is to be considered for all patients with classic ongoing ischemic chest pain and ECG criteria indicating STEMI, as demonstrated on a 12-Lead ECG Time of onset of pain :5 12 hours and any of the12-Lead ECG changes as stated below: ECG Criteria are: Persistent ST-segment elevation of 1 mm in two contiguous limb leads AND/OR ST-segment elevation of 2 mm in two contiguous chest leads (Vl -V6) Normal QRS width (< 0.12 seconds) OR RBBB identified on the 12-Lead ECG Left Bundle Branch Block (LBBB) identified on the 12-Lead ECG which is known to be new or is old in the presence of clinical features which are convincing of an infarction - use the Sgarbossa Criteria below Modified Sgarbossa Criteria for diagnosing Acute Myocardial Infraction Associated with LBBB Concordant ST-segment elevation lmm in any lead Concordant ST-segment depression lmm in lead Vl - V3 Discordant ST-segment elevation lmm in any lead as defined by 25% of the depth of the preceding S-wave.... t -t- ttatio -4/10 4 lta1K> I 11/-10,. 3J ST/S Ratio Ratio of ST-segment elevat1on measured at the J point to the R or S wave, whichever was most prominent Inferior Right Coronary Artery ECG Identification Criteria The vast majority (80%) of inferior STEMls are due to occlusion of the dominant right coronary artery (RCA) The RCA territory covers the medial part of the inferior wall, including the inferior septum ST Elevation in lead Ill > lead II Presence of reciprocal ST Depression in lead I Signs of right ventricular infarction: ST Elevation in leads Vl and V4R Conduct V4R right chest lead placement. ST elevation lmm. AMPCGSllMI TlMI Guideline I V5 0 I Dec21 1 Page I of 6 Posterior Infarction ECG Pattern: V1 - V3 Horizontal ST Depression Tall, Broad R waves (>30ms wide. Measured from the start of the R-wave to the S-wave) Upright T-waves Dominant R-wave(R/S ration >1) in V2 Isolated ST elevation in lead V6 (requires 15-/ead ECG) Usually associated with inferior and/or lateral wall infarctions Acute Myocardial Infarction Acute Myocardial Injury is represented as ST elevation Infarction can also present as a pathological Q wave( 0.04ms wide; deeper than 25% of the height of the R wave) Infarction may also present with T wave changes o Inverted o Large "hyperacute" Coronary Artery Involvement Myocardium Associated Artery Involved Reciprocal Changes Affected Leads Anterior V2- V4 Left Anterior Descending Inferior Anterolateral I, aVL, V3 - V6 Left Anterior Descending and Inferior Circumflex Anteroseptal V1-V4 Left Anterior Descending NAD Inferior II, Ill, aVF Right Coronary(80% Limb Lateral(I, aVL) dominant) Left Circumflex(20%) Lateral I, aVL, VS - V6 Circumflex Inferior Posterior V7-V9 Right Coronary V1-V3 Right Ventricular V4R-V6 Right Coronary NAD I Lateral Vs Lateral V6 Lateral AMPCGSHMIO 5TEMI Gu1dc·h ne I V5 0 Dec 21 I Page 2 of 6 Contraindications for Fibrinolysis Ongoing ischemic chest pain 12 hours Patients is 75 years GCS 10 min) CPR Known pregnancy or delivered within the last three weeks History of serious systemic disease (advanced terminal cancer, severe liver disease or kidney disease) Special Note Patients with relative contraindications may still receive fibrinolytic therapy when the benefits of therapy outweigh the risks. If there is concern about any of the contraindication, it should be discussed with the Medical Officer prior to administration of Tenecteplase, Clopidogrel or Enoxaparin In patients with cardiogenic shock associated with STEMI, there is clear mortality benefit for PCI over fibrinolysis. These patients should be discussed with the Medical Officer regarding the appropriate treatment. Procedure Only give oxygen if required to achieve SpO2 94% Determine and record cardiac rhythm Treatment according to Aspen Medical PCG-CC1 AMPCG5HMl 5TEMI Gwdehne I V5 0 I Dec21I Page 3 of b  Transmit 12-Lead ECG and consult with Medical Officer as soon as possible regarding the possibility of a STEMI patient and treatment guidelines required Conduct a thorough STEMI guideline checklist with the patient and discuss any issues with the Medical Officer Treat hemodynamically unstable arrhythmias as per the appropriate Aspen Medical PCG. Monitor closely as cardiac arrest may be highly likely with associated arrhythmias and reperfusion. Post Fibrinolysis Only give supplemental oxygen to achieve SpO2 2: 94% Monitor the cardiac rhythm continuously and be prepared to treat cardiac arrest The most common life threatening haemorrhage post fibrinolysis is spontaneous intra­ cranial bleeding. If this occurs the patient will usually have: sudden onset of headache, a falling level of consciousness and focal neurological signs. This is usually fatal. Reperfusion arrhythmias include: Bradycardia: complete heart block occurs most commonly with reperfusion of inferior Ml. Usually resolves within minutes. If required treat as per Aspen MedicalPCG-CC7 ldioventricular rhythm: treatment is not necessary if the heart rate is