2013 STEMI guidelines: EMS has been put on notice

[Christopher]

For those that have not already heard, the 2013 guidelines for the management of STEMI have been put out by the American College of Cardiodiology Foundation and the AHA (ACCF/AHA).

If you can read, these guidelines are nothing new or earth shattering.

Of note:

• "New or presumed new" LBBB is no longer an indication for STEMI, they now recommend Sgarbossa's criteria (from 1996) be used
• ST-depression isolated to V1-V4 should be considered a posterior STEMI
• Widespread ST-depression with elevation in aVR is suggestive of proximal LAD/LMCA obstruction
• Hyperacute T-wave changes, such as deWinter T-waves, are an early sign of STEMI

Over at the EMS 12-Lead Blog and Podcast we've been focusing on these points for a number of years and other blogs, such as Dr. Smith's ECG Blog and Life in the Fast Lane, have also pounded these points home.

Moving beyond points such as the Earth not being flat, the most important part of these guidelines is given on page 10 under the section for Regional Systems of STEMI Care and Goals for Reperfusion Therapy (emphasis mine):

For patients who call 9-1-1, direct care begins with FMC, defined as the time at which the EMS provider arrives at the patient’s side. EMS personnel should be accountable for obtaining a prehospital ECG, making the diagnosis, activating the system, and deciding whether to transport the patient to a PCI-capable or non–PCI capable hospital.

Did you catch that?

A joint task force of cardiologists just told EMS the ball is in our court for STEMI diagnosis and activation.

They continue:

Consideration should be given to the development of local protocols that allow preregistration and direct transport to the catheterization laboratory of a PCI-capable hospital (bypassing the ED) for patients who do not require emergent stabilization upon arrival.

That bit should not come as a shock, and honestly is common sense, but it is good they have it on paper.

I'm sure some systems are going to scream about false positives, but don't look now these cardiologists have our back!

Although “false positives” are a concern when EMS personnel and/or emergency physicians are allowed to activate the cardiac catheterization laboratory, the rate of false activations is relatively low (approximately 15%) and is more than balanced by earlier treatment times for the majority of patients for whom notification is appropriate.

So there you have it, a joint task force of cardiologists have just assigned the diagnosis of STEMI and destination plan to EMS. Many areas have already adopted responsibility and accountability for cardiac arrest, so this expansion in expectations should be welcomed.

 

[Smash]

For those that have not already heard, the 2013 guidelines for the management of STEMI have been put out by the American College of Cardiodiology Foundation and the AHA (ACCF/AHA).

If you can read, these guidelines are nothing new or earth shattering.

Of note:

• "New or presumed new" LBBB is no longer an indication for STEMI, they now recommend Sgarbossa's criteria (from 1996) be used
• ST-depression isolated to V1-V4 should be considered a posterior STEMI
• Widespread ST-depression with elevation in aVR is suggestive of proximal LAD/LMCA obstruction
• Hyperacute T-wave changes, such as deWinter T-waves, are an early sign of STEMI

Over at the EMS 12-Lead Blog and Podcast we've been focusing on these points for a number of years and other blogs, such as Dr. Smith's ECG Blog and Life in the Fast Lane, have also pounded these points home.

Moving beyond points such as the Earth not being flat, the most important part of these guidelines is given on page 10 under the section for Regional Systems of STEMI Care and Goals for Reperfusion Therapy (emphasis mine):

Did you catch that?

A joint task force of cardiologists just told EMS the ball is in our court for STEMI diagnosis and activation.

They continue:

That bit should not come as a shock, and honestly is common sense, but it is good they have it on paper.

I'm sure some systems are going to scream about false positives, but don't look now these cardiologists have our back!

So there you have it, a joint task force of cardiologists have just assigned the diagnosis of STEMI and destination plan to EMS. Many areas have already adopted responsibility and accountability for cardiac arrest, so this expansion in expectations should be welcomed.

17 years to put into practice what most of us have been doing for... well, 17 years? What's the rush? I think the AHA should just calm down a little and stop rushing headlong into changes... h34r:

I hope the onus being put on EMS is not too great a change for most places. The biggest issue we still face is trying to get past the ER without them getting their hands on the patient first. I recently had a patient code and die on the table, having spent nearly 20 minutes in the ER getting repeat ECGs and bloods whilst having the mother of all inferior infarcts. It wasn't subtle, it wasn't equivocal, the guy's heart was turning to goo, but rather than get the artery open, the ER preferred to "stabilise" him first. Oh well.

I've also never seen an issue with false positives. I've activated cath lab on a number of occasions for subtle or just plain "that don't look right" ECGs in patients ticking every other box for having the big one. I get some grief from my colleagues about "making our stats look bad" but I'd rather that than have a bad outcome for my patient. False positives are the sign of a healthy system working as it should.

 

[lightsandsirens5]

I was just going to say the same about false positives. I recall hearing something about how the best ratings are given to those agencies and hospitals who have true positives in the low 90s. The implication being that if the diagnostic rate is 100 percent, they must be missing some.

Anyhow, it is nice to see the AHA finally getting on the ball with that. And it's also nice to know some MDs, somewhere believe a little bit in EMS.

At my current service we are doing 15 leads as the new standard. In other words, anyone suspected of having an MI no gets a 15 lead instead of just a 12 lead. Any elevation, depression, or T wave abnormalities in V4R and they just bought a full right sided 12 lead (well 14 including right posterior leads). They claim this increases our diagnostic sensitivity to the high 90th percentile for all times of MI. Any Code STEMI (or NSTEMI) activation and we automatically transport to the nearest cath lab. (Or in some cases, the nearest ER with fibrinolytics....but that's another story). All the ERs around here at Cath lab facilities are really good at standing there while watching you roll by and keeping their grimy mitts off the patient.

All in all I feel that I work in a fairly progressive system.

It sure is nice though to know a well known panel odd cardiologists is backing what we do.

 

[Christopher]

...They claim this increases our diagnostic sensitivity to the high 90th percentile for all times of MI.

The best way to improve sensitivity is to acquire serial 12-Leads. I won't say a 15-Lead doesn't help, but 2+ 12-Lead's at regular intervals will catch more!

It sure is nice though to know a well known panel of cardiologists is backing what we do.

Dr. Christopher Granger is one of the members, and he's out of Duke here in North Carolina. He is very pro-EMS and our entire State is pro-EMS with regards to STEMI and cardiac arrest care.

To those living in areas where you just "don't get no respect," have no fear the calvary is here!

 

[mycrofft]

The cavalry is charging up Golgotha to Calvary
Good-sounding stuff generally, and serial 12 leads AND A RYTHM STRIP are good stuff too.

 

[Handsome Robb]

Thanks for the post Christopher! Glad to see they are taking "New or presumed new LBBB" out of the criteria. So frustrating being bound by protocol to activate our STEMI protocol at O-dark-thirty and waking everyone up because the patient is complaining of ACS symptoms and can't tell me if they have a hx of a LBBB or not with none of Sgarbossa's criteria met We will see how long it takes to roll over into protocols though. I mentioned Sgarbossa's criteria the other day and had a handful of medics look at me like I had three heads, four arms and one eye.

As far as STEMI protocol activation in the field and bypassing the ED that's not really new here...we don't transmit, it's on the Medic to activate or not. Bypassing the ED is about 50/50. I work nights and our cath teams are on call at night generally so we usually get held up in the ER but from what I hear day crews are consistently bypassing the ED and going straight to cath and handing off the patient there. We also do field blood draws for one of our PCI centers under the STEMI protocol and are working to get all three on board. National standard for door-to-ballon is <90 mins, here we aim for <60 and have been getting <30 and aiming to make it the standard at the facility that we draw labs for and bypass the ED.

As far as serial 12-leads. I have always been taught to capture a 12-lead after administration of any medication, specifically NTG. I'm the guy that'll walk into the ER with 3 or 4 separate 12-leads. I'm a STEMI white cloud though and have only had one as a PIC and a couple while working as an Intermediate but all I really did was drive and lift the patient.

15 leads and V4r isn't common practice here. The argument against it is our short transport times with "bigger fish to fry" and I agree, but how long does it really take to pop on V4r and capture while you're setting up for a line or med admin? I admittedly do not do them myself but it's something I should start. This post actually made me wonder if I missed a posterior STEMI tonight with the mention of septal/anterior depression.

Definitely going to talk to our MD about all of this. He's probably sick of hearing from me

Random, but I've noticed the younger ED Docs here are very receptive to EMS and our DDxs and though processes while the older ones totally disregard us.

 

[shfd739]

This will be good for a lot EMS folks to finally get on board.

Like other places we can activate and transmit 12 leads to all of our ERs and have had some downright amazing door to balloon times. I think we have the local record of less than 15mins door to balloon. If we tell the ER stemi alert they activate the cath teams. If we arrive and its determined not to be stemi then the team is canceled- no harm no foul on the medic. They rather us call it and not need it then have not been sure, waited for the ER and lost time.

Serial 12 leads are encouraged and so is keeping up with nitro admin every 3-5 mins even after pain is relieved as long as the blood pressure tolerates it.

The V4r and 15 lead isnt being done as much as it should, I think we have plans already in place to start doing that next year.