STEMI

Bonner County EMS System

Continuing Medical Education
October 2010

Objectives

Review the Patient Care Guidelines for Chest Pain (5000) and
STEMI (5010) at all provider levels.

Review the pathophysiology of Acute Myocardial Infarction.

Define STEMI and discuss the role of prehospital care in

improving patient outcomes.

Introduce the Bonner County STEMI Program.

Discuss the roles of all members of the prehospital care team

in the case of a STEMI Alert.

Demonstrate 12-lead ECG lead placement.

Begin familiarization with the Lifepak 12 and the Lifepak 15.

Definitions

Acute Coronary Syndromes - Result from acute obstruction of

a coronary artery. Consequences include unstable angina, acute
myocardial infarction (AMI), and sudden cardiac death.

Coronary Artery Disease - A major cause of illness and death,

coronary artery disease (CAD) begins when hard cholesterol
substances - plaques - are deposited within a coronary artery.

Atherosclerosis - A process of progressive thickening and

hardening of the walls of medium and large arteries as a result
of fat deposits on their inner lining.

Ischemia - Insufficient blood flow to tissue - usually localized due to a mechanical obstruction.

Infarction - An area of tissue death due to lack of oxygen.

More Definitions
Angina - Chest pain due to an inadequate supply of
oxygen to the heart muscle. The pain is typically severe
and crushing in nature with a feeling of being just
behind the sternum.
Acute Myocardial Infarction - The interruption of blood
supply to a part of the heart, with the subsequent death
of heart muscle tissue. The most common cause is
occlusion of a coronary artery.
Electrocardiogram (ECG) - A recording of the electrical
activity of the heart.
STEMI - ST-Elevation Myocardial Infarction.

Demographics
Number one killer of adults worldwide.
In the United States, approximately 1.5 million heart
attacks occur annually.
Myocardial infarctions result in death for 400,000 to
500,000 people every year, with about half dying before
they reach the hospital.
Acute Coronary Syndrome should be considered in men
older than 30 and women older than 40 years of age
(younger in diabetics).

Pathophysiology
The physiologic process
that can result in an
Acute MI begins
decades earlier, with a
progressive thickening
and hardening of the
coronary arteries
resulting from fat
deposits on their inner
lining.
This is known as
Atherosclerosis.

Pathophysiology
Plaque continues to
build and the
coronary artery walls
continue to thicken
over the years.
The coronary arteries
become progressively
more blocked,
resulting in
decreased blood flow
to the myocardium.

Ischemia
The coronary arteries
supply oxygenated
blood to the entire
heart muscle.
As blood flow to the
heart muscle is
decreased, it becomes
progressively more
oxygen-starved.
This is called ischemia.

Angina
Angina may be described as a vague,
troublesome ache or area of discomfort, or
may rapidly become a severe, intense
crushing sensation.
Angina is typically triggered by exertion or
strong emotion, usually persists for no
more than a few minutes and subsides
with rest or medication, eg Nitroglycerin.

Angina

Infarction
If the coronary artery
becomes completely
occluded, the flow of
blood - and oxygen to the heart muscle
below the blockage
ceases.
Without oxygenated
blood, this area of
myocardium dies.
This is known as
infarction.

Infarction
Once an infarct occurs,
the heart muscle is
permanently damaged.
The patient is now at
risk for further heart
damage, lifethreatening
arrythmias, heart
failure, cardiogenic
shock, cardiac arrest
and death.

Signs and Symptoms

Signs and Sypmtoms

Signs and Symptoms

Signs and Symptoms

Signs and Symptoms

Cardiac Conduction System

Cardiac muscle is
unique in that it has
the ability to generate
its own electrical
current.
This is known as
automaticity.
The state of the hearts
electrical functioning
can be measured and
evaluated on an
electrocardiogram
(ECG).

Normal ECG

Normal ECG
In an uninjured heart,
the ST Segment of the
ECG is flat.
But ischemic or
necrotic heart cells are
incapable of
transmitting electricity
and this will show as
changes on the ECG.

S-T Elevation
As ischemia progresses
to infarction, there may
be a marked elevation in
the S-T Segment of the
patients ECG.
This is known as S-T
Elevation and indicates
that there is significant
injury to the heart
muscle.
STEMI stands for S-T
Elevation Myocardial
Infarction

PCI
The definitive
treatment for most
STEMI patients is a
procedure called
Percutaneous Coronary
Intervention, or PCI.
PCI is performed by
an interventional
cardiologist in a
Cardiac
Catheterization Lab.

PCI
During the procedure,
a catheter with a
balloon and a metal
stent is inserted
through the patients
femoral artery.
When the area of the
affected coronary
artery is reached, the
balloon is inflated the
expand the stent and
allow blood flow to
resume.

Coronary Artery Stents

Minutes = Muscle
Time is of the essence for STEMI patients.
The more time goes by with a coronary
artery occlusion, the more heart muscle is
lost.
Prehospital care providers at all levels
have a vital role to play in improving the
outcomes of patients with STEMI.

STEMI Alerts

Bonner County STEMI

Program
Working in close cooperation with Bonner General
Hospital, Kootenai Medical Center and Heart
Clinics Northwest, the Bonner County EMS System
has developed a progressive STEMI Alert Protocol.
BCEMS System paramedics have received
additional advanced training in STEMI recognition
and treatment and now have more tools available
to them to stabilize patients with suspected STEMI.
Starting November 2010, patients in Bonner County
with suspected STEMI will be transported directly
to the Cardiac Cath Lab at KMC, where a highly
skilled team will be standing by to assume care of
the patient.

The Prehospital Care Team

Every link in the chain of care of the patient with
suspected STEMI is vital to the patients survival,
from the Emergency Medical Dispatcher to the
First Responder to the EMT to the Advanced EMT
to the Paramedic. Everyone has a key role to play.
Recognition that the patient may be having a
serious cardiac event is the first step.
A superior assessment, accurate vital signs,
appropriate initial treatment, a concise but detailed
update to incoming units and a calm, professional
scene presence are all critically important to a
successful outcome.

The 12-lead ECG

The 12-lead ECG is a
key diagnostic tool in
determining whether
a patient with chest
pain may have a
suspected STEMI.
Every prehospital
provider in Bonner
County will have the
opportunity to
become comfortable
with the Lifepak
monitor and 12-lead
placement.

Lead Placement
Correct placement of
the ECG electrodes is
key to obtaining an
accurate, diagnostic
ECG tracing.
Assisting with
placement of the 12lead on patients
presenting with chest
pain is an important
link in the chain of
prehospital care.

Lead Placement
Clark Fork Valley
Ambulance pilot
program - 12-lead
placement and
acquisition before the
paramedic arrives on
scene.
BCEMS System
paramedics and
instructors will
provide initial and
ongoing training on
the 12-lead.